Talk:Cannabinoid hyperemesis syndrome/Archive 1

Synthetic Marijuana
It should be noted that smoking synthetic marijuana would have a much higher chance of resulting in Cannabinoid Hyperemesis Syndrome, due it's much stronger affects on the cannabinoid receptors in the brain. — Preceding unsigned comment added by 68.149.102.89 (talk) 18:35, 22 February 2013 (UTC)

Cyclic Vomiting Syndrome vs Cannabinoid hyperemesis syndrome
I removed the most recent paragraph about CHS being just relabeled CVS "controversy" because the section made assumptions not supported in the reference article. I think the reference provides some useful information, but it mainly says that there isn't enough information to support any association (related or not-related) because the available literature is of poor quality. Here is the article FYI: http://azdhs.gov/documents/licensing/medical-marijuana/debilitating/cyclic-vomiting-syndrome.pdf MartinezMD (talk) 03:31, 17 September 2014 (UTC)

1992 to 2002 ER visits statistics
The article currently reads, "It is evident to see such an enormous increase in the number of emergency room visits increase the health care costs". Not only does this sentence not really make sense ("it is evident to see an increase increase the costs"), but the "enormous" increase is not 23%. The US population increased from 255 million to 290 million between 1992 and 2002. The figures of 90 and 110.2 million ER visits in those years are, in comparison to the total population of the time, 35.29% and 37.93% respectively. Therefore, adjusted for population growth, the number of visits only increased by 1.6%. Clamalam (talk) 14:29, 14 November 2010 (UTC)

Seizures?
"Half of all drug seizures worldwide are cannabis seizures.[5]" 1. If this were true, half of California would be on Topamax. 2. Not relevant to stomach aches from cannabis at all. — Preceding unsigned comment added by 206.171.210.196 (talk) 21:09, 17 June 2012 (UTC)
 * Interestingly, a quick perusal of the medical publications on it includes non-medical information about marijuana in the abstracts, including things like arrest rates. Very, very odd. If you look up articles on medical amphetamines that are specifically about abuse risk, they don't talk about non-medical amphetamine arrest rates or anything like that. They just stick to the subject. So IMO there is a lot of propaganda mixed in with legitimate discussion of this. And there are no actual studies on it, just a description of a few patients that were given the diagnosis. One of the main risk factors seems to be living near one of two doctors that have diagnosed it in other patients.76.105.216.34 (talk) 02:11, 7 April 2016 (UTC)

Epidemiology
Why is this section basically a statement of the illicit nature of cannabis, consumption rates, seizure rates and so on? I would presume that information should be in the main cannabis article, not here in a medical article (other than perhaps to make MDs aware that the incidence could be rising). Very soap-boxy, whatever the Wikipedia term for that is... — Preceding unsigned comment added by 174.61.154.32 (talk) 23:06, 3 November 2012 (UTC)

Compulsive showering in hot water
According to the German Wikipedia article,

Translation attempt by me:

Reference there: "H. S. Kim, J. D. Anderson, O. Saghafi, K. J. Heard, A. A. Monte: Cyclic vomiting presentations following marijuana liberalization in Colorado. In: Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. Band 22, Nummer 6, Juni 2015, S. 694–699, doi:10.1111/acem.12655, PMID 25903855, PMC 4469074."

From PMC 4469074: &#91;…&#93;

The English article cites PMC 24418446:

This appears to be disputed. ~ ToBeFree (talk) 00:18, 28 May 2018 (UTC)
 * Not all patients present the same way. Note the difference in assigning diagnostic importance to the behavior of compulsive hot water exposure. Sontineni lists it as "supportive," whereas others see it as more pathognomonic.― Bio chemistry 🙴 ❤   14:24, 28 May 2018 (UTC)

PLEASE CHECK THIS STUDY IN NCBI
http://www.ncbi.nlm.nih.gov/pubmed/25334345 — Preceding unsigned comment added by 190.97.41.133 (talk) 16:56, 22 October 2014 (UTC)
 * PMID unavailable. Can you provide a different link, please?― Bio chemistry 🙴 ❤   05:56, 10 May 2018 (UTC)

https://www.ncbi.nlm.nih.gov/m/pubmed/22150623/ — Preceding unsigned comment added by 2600:1012:B16E:15FF:F51C:DD68:469C:FA10 (talk) 20:16, 13 April 2019 (UTC)

Neem oil and azadirachtin poisoning theory
Azadirachtin, (C35H44O16) is the active compound in the oil from the neem plant. It is also used in a number of pesticides such as Azamax, Azatrol, and Axatrax. Farmers have been using neem oil against fungal and insect pests for centuries. When used correctly, very little azadirachtin ends up in the food, because most plants can't take it up through their roots. Unlike vegetables, Cannabis is part of a group of plants known as phytoremediators - when grown in contaminated soil, it "cleans" the soil by uptaking heavy metals and other toxins. So it DOES uptake azadirachtin, especially during vegetative stage, then deposits it within the Trichomes. What happens if neem oil is not thoroughly washed from the Cannabis plant or the soil it is rooted in, Thereby being taken in by the roots and up into the flower? The same things that happen to those suffering from the suggested CHS. To be clear, symptoms of Azedarach toxicity include:


 * Nausea
 * Stomach cramps
 * Lethargy
 * Increased breathing
 * Weakness in the limbs
 * Depression

These are the same symptoms listed for CHS and yet, pesticide poisoning is rarely even mentioned as a suspect. Instead, tales of “cannabis poisoning” persist, being upheld by the fact that cessation of cannabis consumption relieves these symptoms. Obviously, if someone consumes a product that is known to cause these side effects then stops consuming said product, the symptoms will cease. Hence, when someone stops smoking weed laced with neem oil, neem oil toxicity will subside. Cannabis Hyperemesis Syndrome is a term coined by J.H. Allen and colleagues back in 2004 as a way of describing the connection between cannabis consumption and Cyclic Vomiting Syndrome. After gathering only nine chronic cannabis consumers (or cannabis “abusers” as the document suggests) who also showed symptoms of CVS, Allen found that all cannabis users showed symptom relief upon smoking cessation. Apparently, this small sample size was sufficient enough to determine that cannabis consumption is the cause of CVS and anti-pot crusaders have been referencing the study ever since. As any scientist knows, correlation does not equal causation. The fact that this researcher based such a large claim on such a small sample without considering other variables should be proof enough of that. But the study has been very convincing, causing even pro-pot publications to share in the hype of CHS.

— Preceding unsigned comment added by 67.60.54.212 (talk • contribs) 16:05, 25 May 2019 (UTC)


 * This is pure speculation about being a cause of cannabinoid hyperemesis. The sources are unreliable; needs much more scientific rigor, such as a WP:MEDRS review. --Zefr (talk) 16:10, 25 May 2019 (UTC)


 * I just don't believe in this misunderstood rare and relatively new set of symptoms to be classified and added to the medical books so quickly. It could easily be a common contaminant in the cannabis causing the symptoms and we associate it with the cannabis itself because of newer production methods due to the modern legalized and taxed and regulated causing a boom in processed cannabis products. I think we will end up finding the true culprit and removing this from the medical texts before too long, I'm sure people have purposely ingested mega-doses of cannabinoids in the form of edibles regularly at some point somewhere in human history without experiencing these symptoms. — Preceding unsigned comment added by 136.63.47.245 (talk • contribs) 00:14, 30 July 2019 (UTC)


 * See WP:NOTFORUM. TylerDurden8823 (talk) 00:16, 30 July 2019 (UTC)

Comment. The "Differential diagnosis" section currently states:
 * {| class=wikitable


 * It is important to ensure that, prior to diagnosing and treating for a presumed cannabinoid hyperemesis syndrome, that more serious, medical conditions be ruled out. Medical conditions that may present similarly to cannabinoid hyperemesis syndrome include cyclic vomiting syndrome, bowel perforation or obstruction, gastroparesis, cholangitis, pancreatitis, nephrolithiasis, cholecystitis, diverticulitis, ectopic pregnancy, pelvic inflammatory disease, heart attack, acute hepatitis, adrenal insufficiency, and ruptured aortic aneurysm.
 * }

I haven't read the referenced studies currently listed in this Wikipedia article. Can others that have read them tell me if any of the studies examined whether such an obvious culprit as Neem oil (or its active ingredient Azadirachtin) was looked at also? The symptoms of Neem oil sensitivity are the same as for Cannabinoid hyperemesis syndrome (CHS). The articles linked to above by the original poster are very convincing about that, especially the comments from people who got rid of their vomiting by finding or growing cannabis without Neem oil ending up in the final product. Of course that does not rule out that CHS might still exist for some people. But of course we need WP:MEDRS studies. Maybe they exist already. Maybe some day the researchers will dig up a clue, and check for contaminants. It took decades though for researchers to figure this out for tobacco products:
 * List of additives in cigarettes. -- Timeshifter (talk) 12:49, 1 August 2019 (UTC)

WP:MEDRS sources for Neem oil contamination
-- Timeshifter (talk) 04:10, 3 September 2019 (UTC)
 * Azadirachtin, Hyperemesis and Herxing? | Hemp Edification. Many WP:MEDRS sources listed at the end of the article.

Pesticide contamination of legal and illegal cannabis products
This would be a reliable source for any other Wikipedia article: -- Timeshifter (talk) 03:42, 3 September 2019 (UTC)
 * 16 Aug 2019: Illicit Cannabis Vape Carts Hospitalized 7 in California, Doctors Say. By David Downs, Leafly. From the end of the article (emphasis added): "David Downs directs news and lifestyle coverage as the California Bureau Chief for Leafly.com. He's written for WIRED, Rolling Stone and Billboard, and is the former cannabis editor of the San Francisco Chronicle, as well as the author of several cannabis books including 'Marijuana Harvest' by Ed Rosenthal and David Downs." From Leafly Wikipedia article: "Leafly is the largest cannabis website in the world, with over 15 million monthly visitors and 40 million page views across its website and mobile applications." From the article (emphasis added):


 * Premature (if we're talking about the lung illness that's been all over the news). From your article - "Officials haven’t yet determined the cause of the lung illness". Inclusion will have to wait as for now it would be speculative. However, if just discussing that it's been a contaminant ((without attributing any illnesses to it) I would have no objection, although I would like to see a more mainstream source if the contamination is that prevalent. MartinezMD (talk) 12:35, 3 September 2019 (UTC)
 * Azadirachtin, Hyperemesis and Herxing? | Hemp Edification. Many WP:MEDRS sources listed at the end of the article. -- Timeshifter (talk) 05:53, 4 September 2019 (UTC)


 * It's still not clear what you are proposing. MartinezMD (talk) 07:23, 4 September 2019 (UTC)


 * Apparently, there are WP:MEDRS sources documenting the side effects of Neem oil (azadirachtin). And those side effects, are the same as with cannabinoid hyperemesis syndrome.


 * And it is documented that Neem oil is used incorrectly by many growers, even though it is an approved pesticide. The growers use it too late in the growing process, and therefore it remains in the finished cannabis product.


 * Those 2 referenced facts should be in the article. They would be in any other Wikipedia article, but WP:MEDRS acts as a censoring agent of the medical priesthood.


 * Apparently, it is OK to mention other "medical conditions that may present similarly" but not this one. Some of the many other known contaminants may also present similarly. But the medical priesthood has long denied until recently even the faintest whiff of the benefits of organic living. I am old enough to remember when the doctors advising Consumer Reports said that enriched white bread was healthy bread because it had vitamins added to it, and that there was nothing wrong with the preservatives in that bread.


 * On an anecdotal level, I would point out other "medical conditions that may present similarly". Another contamination route causing vomiting when using a cannabis product is one I experienced long ago. Once with a lacquered wooden pipe. And once with a plastic pipe (silicone I believe) with a metal screen. Silicone is fine for microwave popcorn poppers, and oven baking. But not higher temps. If I had continued using those pipes on a regular basis I would be vomiting on a regular basis. But I had a clue, even back then, and figured that the problem was the pipe not the cannabis. I stopped using those pipes after only one vomiting session. Plastics leach chemicals, even silicone if the heat is high enough. Stains and lacquer on wooden pipes are poisonous, especially when burned. Same as the additives in cigarettes that are known to be cancerous when burned. Even though they are GRAS at room temperature. See: List of additives in cigarettes. It can be linked to in the "See also" section here. I would do it in any other Wikipedia article. -- Timeshifter (talk) 13:14, 4 September 2019 (UTC)
 * Anecdote really has no place here. Additionally, I am unable to verify "many WP:MEDRS" at the end of the article you linked higher up. You make it sound like it's a bad thing that Wikipedia is biased toward science and the mainstream, but that's actually a really good thing. It reflects what high-quality sources say. So far, the sources you're using would not qualify as good sources. TylerDurden8823 (talk) 13:20, 4 September 2019 (UTC)


 * It's worse than anecdote, it's pure speculation. So many were sure that autism, for example, was caused by the mercury in vaccines. Of course, mercury can be neurotoxic and the kids were being diagnosed at the same time that vaccines were being given. So they take mercury out of 99% of the vaccines and just as many cases, if not more, are being diagnosed now. Forget MEDRS, this wouldn't pass basic RS or moreso WP:SYN. MartinezMD (talk) 16:28, 4 September 2019 (UTC)
 * I said it was an anecdote, and I know the difference.
 * See the bottom of the Azadirachtin and hyperemesis article I linked to previously. Some of the links are WP:MEDRS. Here are the titles of the articles (not all links are WP:MEDRS):
 * Cannabis Hyperemesis Syndrome (CHS) is Azadirachtin Poisoning, Marijuana Legalization in Colorado: Early Findings, Therapeutic Goods Listing Notice 2003 No. 2, Progress on Azadirachta indica based biopesticides in replacing synthetic toxic pesticides, Pesticide Use In Australia, Complementary Medicines Evaluation Committee – Minutes 34th Meeting 2002, Azadirachtin, CHS (Cannabis Hyperemesis Syndrome) and Benadryl, Finally, the Article on Cannabis Hyperemesis Syndrome that Readers Deserve, Comparative assessment for hyperaccumulatory and phytoremediation capability of three wild weeds, Recognition and Management of Pesticide Poisonings, Neem oil poisoning: Case report of an adult with toxic encephalopathy, Azadirachtin,  Handbook of Pesticide Toxicology, Azadirachtin, Cannabinoid Hyperemesis: A Case Series of 98 Patients, Cannabinoid hyperemesis: cyclical hyperemesis in association with chronic cannabis abuse, Neem Tree Risk Assessment,  The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research, Beyond THC: The New Generation of Cannabinoid Designer Drugs, Synthetic Cannabinoid Leading to Cannabinoid Hyperemesis Syndrome,  Cannabinoid Hyperemesis Syndrome: A clinical discussion and A Gut Gone to Pot: A Case of Cannabinoid Hyperemesis Syndrome due to K2, a Synthetic Cannabinoid.


 * There are plenty of WP:MEDRS links showing the toxicity of Azadirachtin, the most toxic part of Neem oil.
 * Neem Oil General Fact Sheet - National Pesticide Information Center.
 * {| class=wikitable


 * Neem oil can be slightly irritating to the eyes and skin. Azadirachtin, a component of neem oil, can be very irritating to the skin and stomach.
 * }


 * 9 Aug 2017: Could Cannabis Hyperemesis Syndrome Really Be Pesticide Poisoning? | PotGuide.com. From the article (emphasis added):
 * {| class=wikitable


 * To control pests on cannabis plants, many home and industrial growers use neem oil, an organic oil excreted from neem (evergreen) trees to protect them from pest and mold infestation. ... Neem oil can be used as a pesticide/fungicide on cannabis plants, too, but only during the vegetative stage of growth. Once flowers start budding, all pesticide use should be ceased lest the product absorb into the flower which cannot be washed clean without washing away valuable trichomes, too.
 * }
 * The above link, or other sources, can be used to reference the timing in the use of Neem oil. This is not a WP:MEDRS reference and it doesn't need to be, since it is only documenting timing. Separate WP:MEDRS sources document Neem oil and Azadirachtin side effects. And other sources document the instructions for the correct and incorrect use of Neem oil and Azadirachtin.
 * -- Timeshifter (talk) 06:36, 5 September 2019 (UTC)


 * It seems to me you're trying to get around MEDRS and imply that CHS is being caused by neem oil. There would be no other reason for you to include it otherwise So sorry, I don't agree. It is currently not known what is responsible for CHS. I suggest you put it up for a WP:RFC if you want to add it. MartinezMD (talk) 06:52, 5 September 2019 (UTC)


 * As I said previously, and you still don't seem to grasp, it is about Differential diagnosis. See that section of this hyperemesis article.
 * Feel free to put it up for WP:RFC. I am fairly sure there are other editors that understand the simple concept of "recurrent nausea, vomiting, and crampy abdominal pain" caused by ingesting a substance over and over again. Azadirachtin (from Neem oil) is just one substance known to have this hyperemesis side effect, and known to contaminate many cannabis products.
 * If after elimination of all other differential diagnoses, and after testing with absolutely pure cannabis, hyperemesis remains, then we will know that cannabis itself is responsible for some hyperemesis.
 * I will continue to supply relevant, high-quality, links as I find them. -- Timeshifter (talk) 05:51, 6 September 2019 (UTC)

Currently used reference article mentions neem oil as a differential diagnoses
See diff and reference added by User:Doc James:
 * 'It's torture': Is a mysterious cannabis-related illness underdiagnosed in Canada?. By Adam Miller. CBC News. Nov 16, 2019. From the article (emphasis added):

-- Timeshifter (talk) 21:27, 19 November 2019 (UTC)
 * CBC is a good enough source for saying someone died from the condition. But not a sufficient source for that content. Doc James  (talk · contribs · email) 23:00, 19 November 2019 (UTC)
 * Neem oil and azadirachtin cause vomiting. That is a fact. They are found in some cannabis. That is a fact. So some cases of CHS are caused by them. That is a fact.
 * Some cases of CHS seem to be due to pure unadulterated cannabis. Not by the contaminants.
 * I have provided various references. I don't have the time to do more. So maybe some day a regular editor of this article will stop the censorship of this article, and include neem oil and azadirachtin as a differential diagnosis. Censorship due to lack of effort or interest in digging deeper and finding a reference that meets the nebulous standards of WP:MEDRS. -- Timeshifter (talk) 11:26, 20 November 2019 (UTC)

More sources on Neem oil and azadirachtin causing vomiting

 * Neem Oil Facts (Definitive Safety Guide).

Google Scholar has many reports of vomiting from Neem oil and azadirachtin: -- Timeshifter (talk) 19:04, 23 December 2019 (UTC)
 * Google Scholar search: Neem oil and azadirachtin vomiting.


 * Please stop spamming the talk page with your theory. To be included in the article you need a reliable medical source that links the oil to the syndrome. MartinezMD (talk) 19:26, 23 December 2019 (UTC)

Unindent. Sorry to confuse you with the facts. I know you think you WP:OWN this article but you don't. Relative newbs such as yourself should not try that strategy. I have been editing Wikipedia since 2005. You, only since 2008.

Please see my previous replies where I pointed out many references showing that neem oil and azadirachtin are found in cannabis products due to incorrect use of neem oil and azadirachtin. Those references do not have to meet WP:MEDRS since they can be used just to show that neem oil and azadirachtin are in cannabis products.

What has to meet WP:MEDRS is whether the ingestion of neem oil and azadirachtin causes vomiting. The links I just provided, especially the Google Scholar ones meet that standard.

It's called differential diagnoses. The vomiting article lists many differential diagnoses.

Since you may not have even looked at the Google Scholar search results, let me provide you some of the scholarly links:

Neem oil poisoning: Case report of an adult with toxic encephalopathy A Mishra, N Dave - Indian journal of critical care medicine: peer …, 2013 - ncbi.nlm.nih.gov … The azadirachtin content of neem oil varies from 300 ppm to over 2500 ppm, depending on the extraction technology and quality of the neem seeds crushed. In children, there are several case reports of Neem oil poisoning causing vomiting, hepatic toxicity, metabolic acidosis … Cited by 12. Related articles. All 11 versions.

MR imaging findings of neem oil poisoning. MV Bhaskar, SJ Pramod, MU Jeevika… - American Journal …, 2010 - Am Soc Neuroradiology … The pesticide action of neem oil is attributed to azadirachtin, which is used as an insecticide for arthropod pests.2 Poisoning causes vomiting within minutes to hours, followed by drowsiness, tachypnea, and generalized seizures associated with loss of consciousness and coma … Cited by 19. Related articles. All 5 versions.

Azadirachtin poisoning: a case report. R Iyyadurai, V Surekha, S Sathyendra… - Clinical …, 2010 - Taylor & Francis … Toxicity is reported to cause vomiting, drowsiness, metabolic acidosis, polymorpho- nuclear leucocytosis, and … of cerebral edema, hydration, and treatment of associated infections.2 Azadirachtin is the ingredient implicated in causing the effects seen in neem oil poisoning … Cited by 10. Related articles. All 7 versions.

If you look at the ecigarette article and its many subarticles there is no lack of info concerning the many additives, and the toxicity of many of them. Those additives are no less toxic when found in cannabis products. '''Some of those additives may also cause vomiting. That needs to be looked at too. Are any of those additives in cannabis products? Many cannabis users use vapes. Many cannabis users mix their own products. Many cannabis users buy illicit vapes that contain all kinds of additives. Even the legal vapes from cannabis dispensaries contain various additives.

Any additive causing vomiting that can be shown to be in cannabis products should be listed in this article in the differential diagnoses section. If this info disturbs you so much that you refuse to put it in the article despite the WP:MEDRS sources I just provided please feel free to follow up with your suggested WP:RFC. -- Timeshifter (talk) 07:19, 24 December 2019 (UTC)


 * No, that's not correct. A case report is an anecdote and does not satisfy MEDRS. "Lower quality evidence (such as case reports) or non-evidence (such as anecdotes or conventional wisdom) are avoided." I am not confused, and I don't claim to own this article. I do claim to try to follow WP policies on medical articles. Go take it up with an admin. MartinezMD (talk) 07:38, 24 December 2019 (UTC)


 * Please see previous replies. We have a difference of opinion. Scientific journals list vomiting as a side effect of Neem oil and azadirachtin. -- Timeshifter (talk) 08:00, 24 December 2019 (UTC)

Toilet image
There's been some contention about the use of the image of a woman curled around a toilet. While WP:Pertinence says that an image doesn't have to be authentic to portray something, I'll agree with those removing it. An image of someone with nausea may be accurate, but it is not specific to CHS and does not convey anything of additional benefit to the article. I reverted it for now, and we can try to get some consensus. Furthermore, lead images "should not only illustrate the topic specifically, but also be the type of image used for similar purposes in high-quality reference works, and therefore what our readers will expect to see". MartinezMD (talk) 22:14, 3 June 2018 (UTC)
 * Thank you for your interest in discussing this topic! I disagree with the claim that the image simply "does not convey anything of additional benefit" to the article. The image clearly portrays a human subject experiencing a primary symptom of CHS, and the placement of the subject near a toilet also fits the concept of recurrent nausea/vomiting. The image is of good quality and resolution, and provides a visual aid for the article. While it is not of a person suffering from CHS (to my knowledge), no image of nausea/vomiting could be perfectly "specific" to CHS; should we hold out for an image of a person holding a blunt in one hand, and vomiting simultaneously? The image appears to be worthy of a high-quality reference work; it's not as if this is cell phone footage of a person vomiting at a fraternity party.― Bio chemistry 🙴 ❤   18:44, 4 June 2018 (UTC)
 * The imagery of someone holding a blunt and vomiting would be ideal lol but unlikely to happen. In a case like this, I'd prefer someone not looking like they've passed out on the floor. I think that detracts from the depiction. I could interpret that as "drunk person passed out on floor". Let's see what other's say. I don't have a problem going with a consensus opinion. MartinezMD (talk) 21:23, 4 June 2018 (UTC)
 * Speaking of drunkenness, without context, I'm sure a lot of images could be misinterpreted—e.g. perhaps Noah has died, there's a gravedigger in the background, and a stranger is placing a blanket over his corpse. I've make a request for opinions from WP:MED here.― Bio chemistry 🙴 ❤   19:10, 5 June 2018 (UTC)
 * I don't think this adds anything of value to the article. It's a woman lying next to the toilet. It does seem more "passed out drunk" to me than nausea. Perhaps this would be appropriate for hangover? Natureium (talk) 19:19, 5 June 2018 (UTC)
 * Would you all prefer the drawing at File:Symptoms-vomiting.jpg? WhatamIdoing (talk) 19:23, 5 June 2018 (UTC)
 * I would, if an image is deemed necessary. (I did the DYK review and still have the page watched.) I don't like the current image either, because to me it speaks to a lot of possibilities that have nothing to do with vomiting.  Also, it apparently came from Flickr and is presumably not a "pose"--using a person's body and condition for illustration without their consent is troubling. Outriggr (talk) 20:30, 5 June 2018 (UTC)
 * I had that thought, too. It's almost certainly someone's girlfriend (or maybe now girfriend) passed out after boozing too hard. The slinky black nightclub dress strongly suggests this too. People don't dress up like this just to smoke out hard on some doobage.  — SMcCandlish ☏ ¢ 😼  10:04, 7 June 2018 (UTC)
 * I don't think that's a slinky nightclub dress. For one thing, club dresses are short; for another, they don't have pockets.  It looks to me like she's wearing pajama pants and a camisole.  WhatamIdoing (talk) 20:28, 10 June 2018 (UTC)
 * About the barfing-dude drawing: seems unnecessarily graphic. And nausea does not equate to vomiting. Due to a medical issue a while back, I spent almost a week intermitently nauseated without ever tossing the cookies.  I don't think we ever actually need an illustration of vomiting except at Vomit.  — SMcCandlish ☏ ¢ 😼  10:04, 7 June 2018 (UTC)
 * Hyperemesis == vomiting a lot (not merely being nauseous). WhatamIdoing (talk) 20:28, 10 June 2018 (UTC)


 * Comment A drawing of a hot shower would be specific for this condition and I would suggest we use that. Doc James  (talk · contribs · email) 21:54, 5 June 2018 (UTC)
 * Drawings of showering? Natureium (talk) 22:10, 5 June 2018 (UTC)
 * Thanks User:Natureium one with steam would be useful to represent the heat. Would support the third one. Doc James  (talk · contribs · email) 01:09, 6 June 2018 (UTC)


 * I don't appreciate the rear nude shot of the girl here, FWIWRogerdpack (talk) 14:59, 18 October 2018 (UTC)
 * Thank you for the additional comments and suggestions. I think that showering would be a good example as well! I would support the 3rd (Girl being in the shower.jpg) or 4th image (Steamy shower.jpg).― Bio chemistry 🙴 ❤   01:33, 6 June 2018 (UTC)
 * That one works for me too. Being sketchy art, it also doesn't have much prurience potential. The first could be anything (Ancient Roman taking off his toga, a guy going into a hot tub, etc.) The second is embarrassingly 1987 "my first paint program" work. q The fourth looks like a gym advert.  — SMcCandlish ☏ ¢ 😼  10:04, 7 June 2018 (UTC)
 * I listed the MS paint masterpiece mostly because it's used many times on the dutch wikipedia and I have no idea why because I don't speak the language. Maybe it's a form of art that I don't understand. The last one is the only one that I thought would indicate that the shower is hot, because it has steam, but it doesn't exactly look like someone seeking relief from nausea. Natureium (talk) 14:25, 7 June 2018 (UTC)

Why does this article even need an infobox? Addiction didn't have one for the longest time.  Seppi  333  (Insert 2¢) 21:49, 11 June 2018 (UTC)
 * I don't think it needs one, but why shouldn't it have one?
 * Wouldn't it be fun to start an RfC on infoboxes? Natureium (talk) 22:21, 11 June 2018 (UTC)
 * Sorry, I meant to say infobox image, not infobox.  Seppi  333  (Insert 2¢) 22:27, 11 June 2018 (UTC)
 * I don't believe it needs an image. If a particular receptor or other chemical factor were to be identified as causative, I would choose an image of that, otherwise I know what nausea/vomiting is. MartinezMD (talk) 03:04, 12 June 2018 (UTC)
 * I don't think many things needs an image for explanatory purposes, but adding images helps to enrich the encyclopedia as a whole. After all, who hasn't seen a cookie before? I think that having an image (indeed, the present image) will also help the reader to remember a key point about CHS, regarding the peculiar fact that hot-water exposure provides symptomatic relief.― Bio chemistry 🙴 ❤   03:14, 12 June 2018 (UTC)
 * Would you prefer a picture of the causative agent? i.e. weed? Natureium (talk) 13:47, 12 June 2018 (UTC)
 * I think something weed-esque or a showering person that looks a little in distress would be good. MartinezMD (talk) 16:03, 12 June 2018 (UTC)
 * I think we're unlikely to find a picture depicting a person showering in distress unless it's a chemical safety shower. Natureium (talk) 16:37, 12 June 2018 (UTC)
 * This is the most hilarious discussion I've ever read on Wikipedia. Just leave it without an image. We don't have to bend over backwards to find an image for every article. That said, if you do find an image of someone holding a blunt while vomiting in the shower, I'll gladly support it's inclusion just for the entertainment value! Kaldari (talk) 04:39, 26 March 2019 (UTC)

Frequent hot showers is a classic and specific symptom of the condition in question. Had a mother just yesterday describe how the drywall in their shower was falling apart due to the frequent number of showers their son was having to try to lower his nausea.

If someone wants to make a similar image of a male showering, agree that would be better as the condition occurs more often in males. Though I see significant numbers of cases in both sexes. Doc James (talk · contribs · email) 10:28, 12 January 2020 (UTC)
 * Thanks for letting me know about this discussion, though I see it's largely fizzled. What value does the image add to the article? People in the discussion above seem to more or less agree that none of these options are particularly great, and several folks have suggested removing the image altogether. GorillaWarfare (talk) 18:24, 12 January 2020 (UTC)
 * Compulsive hot showers are the classific feature of the condition. Doc James  (talk · contribs · email) 18:32, 12 January 2020 (UTC)
 * That doesn't answer my question, though... An illustration of a nude woman in the shower, who is presumably not suffering from cannabinoid hyperemesis syndrome, does not provide any more information that would be missing if the image was omitted. It just seems gratuitous to me. GorillaWarfare (talk) 21:23, 12 January 2020 (UTC)
 * People do not generally shower with their clothing on. It is a drawing that illustrates the condition fairly well. You want to convert it over to a male go ahead. Doc James  (talk · contribs · email) 07:19, 21 January 2020 (UTC)

RfC on inclusion of lead image
Should the Girl being in the shower.jpg be retained as the lead image? GorillaWarfare (talk) 04:43, 21 January 2020 (UTC)


 * Comment: You may wish to refer to previous discussion, at . GorillaWarfare (talk) 04:46, 21 January 2020 (UTC)
 * The hell? No, of course not. Nor does it seem to need any image at all. –Deacon Vorbis (carbon &bull; videos) 05:13, 21 January 2020 (UTC)
 * No, per my comment above: "An illustration of a nude woman in the shower, who is presumably not suffering from cannabinoid hyperemesis syndrome, does not provide any more information that would be missing if the image was omitted. It just seems gratuitous to me." GorillaWarfare (talk) 05:21, 21 January 2020 (UTC)
 * Yes the image is perfectly reasonable. Frequent hot shows is one of the classic symptoms of this condition. Happy to discuss other appropriate images. Doc James  (talk · contribs · email) 07:21, 21 January 2020 (UTC)
 * No per Gorilla Warfare. This isn't a medical image and Wikipedia isn't your dorm room wall. Gamaliel  ( talk ) 16:57, 21 January 2020 (UTC)
 * Weak yes I think I started the issue with the photo of the woman by the toilet which I found vague. Having an image, however, does help portray a concept. I don't think shower girl is gratuitous, and I would expect anyone in a shower to be nude. I think we should refer to WP policies when we have disagreement among editors. MOS:IMAGES says "Intangible concepts can be illustrated; for example, a cat with its claws out portrays aggression", so I'm okay with the shower girl. MartinezMD (talk) 17:23, 21 January 2020 (UTC)
 * No The art style is amateurish and the ass shot is totally unnecessary. I suggest using File:Symptoms-vomiting.jpg (suggested by WAID in the previous discussion) or maybe a generic picture of a showerhead such as File:High_speed_shower_filtered.jpg if an image is needed. (I'm not big on using any picture with a real person in it because of the BLP concerns involved with putting someone's photo on an article about drug use). SpicyMilkBoy (talk) 22:11, 21 January 2020 (UTC)
 * And if the vomiting image is too graphic, there's also File:Symptoms-stomach-pain.jpg, which could be used to illustrate nausea. SpicyMilkBoy (talk) 22:25, 21 January 2020 (UTC)
 * Abdominal pain however is much less specific than hot showering. Doc James  (talk · contribs · email) 12:53, 25 January 2020 (UTC)


 * yes the image is okOzzie10aaaa (talk) 12:24, 22 January 2020 (UTC)
 * Clear no I agree that the "ass shot" is unnessesary. Not showing the face of a naked person is one of the characteristics of sexual objectification, something we should avoid. Two pointers to the MoS on why this image shouldn't be included as lead image: (A) Manual_of_Style/Images: Avoid images that contain irrelevant or extraneous elements that might seem offensive or harassing to readers and per MOS:LEADIMAGE (emphasis mine): they should not only illustrate the topic specifically, but also be the type of image used for similar purposes in high-quality reference works. Femke Nijsse (talk) 17:56, 22 January 2020 (UTC)
 * It is ironic to both admonish against "sexual objectification" while simultaneously summarizing the piece as an "ass shot." Is Weibliche_brust_en.jpg on the front page of "breast" an example of sexual objectification as well, then? The painting in question does not strike me as offensive. I would also echo MOS:IMAGES regarding intangible concepts, quoted above.― Bio chemistry 🙴 ❤   22:05, 25 January 2020 (UTC)
 * Per MOS:IMAGE, lead images should...be the type of image used for similar purposes in high-quality reference work and should be of least shock value; an alternative image that accurately represents the topic without shock value should always be preferred. If I go to the Breast article, I can reasonably expect to see pictures of breasts. If I go to the article on cannabinoid hyperemesis syndrome I'm not going to expect to see someone's amateur watercolor painting of a nude woman. Would you expect to see that sort of image in the Britannica or on the CDC website? This is the sort of thing that makes people take Wikipedia less seriously. SpicyMilkBoy (talk) 12:38, 26 January 2020 (UTC)
 * Agree with SpicyMilkBoy 100% on this point. GorillaWarfare (talk) 23:57, 26 January 2020 (UTC)
 * While I would cede a lack of expertise in evaluating the amateurishness of the art in question, I hardly see the "shock" value in it. Given that hot showering is practically pathognomonic for CHS, I think it is quite reasonable to expect to see an image of this key symptom on the page. If one is unfamiliar with the condition, perhaps it is "shocking" to learn of the aforementioned association. If we can agree on the appropriateness of the subject, we can direct our attention to finding a better representation of it. ― Bio chemistry 🙴 ❤   01:20, 29 January 2020 (UTC)


 * Yes, because I don't see a good reason not to. It's loads better that the previous image, which can be seen further up this page. In response to GW's who is presumably not suffering from cannabinoid hyperemesis syndrome, relief of symptoms from a hot shower is nearly pathognomonic of this condition. Having this image on probably any other medical article other than perhaps dry skin, would be pointless, but here it does illustrate something. Natureium (talk) 00:51, 25 January 2020 (UTC)
 * Yes, as the image represents an artistic rendition of the hot showers that are so characteristic of cannabinoid hyperemesis syndrome. I fail to see how it could be taken as provocative.― Bio chemistry 🙴 ❤   22:05, 25 January 2020 (UTC)
 * No. Nor should "File:Steamy shower.jpg" or any other hot shower picture not specific to Cannabinoid hyperemesis syndrome be used. The article should employ artwork, or photos, displaying (mock or real) those who suffer from Cannabinoid hyperemesis syndrome. A generic hot shower photo is WP:SYNTH and WP:OR in relation to the appropriate depiction of those who suffer from this malady.Eostrix (talk) 09:13, 28 January 2020 (UTC)
 * No. It is not easy to find any illustration to such a vague subject, but I don't agree with this compulsive illustrating at all and any cost. A generic person showering or for my sake a vomiting one or someone sitting in the doctor's waiting room is simply not relevant. If the peace of your mind requests you to put any illustration at all, then put please someone smoking a joint or the picture of a chillum or a bar of Lebanese Gold or yes, a video of some real patient wildly scratching themselves. 2003:F5:6F0E:7200:3461:3461:C6F3:C7C7 (talk) 12:29, 16 February 2020 (UTC) Marco Pagliero Berlin

Discussion
This image is not as good IMO as it does not show the heat of the shower. Doc James (talk · contribs · email) 12:37, 26 January 2020 (UTC)
 * It also seems to me like we're suggesting that the Senator is experiencing CHS. This article isn't just about showering. Natureium (talk) 21:07, 26 January 2020 (UTC)
 * Is the woman in the watercolor experiencing CHS? GorillaWarfare (talk) 23:19, 26 January 2020 (UTC)
 * The women in the watercolor is an illustration, not a real person. The senator died years ago, and I hadn't heard of him before seeing that picture, but that doesn't mean we should use photos of a public figure to illustrate medical conditions. Natureium (talk) 23:46, 26 January 2020 (UTC)
 * I happen to agree we shouldn't use an image of a real, identifiable person for this article. But your argument about him not suffering from CHS would seem to also mean we should not use the watercolor. GorillaWarfare (talk) 23:56, 26 January 2020 (UTC)
 * I agree with removing an identifiable person (unless perhaps we find a public person who has the condition). We're trying to express a concept that is largely intangible, so I'll argue the water color image is not exclusionary. Although I don't see how, since some editors find it objectionable, we should keep looking for another image. MartinezMD (talk) 00:12, 27 January 2020 (UTC)

Edit war
I am not going to continue the edit war happening on the page by undoing the latest edit, but I agree with MartinezMD that the image should be removed pending consensus. The discussion from June above at did not, as has been claimed, end with a consensus to change the image to the showering woman. GorillaWarfare (talk) 00:29, 27 January 2020 (UTC)
 * The current image has been in place for a significant period of time. The best thing to do would be to suggest alternative images. Doc James  (talk · contribs · email) 00:43, 27 January 2020 (UTC)
 * But it is false to imply that it was a consensus result from the previous discussion. For what it's worth, I think the latest image is a good alternative. No butts, not an identifiable person. GorillaWarfare (talk) 00:58, 27 January 2020 (UTC)
 * Yah, it is reasonable. And has the benefit of being of the more commonly affected sex. Doc James  (talk · contribs · email) 01:40, 27 January 2020 (UTC)
 * I think this image is a good choice. And I disagree with the argument that a picture of someone showering is not relevant. It's not a specific illustration of the disease, no, but it's useful as a mnemonic device for one of the characteristic symptoms. SpicyMilkBoy (talk) 13:39, 27 January 2020 (UTC)
 * A photo of a person in a shower on this article is about as relevant as it would be on water. Praxidicae (talk) 01:37, 27 January 2020 (UTC)
 * Just as relevant as the dozens of picture of water at water yes. Doc James  (talk · contribs · email) 02:22, 2 February 2020 (UTC)

Alternatives
I was thinking about what may help address some of the feedback given above. In an effort to address the critique that the previous image contains "shock value" due to the portrayal of a woman's behind, and to address the critique that the previous piece is amateurish, I present the following: |"Head I" by Peter Churcher. As this work is copyrighted, I have briefly discussed the option of including the image on Wikipedia with the artist, whom would be amenable to it should we so choose it. While this is still a portrayal of showering, which is unlikely to satisfy those for which nothing less than a portrayal of someone with documented CHS vomiting under a hot shower whilst holding a blunt will suffice, I think that it may otherwise be a viable alternative. Any thoughts? ― Bio chemistry 🙴 ❤   15:01, 6 February 2020 (UTC)
 * Would be nice if the image had a bit more "steam" in it, as the hot part is needed. Doc James  (talk · contribs · email) 05:14, 15 February 2020 (UTC)
 * I think it would be excellent –Esponenziale (talk) 14:36, 23 March 2020 (UTC)

Weekly use
Everything I've seen on this indicates it takes multiples uses per day to trigger the syndrome... not weekly use. I couldn't find any support for the weekly thing, so just raising it as an issue here. — Preceding unsigned comment added by 24.17.192.70 (talk) 15:50, 10 December 2017 (UTC)
 * https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5330965/ Sandy Georgia  (Talk)  04:01, 27 March 2018 (UTC)

This vagueness is typical of invented scare stories. It comes from ignorance of the reality of cannabis effects, supposed dangers many times recycled and never backed up with science fact, stabs in the dark in effect, and based on the principal that if a lot of mud is slung some will stick. There simply is no scientific link with cannabis use. I have used cannabis for sixty years and have never experienced any vomiting associated with it. My daily use would according to this nonsense, qualify me for it, yet nothing. Scientists would be interested in discovering why some and not others. They would examine how so-called sufferers of this syndrome differed from the millions of other regular users who don't. And now in 2021 with masses more users in the medical field across the world, including small children, one would expect facts to have emerged, if only as guidelines to consumption. Interestingly, there are many on Youtube claiming to have stopped using cannabis because of it, exactly what disinformation is aimed at achieving PetePassword (talk) 08:14, 7 June 2021 (UTC)

What is the point of this page?
An imagined 'syndrome' that doesn't appear in mainstream literature, but which the writer of this page has two references that claim, without any proof it seems to me, that it exists. There appears to be little actual factual information, is it talking about pregnancy? Or is it claiming cannabis causes cyclic vomiting in any user? Over fifty plus years I have never heard of anyone experiencing this, and I have known thousands of cannabis users, including myself. This reads like yet another gobbet of misinformation,regularly spewed out with no proof, but they all help create a sense of 'medical problems with cannabis' among those with no personal experience, who are presumably using Wikipedia for information. This page should be scrapped until such time as the author finds something to back up an unsubstantiated allegation. Unless no one is concerned that Wikiedia is being used to push misinformation on a subject that is currently high profile and disputed. I constantly find insinuations like this with no proof, coincidental presence of cannabis attributed to causation of a range of effects, again with no science behind them, and a partisan and uncritical attitude by those who should know better, who have higher standards on all other subject matter. Since cannabis is an anti-emetic, the claim it induces vomiting really MUST have some scientific proof if not to be regarded as propaganda. PetePassword (talk) 09:37, 12 March 2015 (UTC)


 * You don't set the standard so you don't have to be convinced. There are multiple sources on this.  Even High Times, probably one of the biggest advocates of cannabis use, gives it credibility and lists the sources it considers in their article. You could improve the article by doing a literature search and adding those references.MartinezMD (talk) 17:08, 12 March 2015 (UTC)


 * Who does 'set the standard'? I have yet to see any actual scientific evidence this is not part of the organised and funded anti-cannabis campaign that has existed since Reefer Madness and Anslinger's racist diatribe that convinced US politicians that cannabis was evil. If this has been around since the 1990s, and it's now 2021, some actual evidence would surely have surfaced showing the causative pathway, no such evidence has come to light. With all the money pharmaceuticals make and stand to lose to use of medicinal cannabis, one of them would surely have funded a real science study to show how cannabis use causes something so inexplicable. Having failed miserably to link cannabis use to schizophrenia [despite a massive rise in cannabis use over the past 60 plus years schizophrenia incidence has remained totally static, indicating a genetic factor], it seems the anti-cannabis lobby has now created this scare story and is pushing it on Youtube where, of course, all real researchers go to publish their results. The evidence appears to be; vomiting and stomach pain IF also associated with cannabis use, is caused by cannabis use. Hardly worthy of a peer reviewed paper published by a reputable science publisher.

If it were real some science would have been directed at it to discover the pathway; what represents heavy use, what type of cannabis is associated with it - plain organic weed, industrial-scale cannabis, THC capsules, fake THC capsules, contaminated products etc. Based on hearsay, there appear to be a lot of people swearing off capsules, which might be a productive area of research. But none has been done. We are left to association, and that simply isn't science but bigotry. This has all the hallmarks of a disinformation campaign, with heavy use of cross references between disseminators who are clearly anti-cannabis. If they were genuine they would at least have pinpointed the use of cannabis for thousands of years without one reference to vomiting other than as a treatment FOR it, yet suddenly, in America, it has appeared and been accepted by a number of medical professionals, many of whom are shills of big pharma. I've heard the supposed 'more potent cannabis available now' as an explanation by an alleged 'doctor' who was unaware that there has been no change in cannabis potency, and cannabis in the 60's wasn't mild and thus no match with 'skunk' which the ignorant have latched on to as the big threat, not understanding that it's simply one among hundreds of cultivars created by expert plant breeders, not understood that cannabis users don't consume fixed amounts which are subject to quality changes, but adjust consumption reletive to the potency, just as a beer drinker used to downing pints wouldn't down a pint of whisky in the same manner. Having seen the whole gamut of ignorance and disinformation spewed out over decades, I can spot the fakes from a distance, and this is one of them. This page is a disgrace to Wikipedia, it confirms what many who don't trust Wikipedia believe, that it is too easily used to propagate untruths. It isn't up to me to produce evidence, it is for those claiming this is real to produce real proof and not these vapid suggestions and assumptions. None of the quoted 'papers' do this, as usual, they depend on each other for quotes, make unfocused claims and make unfounded insinuations. Someone needs to go read a definition of science and the scientific method. A recent attempt in the UK to link cannabis with schizophrenia used a small sample of inner-city youth filling in questionaires. On the basis of their answers, the psychiatrists running this 'survey' claimed cannabis caused schizophrenia, until I pointed out to the lead researcher the difference between cannabis use which has grown massively and schizophrenia which hadn't. He abandoned his position anc called for cannabis to be legalised. The tabloids had already reported his 'findings' as fact of course. Too many people think psychiatrists are scientists. PetePassword (talk) 08:02, 7 June 2021 (UTC)
 * Wikipedia sets its own standards. You can read about it at WP:V, WP:RS, and WP:MEDRS applies especially in a medical article. Also, read WP:NOTAFORUM. MartinezMD (talk) 14:37, 7 June 2021 (UTC)


 * High Times uses the same sources, so that isn't meaningful. Looking into the references, the main one describes 9 patients. The other describes 4 patients. The reason this isn't controversial, IMO, is that so few doctors have even heard of it! ;) There is a bunch of medical publications on it, but they all refer to those same 2 original sources, and mostly are just speculating about possible causes. There aren't any real studies. Obviously, it has citations so it is appropriate for wikipedia, but perhaps it should be described as a proposed syndrome rather than just as fact, as the citations describe it uncritically but don't actually claim that it is well established.76.105.216.34 (talk) 02:06, 7 April 2016 (UTC)

Additional information
Given how long cannabis has been consumed throughout human history it is interesting this disease occurs now. Maybe it existed before but was not described, which is unlikely. More to the point, it is found where cultivation is legal. Most, if not all commercial marijuana producers use a lot of artificial and highly toxic fertilizers in order to increase yield and potency. It is well known that those plants need so called "flushing" which means running copius amounts of water through the plant and soil in order to get rid of toxic elements. Did any study examine this? Brtbng (talk) 18:10, 17 August 2021 (UTC)

2020 CHS articles found by Google Scholar
Out of curiosity I checked Google Scholar for 2020 articles. There are a lot of articles:
 * https://scholar.google.com/scholar?as_ylo=2020&q=Cannabinoid+hyperemesis+syndrome

I hadn't looked since Feb 2020 when I last commented on this talk page. Then Covid-19 broke out, and I was busy with other stuff.

A lot of 2019 articles too: --Timeshifter (talk) 07:18, 30 August 2020 (UTC)
 * https://scholar.google.com/scholar?as_ylo=2019&q=Cannabinoid+hyperemesis+syndrome

2021 CHS articles found by Google Scholar
I checked Google Scholar for 2021 articles. There are a lot of articles:
 * https://scholar.google.com/scholar?as_ylo=2021&q=cannabinoid+hyperemesis+syndrome

Here is a recent 2021 medical media article:
 * https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2784270

Non-medical media on that study, and more: From that article (emphasis added): --Timeshifter (talk) 09:37, 18 September 2021 (UTC)
 * https://theberkshireedge.com/cannabinoid-hyperemesis-syndrome-when-cannabis-causes-the-pain

October 13 Reversion
Can you provide a valid Wikipedia-guideline based reason for your Oct 13 reversions of the changes by 2601:244:4e02:cc00:6965:b95b:6ef8:9b18? I have not looked at the original source material, but they appear to be useful, factually based changes based on the source. See WP:Reverting. Finney1234 (talk) 14:24, 10 November 2021 (UTC)


 * OK, looking at the Lu article that the changes supposedly referenced, I can see that it was not a good factual and reference-based change. However, it appears to be a "good-faith" edit (not vandalism), so I would like to suggest (in the future) posting a reason for reversions/rollbacks of this sort (again, WP:Reverting).


 * Interesting: it's an issue I'd never heard of! Finney1234 (talk) 16:13, 10 November 2021 (UTC)

Frequency
I did what I believe is a reasonable edit to the "Epidemiology" section before noting the extended discussion above, but I believe the change is valid (added "emergency room", because it's relevant and important, and did a little clarification on the mostly accurate section). I believe the speculative "frequency" number in the info box should also be removed, but I stopped after I noticed the controversy (I tried changing it to "hypothesized frequency", but that doesn't work). The following was my planned description for that change.

Remove frequency from the info box. This is a speculative number based on a single primary study of emergency room patients, and even the author states "*if* this is extractable...". As such, this doesn't belong in a factual info box; the discussion in "Epidemiology" is sufficient.

Comments? Finney1234 (talk) 16:57, 10 November 2021 (UTC)


 * I suggest leaving the infobox section title: "Frequency". But remove the number since it is speculative, poorly supported, and requires context. Leave this in the infobox:
 * See Epidemiology section.
 * "Epidemiology" would remain as a link.
 * --Timeshifter (talk) 03:07, 11 November 2021 (UTC)

Very questionable 2.7 million number
Reefer Madness?

-- Timeshifter (talk) 22:05, 13 November 2019 (UTC)
 * ‘It’s honestly hell.’ Hospitals see rare vomiting syndrome in heavy marijuana consumers. By Naomi Martin, Globe Staff, November 11, 2019. Boston Globe. From the article, emphasis added:


 * I highlighted the last sentence in the above quote. -- Timeshifter (talk) 11:33, 20 November 2019 (UTC)

The 2016 systematic review does not mention this 2.7 million number, or any overall yearly US estimate. I read the article:

Here is the full-text source for the idiotic 2.7 million number:
 * The Prevalence of Cannabinoid Hyperemesis Syndrome Among Regular Marijuana Smokers in an Urban Public Hospital. By Joseph Habboushe, Ada Rubin, Haoming Liu, Robert S. Hoffman. 12 January 2018. https://doi.org/10.1111/bcpt.12962

If this is the state-of-the-art of math understanding among medical researchers and writers, then it helps explain the amount of crap info in medical articles on Wikipedia. And it is not a review article.

If I have to break it down further to those reading this, then you are not qualified to be writing the math-related sections of Wikipedia medical articles. -- Timeshifter (talk) 02:50, 15 February 2020 (UTC)


 * Who are you trying to insult? The whole point of requiring sources is for them to be checked by the interested reader. If some editor made an error, change it. MartinezMD (talk) 03:19, 15 February 2020 (UTC)


 * I rarely edit medical articles on Wikipedia, except to add drug overdose charts and tables. WP:MEDRS rules and their enforcement seem to operate in a separate universe from the rest of Wikipedia. I often go elsewhere to look up info on medical stuff. So rather than fight all the WP:MEDRS trolls by editing their articles, I just make suggestions based on standard Wikipedia guidelines and rules. I notice that months or years later my suggestions often get implemented after the medical orthodoxy and reviews are shown to be wrong. Some day Wikipedia's WP:MEDRS rules may even allow the acknowledgement in Wikipedia articles that an organic diet is healthier. I haven't checked in awhile though. Maybe it has happened already. I digress. -- Timeshifter (talk) 03:45, 15 February 2020 (UTC)


 * MEDRS or just RS, either would apply here. The source doesn't support the statement. It would have taken a lot less work on your part to just make a simple correction. I'll do it for you if you find it difficult. MartinezMD (talk) 04:59, 15 February 2020 (UTC)

User:MartinezMD The source is a review article in the BMJ https://pubmed.ncbi.nlm.nih.gov/31324702-cannabinoid-hyperemesis-syndrome/

And it says quote "Extrapolating those results to the population of the United States, it is estimated that 2.1-3.3 million people might suffer from CHS annually"

No one was quoting the Boston Globe. Doc James (talk · contribs · email) 05:18, 15 February 2020 (UTC)


 * I, and nobody else, said that the original reference in this Wikipedia article was the Boston Globe article mentioned higher up. The popular press articles passing on that idiotic number either mention no reference, or go back to this 2018 article that I mentioned higher up:
 * The Prevalence of Cannabinoid Hyperemesis Syndrome Among Regular Marijuana Smokers in an Urban Public Hospital. By Joseph Habboushe, Ada Rubin, Haoming Liu, Robert S. Hoffman. 12 January 2018. https://doi.org/10.1111/bcpt.12962
 * That is where the math ignorance started as far as I can tell.


 * The July 2019 BMJ article is hidden behind a paywall. Please quote all their calculations here. Nothing I have read in the other review article, nor in the 2018 article with the original poor estimate justifies those numbers.


 * I have been adding and editing charts, graphs, tables, and maps to Wikipedia and the Commons since 2005. People are just bad at math. It is common for writers and researchers to pass on incorrect math, or conclusions based on incorrect math. If the BMJ is using the same logic, then we should be able to see it very easily. And we are allowed, even required, to use simple math logic to determine if something should be passed on into a Wikipedia article.


 * Here is a Google Search:
 * https://www.google.com/search?client=firefox-b-1-d&q=2.7+million+people+cannabis+hyperemesis
 * Articles blindly pass on that 2.7 million number, but most don't reference it. The New York Times article references it to that Jan 12, 2018 article I linked above. Google's first result is Wikipedia. So Wikipedia shouldn't be passing on bad math. -- Timeshifter (talk) 15:10, 15 February 2020 (UTC)

(unindent). WP:NPOV requires all significant points of view. Also, we are not talking about the actual medical condition here. We are talking about the numbers. So WP:RS also applies. Not just WP:MEDRS.

So, or anyone else, please supply the full context for the numbers: "2.1-3.3 million people might suffer from CHS annually". Please quote the full text related to those numbers in the BMJ article. It is behind a paywall, and so I can not do it. Quote it here on the talk page. Here is the BMJ article:

Then in the article we can paraphrase or quote BMJ's logic (or lack thereof). This will explain their logic to the readers here. Then the reader can come to their own conclusion about those numbers. That is the WP:NPOV way everywhere else on Wikipedia.

Also, since we are talking numbers and since WP:RS applies, then we can quote doctors questioning that number. For example;


 * ‘It’s honestly hell.’ Hospitals see rare vomiting syndrome in heavy marijuana consumers. By Naomi Martin, Globe Staff, November 11, 2019. Boston Globe. From the article, emphasis added:

Wikipedia is not another branch of government drug war propaganda, nor a tool of any one group of doctors and researchers writing a review article. The other review article did not come up with such numbers. That should be mentioned too.

And finally, WP:NPOV requires that we not use Wikipedia's narrative voice to declare that number as a fact. The infobox is a poor place to put that number, since there is no context there, and no significant dissenting opinion as required by WP:NPOV.

Even BMJ uses the word "might". BMJ quote: "2.1-3.3 million people might suffer from CHS annually". -- Timeshifter (talk) 12:14, 17 February 2020 (UTC)


 * I'll try to pull the article this week. I'm not impressed with a single source extrapolating an estimate this large. MartinezMD (talk) 15:30, 17 February 2020 (UTC)
 * We say "though one estimate puts the number at about 2.7 million people in the United States a year."
 * For an estimate that is a fairly small range. I see cases frequently. The number seems fair. Being quotes in the Boston Globe does not make it a RS for this purpose. Doc James  (talk · contribs · email) 16:52, 17 February 2020 (UTC)
 * I see cases too, but this estimate comes across more as speculation. It's using a survey of 155 people, which is already weak data, and generalizes that to millions? It makes me think it's undue weight so I wonder if it should be included at all. I'll read the article this week and finalize my thoughts on it.MartinezMD (talk) 17:48, 17 February 2020 (UTC)

Full text
"Evidence from a US retrospective study including 1571 patients showed that CHS affects up to 6% of patients consulting for recurrent vomiting in emergency departments.3 Moreover, among regular cannabis smokers, about one third of them reports hot showers or baths as a means to relieve nausea and/or vomiting.10 Extrapolating those results to the population of the United States, it is estimated that 2.1-3.3 million people might suffer from CHS annually.10 In Colorado, which legalised cannabis in 2009, visits to emergency departments for cyclic vomiting doubled after legalisation.11 An estimated 182 million people worldwide were cannabis consumers in 2013, increasing to 192 million in 2016,12 13 therefore CHS may represent an important diagnosis to consider in any patient consulting for recurrent vomiting." Doc James (talk · contribs · email) 16:56, 17 February 2020 (UTC)


 * On first impression, it sounds like they are making the same mistake that the other study mentioned above made to get their estimate:
 * The Prevalence of Cannabinoid Hyperemesis Syndrome Among Regular Marijuana Smokers in an Urban Public Hospital. By Joseph Habboushe, Ada Rubin, Haoming Liu, Robert S. Hoffman. 12 January 2018. https://doi.org/10.1111/bcpt.12962


 * But I am not sure because the part you quoted does not say exactly how they extrapolated. What is the retrospective study they are using for their numbers? Maybe that has the full text online for free, and I can go read it, and try to figure out their calculations. I am a math geek. I could dig up my GRE test results. Numbers in studies are often questioned. Take a look at the arguments over the numbers and extrapolation methods used in the Lancet studies, and in other casualty estimates, mentioned in Casualties of the Iraq War. I am a longtime editor of that article. The estimates have a wide confidence interval.


 * From the quote: "Moreover, among regular cannabis smokers, about one third of them reports hot showers or baths as a means to relieve nausea and/or vomiting." Are they talking about regular cannabis smokers that presented to an emergency department? If so, then they can't use that to extrapolate to all regular cannabis smokers. Was there some kind of local, regional, or national study that asked regular cannabis smokers (not just the ones presenting at hospitals) if they used hot showers or baths as a means to relieve nausea and/or vomiting? I have never heard of such a study.


 * I did a Google search for cannabis hyperemesis US retrospective study including 1571 patients.
 * This looks like the original article linked below. "Of 1571 patients identified, 98 patients (6%) met inclusion criteria."
 * Mayo Clin Proc. 2012 Feb; 87(2): 114–119. Cannabinoid Hyperemesis: A Case Series of 98 Patients. Douglas A. Simonetto,a Amy S. Oxentenko,b Margot L. Herman,a and Jason H. Szostekc. doi: 10.1016/j.mayocp.2011.10.005 PMCID: PMC3538402 PMID: 22305024
 * But it does not make an estimate of a yearly nationwide number.


 * The Wikipedia article currently says this:
 * "A 2018 surveyed of 155 heavy cannabis users in hospital found 51 of them experienced cannabinoid hyperemesis syndrome. This ratio was used to estimate that in the United States, 2.7 million out of 8.3 million heavy cannabis users should be experiencing the syndrome."
 * It references that 2019 BMJ article. But I don't see that in the full text copied here so far. What is the Wikipedia article referencing exactly from the BMJ article? --Timeshifter (talk) 11:02, 20 February 2020 (UTC)


 * Just got the article. It, in turn, is referencing other articles for these figures. The BMJ got it's information from a Basic & Clinical Pharmacology & Toxicology article in which 189 of 344 eligible people refused to participate in the survey. The estimate that 6% of users with recurring vomiting may have the condition seems a bit more robust. It comes from a Mayo article  reviewing 5 years worth of ER visits (1572 people) for unexplained vomiting, with 98 of them (6%) being long-term regular marijuana users. It is not "the same study" as is currently written in our article; it is from 2 different studies being summarized in a third. I think we should make a basic correction in phrasing and reduce the emphasis of the survey in the article while waiting better public health data. MartinezMD (talk) 19:24, 24 February 2020 (UTC)
 * What wording do you suggest User:MartinezMD? Doc James  (talk · contribs · email) 20:55, 26 February 2020 (UTC)


 * I might do something like this, but I'll leave it up to a consensus position. The correction of which study is which is a minimal requirement.


 * "The number of people affected is unclear. A 2018 review of the topic found that one third of 155 heavy cannabis users surveyed in hospital experienced CHS.[1][21] Another study in the same review found that of those who go to the emergency department in the United States with unexplained recurrent vomiting, about 6% have the condition.[1][insert Mayo article here] It has been reported more frequently in people that use cannabis daily (47.9% of patients) and greater than daily (23.7% of patients), compared to once weekly users (19.4% of patients) and less frequent users (2.4% of patients).[3] A significant increase in the incidence of CHS (and other marijuana-related visits to the emergency department) has been noted in U.S. states that have legalized marijuana, with the incidence of cyclic vomiting prominently doubling in the US state of Colorado after legalization.[19] As the use of marijuana continues to be legalized at the state level, the prevalence of CHS is expected to increase in the US.[3]


 * In 2018 a 17 year old died of the condition.[22]" MartinezMD (talk) 22:31, 26 February 2020 (UTC)

(unindent). I compiled all the known references and what they had to say in the table below with the red border. I will add more references and quotes as we find them. Please let me handle the editing of this red box. Feel free to start your own. I am not trying to spin anything. I am not emphasizing anything in the quotes in the red box.

The 12 Jan 2018 article can not be used as a reference for claiming that there are 2.13–3.38 million Americans suffering annually from CHS. They don't say that. They say "If this is extractable to the general population".

It obviously is not extractable to the general population, because they did not interview cannabis smokers who did not present themselves to an emergency department.

If you are going to mention those numbers in the Wikipedia article at all, then it must be presented accurately, and the full context explained concerning the survey population being people that presented to an emergency department.

And for a reality check I googled the [https://www.google.com/search?client=firefox-b-1-d&q=total+emergency+department+visits+in+a+year+in+the+US. total emergency department visits in a year in the US].


 * FastStats - Emergency Department Visits. National Center for Health Statistics. "Number of visits: 145.6 million".

2.75 million divided by 145.6 million equals 1.9%. Are you or others seeing 2% of ER patients with vomiting relieved by hot showers and/or experienced by regular cannabis users?

By the way, I respect the work you guys do under such high stress. My mother (now passed) was a charge nurse, and mentioned how things were becoming even more stressful due to the corporatization of medicine everywhere. Hopefully, we can get single-payer healthcare in the US, and everyone will be filling out less paperwork, and have more time. More time for Wikipedia, too. --Timeshifter (talk) 12:39, 27 February 2020 (UTC)


 * To play devil's advocate, the current wording is clear that it's an estimate. "This ratio was used to estimate..." and "...should be experiencing the syndrome" But if you read my proposed wording above, it eliminates their estimate as I agree the figures are just too speculative, especially since nearly half the people who actually met inclusion criteria didn't participate, which can wildly skew the results (potentially reducing them in half). MartinezMD (talk) 15:45, 27 February 2020 (UTC)


 * After carefully reading the 2018 article again, I see that I made some errors, and I realized that I was not focusing on the most egregious flaw in the study. They basically found a pool of 155 heavier users of cannabis. That pool was NOT from those who presented to the emergency department with vomiting.


 * Then if any of those 155 users said they liked hot showers when they are sick then they were classified with CHS. I like hot showers when I am sick enough to vomit. Or anytime I am sick. Vomiting is a very rare event for me in my lifetime. I also rarely use cannabis nowadays. I was never a heavy user.


 * "Respondents were also asked to rate eleven methods for relieving past nausea/vomiting on a ten‐point Likert scale (one being ‘not helpful at all’ and 10 being ‘the most helpful’). These relief methods included: hot showers, cold showers, fresh air, antiemetic medications, smoking marijuana, abstaining from smoking marijuana (taking a break from it), turning up the heat (increasing ambient temperature), eating, drinking water, smoking cigarettes and sleeping/napping."


 * I emphasized what I like when I am sick. I am sure many others like what I like too.


 * So basically the study says that people who get sick and use cannabis and like hot showers must have some mild form of CHS.


 * To your question, I think this is incorrect in your proposed wording: "A 2018 review of the topic found that one third of 155 heavy cannabis users surveyed in hospital experienced CHS."


 * Their survey did not prove that those 155 heavy cannabis users had CHS. Not even a mild version of CHS. It just proved that sick people like hot showers. Those heavy cannabis users were not coming to the hospital because of vomiting. So there was no way that anybody could know whether they ever had CHS. They weren't examined for that.


 * They may have only experienced nausea or vomiting a few times in their lives, or the past year. But if they happened to like hot showers when they are nauseous then they are assumed (according to this study) to have CHS, or mild CHS. Heavy cannabis users are sometimes binge drinkers too. They will have nausea too. I bet many of them like hot showers afterward to clean themselves up, and to sweat out the toxins. It's a very poor study on so many levels.


 * The 2012 study basically says that over 5 years at one emergency department they came up with 98 patients with unexplained vomiting who were heavy marijuana users. 52 of these patients reported relief of symptoms with hot showers or baths.


 * That is around 20 patients a year. I think there are around 5000 emergency rooms in the US? That comes to around 100,000 people a year with unexplained vomiting who are heavy marijuana users. Half of those get relief with hot showers or baths.


 * I don't know if the emergency department used in the study is representative, or busier than, or less busy than, other emergency departments.


 * "The system gathers data from a sample of about 100 of the nation’s 5,000 or so hospital emergency departments, ..." - Quote is from:
 * Hospital emergency rooms see boom in patients around the Fourth of July. By Drew DeSilver. July 3, 2019. Pew Research Center.
 * --Timeshifter (talk) 06:17, 28 February 2020 (UTC)


 * And now you might see why I don't like using survey studies, especially small ones lol. Also, my phrasing is just a proposed revision of what is currently in the article. It likely needs further editing. I just figured it would be an improvement over what we have now. I'll be out of town for a few days starting tomorrow and will check in after I return. MartinezMD (talk) 14:30, 28 February 2020 (UTC)

2.7 million yearly. No studies show that many people are experiencing CHS yearly
Well, we have had a minor interruption (Covid-19 pandemic), but this sentence in this Wikipedia article is still not put in the correct context:

At the very minimum, the word "should" ought to be changed to "might". And some sentence should be added like: "But there are no studies that show that number actually are experiencing the syndrome yearly."

As I pointed out higher up the 2012 study showed 98 patients in a US hospital emergency department over 5 years. Doing the math for 5000 hospitals equals around 100,000 people a year with unexplained vomiting who are heavy marijuana users. We are allowed to do simple math in Wikipedia articles.

We have no studies showing the gradation of cannabis use and when the syndrome kicks in. So the 2.7 million number is purely speculative. And legal medical and adult-use states are getting stricter and stricter concerning additives and contaminants too. Because we now know much more about the harm those additives cause. In both cannabis products and e-cigarettes. --Timeshifter (talk) 07:00, 29 August 2020 (UTC)


 * I have a problem including the number or anything having to do with that weak survey study at all. See my prior comments. This is not an estimate we should be including in the article imho. MartinezMD (talk) 15:19, 29 August 2020 (UTC)


 * I agree. The numbers are still relatively small in this 2020 article:
 * LO48: Pediatric cannabinoid hyperemesis syndrome in the emergency department: a 5-year retrospective review. Canadian Journal of Emergency Medicine. . Published online by Cambridge University Press: 13 May 2020. Article quotes with emphasis added:
 * {| class=wikitable


 * A retrospective chart review was conducted of pediatric patients (12-17 years) with suspected CHS presenting to one of two tertiary-care EDs; one pediatric and one pediatric/adult (combined annual pediatric census 40,550) between April 2014-March 2019. ... Results: 242 patients met criteria for review. 39 were identified as having a confirmed or likely diagnosis of CHS
 * }


 * We are talking dozens of cases of "confirmed or likely diagnosis of CHS" in a 5 year period for that age group at 2 emergency departments. Let's say we double or quadruple the number for all age groups. 39 times 4 = 156. That comes to 16 CHS patients in each ED per year. Those are similar numbers to the 2012 study. Doing the math for 5000 EDs in the US equals 80,000 per year in the US.
 * The fact is that we don't have good overall numbers. We should only be reporting the numbers we have for emergency departments. We should say that we don't have studies showing gradation of symptoms. Or if there are gradations, or how steep those gradations are. We just don't know. From what I read it seems specific to the person. Some people only get relief by completely stopping. Some people get relief by using cannabis grown without fertilizers, pesticides, etc.. --Timeshifter (talk) 08:01, 30 August 2020 (UTC)


 * Biggest issue is that these are WP:Primary studies and not in accordance with WP:MEDRS to make generalizations. If we want to include them as examples of epidemiologic reasons, they should only report the numbers, not the extrapolations. MartinezMD (talk) 18:52, 30 August 2020 (UTC)
 * I agree. --Timeshifter (talk) 16:06, 31 August 2020 (UTC)

Article with nationwide stats: 13.3 per 100,000 ED visits. Equals 19,000 per year

 * Full text with charts: Emergency Department Burden of Nausea and Vomiting Associated with Cannabis Use Disorder: U.S. Trends from 2006 to 2013. From Journal of Clinical Gastroenterology. J Clin Gastroenterol. 2018 Oct; 52(9): 778–783. doi: 10.1097/MCG.0000000000000944 PMCID: PMC5930153 NIHMSID: NIHMS906217 PMID: 29095419

From the article:

Lots of caveats in the article that could make the number both higher and lower. The increase in legal states since 2013 logically implies a higher number. A lower number indicated by: "Finally, it is possible that the increase is confounded with increasing rates of opioid use given its association with nausea and vomiting." A plateauing number possibly now that more and more people believe the condition is real, and they have to abstain if they have a problem.

Doing the math:
 * The Big Number: 145.6 million patients a year go to hospital ERs. April 15, 2019. Washington Post.

1456 times 13.3 equals 19,365.

If you keep the 2.7 million number in the article also, it needs to be removed from the infobox. This way its calculation can also be explained. And people can make up their own minds as to its validity. Per WP:NPOV and WP:Undue. --Timeshifter (talk) 01:14, 4 February 2021 (UTC)


 * I went ahead and made an attempt to add the new info to the article:
 * {| class=wikitable


 * Of those who went to the emergency department (ED) with recurrent vomiting in one institution in the United States from 2005 to 2010, about 6% had the condition. The rate of ED visits in over 950 emergency departments for vomiting with cannabis use disorder from 2006 compared to 2013 increased from 2.3 to 13.3 per 100,000 ED visits.
 * }
 * I cleaned up the new reference a bit:
 * Andrea Bollom, BS, Jasmine Austrie, William Hirsch, BS, Judy Nee, MD, Daniel Friedlander, MD, Johanna Iturrino, MD, Sarah Ballou, Ph.D., and Anthony Lembo, MD. Emergency Department Burden of Nausea and Vomiting Associated with Cannabis Use Disorder: U.S. Trends from 2006 to 2013. (Full text with charts). From Journal of Clinical Gastroenterology. J Clin Gastroenterol. 2018 Oct; 52(9): 778–783. . ..
 * --Timeshifter (talk) 15:03, 24 February 2021 (UTC)


 * I added this to the intro:
 * "With 130 million ED visits a year that 13.3 rate produces 17,290 CHS ED visits per year."
 * See WP:Routine calculations. (130,000,000/100,000) x 13.3 = 17,290. See also: These are not original research
 * Reference:
 * FastStats - Emergency Department Visits. National Center for Health Statistics. CDC.
 * --Timeshifter (talk) 18:42, 7 June 2021 (UTC)

See more discussion on this issue farther down: --Timeshifter (talk) 14:04, 20 November 2021 (UTC)
 * 

2,130,000 to 3,380,000 numbers explained in article
I expanded the info in the Epidemiology section:

Original reference: --Timeshifter (talk) 20:33, 24 February 2021 (UTC)

Phases
I am concerned the "phases" of CHS appear to be attributed to one non-WP:MEDRS source, 24421535, and used to structure the article without attribution which risks being WP:PLAGIARISM. I think for these reasons that source's novel use of phases needs to be removed from the article. Alexbrn (talk) 09:47, 5 December 2021 (UTC)
 * Okay, as you were. Reading 33712244 it seems to have the same staging, so I am less concerned we are mirroring the original thought of one publication. Alexbrn (talk) 15:23, 6 December 2021 (UTC)
 * Is this relevant to the huge "plagiarism" warning you put up in the article? If so, could you clean up the problem and remove the warning? You apparently understand the relevant content now. Finney1234 (talk) 15:33, 6 December 2021 (UTC)
 * No, that looks like an editor (not a regular on this page, and a while ago) copy-pasted diagnostic tables verbatim from copyrighted journal articles directly into Wikipedia. It needs to be investigated using the usual processes. Alexbrn (talk) 15:38, 6 December 2021 (UTC)

2013 Hospital Numbers

 * Note previous discussion: 

User:Timeshifter: The frequency number for 2013 was 13.3 per 100,000, and it changes over different years. The citation for the 130 million visits, based on the reference, appears to be from 2018. If the ER visit data was from 2013, it could be argued to be a valid calculation (although there might be issues with what subset of visits the 13.3 was derived from, and whether it was extensible), but using different years is not valid. Can you explain what I'm missing? Finney1234 (talk) 23:26, 17 November 2021 (UTC)


 * I found Timeshifter's justification of the claim I recently removed (after which they reverted my removal). The claim is:


 * "With 130 million ED visits a year that 13.3 rate in 2013 produced 17,290 CHS ED visits in that year"


 * The justification for this claim, as stated by Timeshifter in this talk page (see above), is as follows:


 * "With 130 million ED visits a year that 13.3 rate produces 17,290 CHS ED visits per year. See WP:Routine calculations. (130,000,000/100,000) x 13.3 = 17,290. See also: These are not original research :--Timeshifter (talk) 18:42, 7 June 2021 (UTC)


 * However, the source/reference for the 130 million number appears to be for the year 2018. Application of a statistic specific to 2013 to data from 2018 is not a WP:Routine calculation, but is a claim that explicitly violates a guideline in the opening paragraph of WP:No Original Research: "(Original research) includes any analysis or synthesis of published material that serves to reach or imply a conclusion not stated by the sources." Unless the emergency room data can be shown to be from 2013, the claim needs to be removed.


 * In fact, even if the ER data *were* from 2013 this would still be an improper "original research" conclusion. Assuming that data from a subset can be expanded to a larger population can be complex and is not simply a "routine calculation" (e.g, see Talk:Cannabinoid_hyperemesis_syndrome directly above). Finney1234 (talk) 14:33, 18 November 2021 (UTC)
 * I found official 2013 numbers from Agency for Healthcare Research and Quality (part of United States Department of Health and Human Services.
 * Long URL after my query for 2013. Not sure this will always work. Click "Accept".
 * Starting point for 2013 query:
 * https://hcupnet.ahrq.gov -
 * Click: "Get Quick Statistics Tables" > Emergency Department > National > 2013 > No > Create Analysis.
 * Number of 2013 ED visits: 134,869,015.
 * See section higher up:
 * .
 * Plug in 2013 number:
 * (134,869,015/100,000) x 13.3 = 17,938.
 * None of this can now be claimed to be original research.
 * --Timeshifter (talk) 16:27, 18 November 2021 (UTC)


 * Timeshifter Thanks. If that is 2013 ER data (something that is not at all clear from a casual look at the provided reference), that improves the claim by about 80%. However, in my opinion it is still "original research". E.g., WP:NOR states "(Original research) includes any analysis or synthesis of published material that serves to reach or imply a conclusion not stated by the sources", which is true here. In addition, These are not original research provides (as an acceptable example) "if given the population and the size of a specific area, then the population density of that area may be included". This is Basic arithmetic, but extrapolating (or extracting :-) ) from a subset to a larger group is not. What subset of emergency rooms provided the 13.3/100,000 numbers? Was it a particular geographical region that might have had a low or high rate of CHS? Were they urban or rural? Did they have a predominance of patients who were low-income rather than high-income? These, and many other factors, could affect the validity of your calculation, and the complexity of the discussion is not "straighforward arithmetic".
 * My own opinion is that the statement I removed is inappropriate "original research", but let's see if anyone else chimes in with an opinion in the next 3 or 4 days (an informal version of WP:Consensus). If no one does, you can do as you wish and I will not do another reversion. Finney1234 (talk) 16:51, 18 November 2021 (UTC)

From talk section higher up:
 * Full text with charts: Emergency Department Burden of Nausea and Vomiting Associated with Cannabis Use Disorder: U.S. Trends from 2006 to 2013. From Journal of Clinical Gastroenterology. J Clin Gastroenterol. 2018 Oct; 52(9): 778–783. doi: 10.1097/MCG.0000000000000944 PMCID: PMC5930153 NIHMSID: NIHMS906217 PMID: 29095419

From the article:

See the part about "weighted to provide national estimates." So I am not doing original research by doing the obvious math. --Timeshifter (talk) 17:07, 18 November 2021 (UTC)


 * Wow, you did a lot of careful detailed research! (semi-:-) ).
 * Cool about "{ {od|:::} }", it's a template I'd never seen before (and that I may use in the future). Finney1234 (talk) 17:22, 18 November 2021 (UTC)


 * Timeshifter You have convinced me that your calculation is reasonable, but a less controversial approach (I'm not the only one who might look at the statement and references and consider it questionable) would be to simply use the 17904 number that is actually cited on page 4 of the Bollom paper. I might add it, but you're welcome to change it. Here's the text:


 * "We identified 2,915 patients in 2006 who presented to the ED with a primary diagnosis of vomiting and also had cannabis use disorder. In contrast in 2013 we identified 17904 patients." Finney1234 (talk) 02:24, 20 November 2021 (UTC)
 * Good catch. I found this too (emphasis added):
 * {| class=wikitable


 * The 2006 NEDS contains data from about 26 million ED visits from over 950 hospitals weighted to approximate over 120 million ED visits, and the 2013 NEDS contains data on 30 million ED visits at 947 hospitals that are weighted to provide national estimates for 135 million ED visits.
 * }
 * So the numbers all match up closely.
 * --Timeshifter (talk) 14:00, 20 November 2021 (UTC)

Dec 4, 2021 removal of 2013 hospital numbers
See diff. Why was this removed from the article? It seems to be the best sourced stats so far. edit comment: "cut WP:LEDEBOMB constructed around unreliable, primary source". I really don't care if this is in the first paragraphs of the article, but it should be in the article. Maybe put it in the Epidemiology section with other stats. That's fine by me. Then readers can compare the available stats and sources. Here is what was removed:

--Timeshifter (talk) 02:51, 5 December 2021 (UTC)
 * It's primary research, so not WP:MEDRS. Alexbrn (talk) 02:55, 5 December 2021 (UTC)
 * I removed another stat from the lede for the same reason. Reference is:
 * Here is the diff. Here is the stat that was removed:
 * {| class=wikitable
 * {| class=wikitable


 * Of those who went to the emergency department (ED) with recurrent vomiting in one institution in the United States from 2005 to 2010, about 6% had the condition.
 * }
 * As far as I can tell there are now no non-primary source stats in the lede of the article. WP:MEDRS does not have a blanket prohibition against primary sources. I think the stats should go in the Epidemiology section. We can note that the stats are from primary sources. --Timeshifter (talk) 03:24, 5 December 2021 (UTC)
 * Why would you use unreliable sources? Where's the weight? There are ample reliable sources for this topic. Alexbrn (talk) 03:27, 5 December 2021 (UTC)
 * Show me a non-primary source with stats. --Timeshifter (talk) 03:28, 5 December 2021 (UTC)
 * In general Wikipedia articles should follow reliable sources, rather than trying to substantiate material editors want. For "stats" we would need reliable sources. Alexbrn (talk) 03:31, 5 December 2021 (UTC)

I am not WP:POVSOURCING. I have looked for stats, as have others. Primary sources are all I have seen so far. Primary sources are not necessarily unreliable. These are well-sourced stats from this primary source:
 * Full text with charts: Emergency Department Burden of Nausea and Vomiting Associated with Cannabis Use Disorder: U.S. Trends from 2006 to 2013. From Journal of Clinical Gastroenterology. J Clin Gastroenterol. 2018 Oct; 52(9): 778–783. doi: 10.1097/MCG.0000000000000944 PMCID: PMC5930153 NIHMSID: NIHMS906217 PMID: 29095419

From the article:

User:MartinezMD is not a lightweight, and edits this article, and hasn't objected to these stats being in the article for a long time now. --Timeshifter (talk) 03:47, 5 December 2021 (UTC)
 * We need reliable sources and WP:NOR is policy. We are not going to try and suggest something about CHS prevalence by using old figures for Cannabis use disorder, especially when the source itself explicitly says CHS prevalence is "unknown". 29132050 has some recent figures. Alexbrn (talk) 04:05, 5 December 2021 (UTC)
 * I haven't been paying much attention lately to this article. Can you review very briefly what the contentious issue is with the stats? i.e. what statement is being debated, the calculated average visits per year or something else (e.g the source itself)? The J Clin Gastroenterol article, while technically being a primary study, really is more of a secondary one since it is reviewing aggregated data. MartinezMD (talk) 04:18, 5 December 2021 (UTC)
 * . The Journal of Clinical Gastroenterology article made no claims for the prevalence of CHS outside hospitals. And 2013 numbers is the latest they produced. The article you linked to is for France, not the US. I did not see any stats in the abstract for the number of people with CHS in emergency departments in France. That was not the purpose of the article. "Our aim was to compare French cases to those identified in the international literature in order to further our knowledge of the clinical criteria, pathophysiology and treatments for cannabinoid hyperemesis syndrome." --Timeshifter (talk) 07:18, 5 December 2021 (UTC)
 * The article says the French addictovigilance network has recorded 29 cases, a likely underreporting. 113 cases have been described in the medical literature internationally. We can't make up number because editors want them to exist. Alexbrn (talk) 08:46, 5 December 2021 (UTC)
 * As I said that article you linked to (29132050) is not about how many people visited emergency departments with CHS. From the conclusion in the abstract:
 * "French cases display the same characteristics as the cases identified in the international literature."
 * So it is not relevant to this discussion. Please stay on topic.
 * --Timeshifter (talk) 09:53, 5 December 2021 (UTC)
 * This is about what numbers can be reliably cited. The French article gives us such. We are not going to be using the preposterous WP:OR you disgracefully put in this article's lede. Alexbrn (talk) 09:58, 5 December 2021 (UTC)
 * It is in no way WP:OR. I put it in the lede in Feb 2021 (see diff). I put it there partly because it was, and is, the best data on the number of ED visits so far in the US. And because there is a hidden note placed there by previous editors that says: "Epidemiology and history". But as I said it doesn't matter to me where it is placed in the article.
 * You haven't replied to MartinezMD.
 * And you seem to be alone in this quest to remove the number of CHS patients visiting US emergency departments in 2013. That is the latest number we have. --Timeshifter (talk) 10:16, 5 December 2021 (UTC)
 * has said nothing relevant. I am sure they do not support inclusion of original research based on primary research. There is no source for "the number of CHS patients visiting US emergency departments in 2013" that I can see. I can only see your preposterous OR. Alexbrn (talk) 10:28, 5 December 2021 (UTC)
 * Then you obviously need to reread this whole talk section. --Timeshifter (talk) 10:31, 5 December 2021 (UTC)
 * It just confirms you are engaged in preposterous OR. Shame on you, for such a high-traffic article, to be spreading misinformation. Alexbrn (talk) 10:34, 5 December 2021 (UTC)

. Please stop the personal attacks. See WP:NPA. Rather than repeat myself, please see my previous comments and replies. --Timeshifter (talk) 13:09, 5 December 2021 (UTC)
 * I have made no personal attacks. Anyway, I believe we are done. If you want to argue further I suggest you open a section at WP:NORN, because WP:OR is the problem your edits have. Alexbrn (talk) 13:15, 5 December 2021 (UTC)
 * No one agrees with you here concerning the 2013 numbers. So feel free to argue elsewhere. See previous discussion. --Timeshifter (talk) 13:40, 5 December 2021 (UTC)
 * That nobody else has contradicted me shows that consensus has changed, as it had to once editors remembered we have core policy that needs to observed. You simply cannot quote numbers in a primary source about one condition to imply something about a different condition. Alexbrn (talk) 14:00, 5 December 2021 (UTC)
 * Your first comment in this thread was today Dec 5, 2021. MartinezMD has already questioned your removal. The 2013 info has been in the article since Feb 2021. agrees with the 2013 info. See previous discussion. No one supports your deletion of the 2013 numbers. --Timeshifter (talk) 14:09, 5 December 2021 (UTC)
 * Questioned? That is false. I am not going to bother responding further since this is clear-cut and you're now getting into dishonesty. Do not take my lack of response for agreeing to your bad edit. If you want to be told the same thing by others, go to WP:NORN. Alexbrn (talk) 14:17, 5 December 2021 (UTC)
 * MartinezMD wrote:
 * {| class=wikitable


 * I haven't been paying much attention lately to this article. Can you review very briefly what the contentious issue is with the stats? i.e. what statement is being debated, the calculated average visits per year or something else (e.g the source itself)? The J Clin Gastroenterol article, while technically being a primary study, really is more of a secondary one since it is reviewing aggregated data.
 * }
 * To me it sounds like he is questioning the removal of the 2013 numbers. And you still haven't deigned to respond to him. --Timeshifter (talk) 14:22, 5 December 2021 (UTC)

I think both of you need to tone down the rhetoric. The current one isn't helpful. I would also like to speak for myself thank you. I am a simple editor here with no more authority than either of you. I do have a good working understanding of medical topics and data due to my background however, and believe I have a fair grasp of WP policy. I've been on WP lately but not participating much due to recent surgery significantly limiting use of my arm. This will continue for the near future and my responses are burdensome.

There is a significant lack of data on the topic that we can do nothing about unfortunately. Even eight years later, articles that call themselves prevalence studies really aren't imho. Reviewing the issue more, I don't think we can place estimates of numbers of cases in the lead. The data just aren't there.

I do think it is acceptable to discuss the issue of data or lack thereof in the body of the article as long as it is made clear that these are estimates provided by the investigators. Phrasing such as "large scale investigations into the extent of cases have not been performed, but estimates have ranged from X to Y" I think is good. I also think we should discuss changes to the article here before continuing an edit war. We're here to write a good article, no? So let's be collegial with each other, let's come up with constructive proposals, and move the article forward. MartinezMD (talk) 21:35, 5 December 2021 (UTC)


 * Note that WP:MEDRS doesn't absolutely rule out primary sources, although it does strongly discourage them and insists on very careful use. Since solid CHS case numbers *only* occur in primary sources, possibly they could be argued to be useful here.
 * In modifying the Epidemiology section in this article a week or two ago, I was attempting to follow standard Wikipedia guidelines WP:Primary and WP:How_to_use_primary_sources_(biological_sciences) (I did not know of WP:MEDRS at the time). With this approach, one basically provides text in the article that accurately summarizes what a decent primary source is stating, but you do not state it as an absolute fact. Primary sources are extensively used in many scientific articles in Wikipedia in this way (e.g., chemistry articles, see Talk page and article history in Terpenes). Possibly it would be a good thing to use here. However, since I have to deal with User:Alexbrn's arguably non-collegial (at least in the past) approach elsewhere (see, e.g., this reliable sources discussion, and the recent history and talk page activity at Cannabis_(drug)), I'm not going to pursue it here. It'd be nice if the suggestions in the WP:Reverting essay were followed . e.g., "revert an edit made in good faith only with an explanation and after careful consideration". (Actually, User:Alexbrn's "Phases" section below *is* collegial. Cool!)
 * Actually, the Identifying reliable sources example provided above is directly relevant to this topic. It dealt with the fact that the Habboushe non-factual statement of 2.7 million CHS cases was cited in an arguably WP:MEDRS qualifying secondary source, and it was relevant to a general discussion of how to deal with poor primary or secondary sources. It is not good behavior to remove someone's choice of reference without a solid Wikpedia guideline (e.g., WP:MEDRS is one), so I just worked on making sure the description of the Habboushe primary research clearly revealed its issues. That is one reason I felt it was important to include the 2013 (admittedly primary source) number here,  because it would be very, very difficult to argue for removal of the Chocron (secondary)/Habboushe(primary) source, and it at least provided more reliable data. As noted in that "reliable sources" discussion, my personal opinion about the Habboushe source is not a sufficient basis for removal. The discussion above on the 2013 CHS ER data (relating to my claim of WP:NOR with User:Timeshifter) was not totally warm and fuzzy, but it was collegially and factually resolved.Finney1234 (talk) 00:05, 6 December 2021 (UTC)
 * Alexbrn keeps saying the 2013 hospital numbers he removed is original research. It baffled me the first time he said it, and it still baffles me. Here is what he removed from the article:
 * {| class=wikitable


 * The rate of ED visits in over 950 emergency departments in the US for "vomiting with cannabis use disorder" from 2006 compared to 2013 increased from 2.3 to 13.3 per 100,000 ED visits. Extrapolating to all US emergency departments the source says that there were 17,904 patients in 2013.
 * }
 * Every bit of it is from the reference (see the beginning of this talk subsection). All the numbers are directly from the reference including the 17,904 number. I did not calculate that.
 * As I have said before I agree completely that it should not be in the lede. I think it should be in the epidemiology section. Alexbrn can feel free to explain it further there since there is now more room to do so.
 * The study that MartinezMD linked to has good info and numbers for one local healthcare system. It should be summarized in the epidemiology section too. An example of some good info from the Study:
 * {| class=wikitable


 * Data for 458 patients with a diagnosis of nausea and vomiting were pulled from the electronic database. A total of 321 patients with nausea and vomiting in the setting of marijuana use were reviewed and compared with 137 controls with a diagnosis of nausea and vomiting without marijuana use. Among the 321 patients, 53 (16.51%) were suspected of having CHS (CHS Yes), while 268 (83.5%) were not suspected of having CHS (CHS No) (Figure 1). In the 321 patients, there were 664 ED visits, 350 clinic visits, and 296 admissions; patients with suspected CHS comprised 21.5% of the ED visits and 34.9% of the admissions.
 * }
 * --Timeshifter (talk) 00:28, 6 December 2021 (UTC)
 * The problem is that refers to "the 2013 CHS ER data", but there is no 2013 CHS ER data. The very large number headlined in the lede was not for CHS. Implying or stating that it is, is WP:OR. 34732980 is at least on topic, as it's about CHS, but it's a weak primary source and per WP:MEDRS should be avoided. There is no need to start to edit against the WP:PAGs on this topic when we have several solid WP:MEDRS sources. If there is a move to start using unreliable sources we will need more eyes from WT:MED. Alexbrn (talk) 05:32, 6 December 2021 (UTC)
 * It says "vomiting with cannabis use disorder". So that is not WP:OR.
 * {| class=wikitable


 * The rate of ED visits in over 950 emergency departments in the US for "vomiting with cannabis use disorder" from 2006 compared to 2013 increased from 2.3 to 13.3 per 100,000 ED visits. Extrapolating to all US emergency departments the source says that there were 17,904 patients in 2013.
 * }
 * --Timeshifter (talk) 06:05, 6 December 2021 (UTC)
 * Of course it is. You are aware that cannabis use disorder is a different condition? The number is for people who present with it who are also vomiting. That tells us nothing about whether/how the vomiting is connected with the cannabis or whether this amounts to CHS. To repeat: "interpretation" of primary sources like this is explicitly prohibited by core policy. Alexbrn (talk) 06:09, 6 December 2021 (UTC)
 * There is no interpretation in presenting the info. The reader interprets it. How would you present the 2013 hospital info from that study? Feel free to rewrite it. There is more room now that this info is going in the Epidemiology section, and not the lede.
 * As MartinezMD wrote: "I do think it is acceptable to discuss the issue of data or lack thereof in the body of the article as long as it is made clear that these are estimates provided by the investigators."
 * We present what we have in an WP:NPOV way without interpretation. I believe there were 4 studies with info we presented in the lede and in the Epidemiology section. You and I deleted info from the lede. You deleted the 2.7 million estimate from the Epidemiology section.
 * Let's put it all back in the Epidemiology section along with the French info you presented it there. And other useful studies we find. All without interpretation. Feel free to rewrite it all as you wish. We can then discuss further modifications while we wait for a more comprehensive review study. --Timeshifter (talk) 12:45, 6 December 2021 (UTC)
 * No. What possible relevance have statistics for a different condition, for this article? Seems to me you confused this data with CHS data (and managed to confuse too). This is not CHS data
 * To be very plain: I strongly object to the use of unreliable (non-WP:MEDRS) sources for epidemiological content. And I especially object using a primary source to undercut reliable sources which say we don't really know anything about CHS numbers, and indeed to undercut itself, as it says "the true prevalence of this disorder [CHS] is unknown " [my emphasis]. Alexbrn (talk) 12:50, 6 December 2021 (UTC)
 * The GI article overlaps with CHS specifically saying "CHS is not well recognized by many ED physicians and therefore even the 2013 rates may not accurately represent the number of ED visits and therefore likely grossly underestimate the true problem." "Further research is needed to diagnose patients presenting to the ED with CHS and formulate a standardized regimen of treatment" along with several references to it in the introduction. The content can be used provided it is made clear what these numbers are. It is not ideal, but they can be included if they "have minimal weight, only describe conclusions made by the source, and describe these findings so clearly that any editor can check the sourcing without the need for specialist knowledge." (per WP:MEDRS) MartinezMD (talk) 13:28, 6 December 2021 (UTC)
 * MEDRS prohibits the use of primary sources to undercut reliable ones. This irrelevant CUD data has already confused two (maybe three) editors on this talk page to who are referring to it as numbers of "CHS patients", so inevitably it will confuse our readers too. Editors should be using reliable sources, and the relevant standard here is WP:MEDRS. If any editor here still wants to push this crap, we will need to go to WT:MED. Alexbrn (talk) 13:36, 6 December 2021 (UTC)
 * Again, your tone isn't helpful. Second, the policy is clear. The source can be used if presented correctly. Feel free to go to WT:MED. Their input will likely be more helpful than you have been. MartinezMD (talk) 13:47, 6 December 2021 (UTC)
 * The WP:ONUS is on the editor(s) pushing for inclusion. Say something is WP:CLEARLY so is not helpful, now is it? Alexbrn (talk) 13:54, 6 December 2021 (UTC)

Alexbrn. WP:MEDRS does not prohibit primary sources. Especially if that is all that is available. So you seem to be alone in not wanting to present the available data on how many people are going to emergency departments nationwide in the US with vomiting and regular cannabis use. Whether that vomiting is caused by the regular cannabis use is not easy to determine. As noted in nearly all the articles on CHS. This should be reported to the reader in a WP:NPOV way. The French data you presented in the Epidemiology section is not very useful. It presents no estimates on how many people are presenting to emergency departments. It only shows that CHS exists in France and the US. And prevalence outside hospitals, etc. is unknown. I have seen only one estimate: the 2.7 million number per year. We presented that in context, and any discerning reader could see its flaws. --Timeshifter (talk) 13:59, 6 December 2021 (UTC)
 * MEDRS does not "prohibit" primary sources, but it says they should be avoided and never used to undercut more reliable sources. WP:MEDFAQ suggests some scenarios where they might be useful. More generally, policy prohibits them being used for leaps of knowledge. You have mistakenly written of this 17,000 number as being for "CHS patients", and this is the intent with which it is included here. This is misleading and it is not what the source says. The 2.7 million number has been cut too. We should stick to reliable sources, as there are ample ones available. Alexbrn (talk) 14:11, 6 December 2021 (UTC)
 * Not there aren't "ample" reliable sources available on epidemiology data for CHS. In fact, there are almost NO data available of any kind. That's why we're stuck with what we've been discussing. If you somehow have a reliable, secondary, widescale article on the prevalence of CHS, we'd love to see it. MartinezMD (talk) 14:25, 6 December 2021 (UTC)
 * There are ample sources, but the recurrent theme is that the epidemiology is uncertain (though incidence likely underreported). If that's what reliable sources are saying Wikipedia should not take it upon itself to contradict that by essaying some figures from an unreliable source, especially since those figures aren't even for CHS. By using them as a proxy for CHS, we'd be engaging in original research. Even if we did want to use this primary source (and I will resist that) we'd be restricted to "only describe conclusions made by the source". Yet the idea here seems to be to pluck some figures out of the source, and not merely to mirror its conclusion. Alexbrn (talk) 14:44, 6 December 2021 (UTC)

Please list a few of these ample sources since none of us can find them. MartinezMD (talk) 01:26, 7 December 2021 (UTC)
 * See:




 * So far as I find these are some of the WP:BESTSOURCES on this topic within the last five-years as MEDRS encourages, and the kind of sources the article should be based on. Over the past few days I have been removing biomedical content based on case reports, news reports, tabloids etc. and starting to use these instead. If there was anything concrete to say about ER numbers it would be reflected in the literature, but it isn't. Wikipedia is meant to be a tertiary source based on high-quality secondary sources. By re-interpreting data in an old primary source which has been otherwise ignored by the literature, we would be becoming an ersatz secondary source. As MEDRS says: cite reviews don't write reviews. Alexbrn (talk) 03:05, 7 December 2021 (UTC)


 * Those are not PREVALENCE studies. That is what we are discussing for the epidemiology section. Again, the primary studies are the only ones that discuss kind of data currently. For that reason, they are acceptable in a limited scope. Let's stick to the topic. MartinezMD (talk) 03:18, 7 December 2021 (UTC)
 * The true prevalence of CHS is unknown. That is the what the reliable sources are saying and is the accepted knowledge Wikipedia is bound to reflect. We cannot contradict that with original research. That is the point here. It may be frustrating, but our task here is to write an encyclopedia. It is just not our job to try to plug perceived gaps in the literature with ingenious interpretations of primary sources. Alexbrn (talk) 03:29, 7 December 2021 (UTC)

This is interesting from 31241817: --Timeshifter (talk) 16:01, 7 December 2021 (UTC)
 * 31241817 has some commentary on ER numbers, and much else of interest besides. Alexbrn (talk) 06:50, 7 December 2021 (UTC)
 * That is a good review article. It points out the flaws we pointed out concerning the study with the 2.7 million CHS yearly estimate. It shows what is most useful in the 2013 hospital numbers study. It is not the absolute numbers that are most important. It is the five-fold increase in the numbers from 2006 to 2013. I see that you have reported their note on that in the epidemiology section. So we were correct in how we reported the primary studies earlier until better studies and reviews came along. --Timeshifter (talk) 13:07, 7 December 2021 (UTC)
 * Yes it's a very comprehensive source, and probably solves all these number problems. It's interesting that it seems rather sceptical about what these ER numbers represent, or indeed whether CHS is even a distinctive condition. Interesting too that the diagnostic criteria seems to have been settled on a very simple set of tests. Alexbrn (talk) 13:24, 7 December 2021 (UTC)
 * I don't know about you, but I am satisfied with how the data and articles have been included with these last edits. MartinezMD (talk) 13:29, 7 December 2021 (UTC)