User:Wikieditor9584/sandbox

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This is place to practice clicking the "edit" button and practice adding references (via the citation button). Please see Help:My_sandbox or contact User_talk:JenOttawa with any questions.

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 * Note: Please use your sandbox to submit assignment # 3 by pasting it below. When uploading your improvements to the article talk page please share your exact proposed edit (not the full assignment 3).


 * Talk Page Template: CARL Medical Editing Initiative/Fall 2019/Talk Page Template

Noonan Syndrome

Assignment #2:
Source: ​Stevenson, D. Noonan Syndrome. BMJ Best Practice. May 2018. https://bestpractice.bmj.com/topics/en-gb/1193. Last accessed 6 Nov 2019. .

1) How you searched for a source (search strategy – where you went to find it).

To find my source I used the Trip database (​ https://www.tripdatabase.com/​ ). The search term utilized was “Noonan syndrome”. Results were filtered by quality (to return results in order of highest to lowest quality evidence) with “evidence-based synopses” selected as the evidence type. The chosen source was the first of the 83 total search results.

2) What potential sources were identified and considered (give examples of 1 or 2).

Other sources considered included a review article published in ​The Lancet ​which was identified by searching PubMed and the Genetics Home Reference page for Noonan Syndrome from the NIH website.


 * 1) Roberts, A. E., Allanson, J. E., Tartaglia, M. & Gelb, B. D. Noonan syndrome. ​Lancet​ ​381​, (2013).
 * 2) National Library of Medicine (US). Genetics Home Reference [Internet]. Bethesda (MD): The Library; 2019 Oct 29 [cited 2019 Nov 6]. Available from: https://ghr.nlm.nih.gov/condition/noonan-syndrome#

3) Why the source was chosen (what made it better than other choices).

My source was chosen because it is an evidence-based synopsis and is therefore at the top of the evidence-based medicine hierarchy. The article in ​The Lancet ​was also more than 5 years old (published in 2013), which makes the information somewhat outdated compared to my source (published in 2018). The Genetics Home Reference article on Noonan Syndrome is high quality in that it is evidence-based and published on a high quality website (NIH), however the information seems to be catered more to patients than physicians. Additionally, most of the page links to other resources rather than summarizing or reviewing the relevant information itself.

4) List at least three reasons why the source that was selected meets Wikipedia’s reliable medical sources (MEDRS) criteria.

1) The source reflects current knowledge in the field (ie. is recent and published within the last 5 years). 2) The source is published in a reputable database (BMJ Best Practice). 3) The article is not a primary source, it is an evidence-based synopsis which is at the top of the evidence-based medicine hierarchy. 4) The source was written and peer reviewed by experts in the field.

5) How do you plan to use the source for improving the article?

This source contains a variety of information that can be used to improve the article. It can help expand the prognosis section, fact-check information regarding heart abnormalities in Noonan syndrome, and/or update and better explain the treatment section on the Wikipedia page.

Assignment #3:
The current prognosis section on the Wikipedia page for Noonan syndrome is:

"A 2007 study followed 112 individuals for a mean of 12 years (mean age 25.3, range 12–71). No one died during follow-up, but several required medical interventions. The mean final heights were 167 and 153 cm for men and women, respectively, which is about 2 standard deviations below normal ."

 Proposed Changes: 

1) Delete the information currently present in the prognosis section.

2) Add the following:

The greatest contributor to mortality in individuals with Noonan syndrome is complications of cardiovascular disease. Prognosis is therefore largely dependent on the presence or absence of cardiac disease, as well as the type and severity of the disease (if disease is present). Most notably, Noonan syndrome with hypertrophic cardiomyopathy is associated with increased mortality.

 Rationale for proposed changes: 

1) The first change I propose is to remove the information currently found in the prognosis section. There are many reasons this change should be made. For one, all of the information currently found in the prognosis section references a primary source (specifically a prospective cohort study following a group of Noonan syndrome patients). The Wikipedia reliable medical sources (MEDRS) criteria outlines that only reliable, third-party published secondary or tertiary sources be used to provide biomedical information. Therefore, the use of this information does not meet Wikipedia's suggested guidelines and should be removed. Furthermore, the information presented is factually incorrect. When referencing the study in the current section, it is stated that "No one died during follow-up, but several required medical interventions". If one checks the study that is referenced, it can be seen that ten subjects did die during the study interval. Additionally, updated information regarding the height of individuals from a more reputable source is available. This source highlights that the final adult height of individuals with Noonan syndrome ranges from 161-167cm in males and 150-155cm in females, which approaches the lower limit of normal. The information in this section is therefore inaccurate, and should be removed.

2) The current prognosis section of the article for Noonan syndrome (NS) is extremely limited and offers little insight into how individuals living with the condition may ultimately be impacted. Considering somebody may search "Noonan syndrome" to gain information regarding themselves or a loved one diagnosed with NS, I therefore felt it was necessary that more information be added to this section to provide a broader picture of the health of patients with NS. One of the most important pieces of information related to any disease/condition are the aspects of the disease/condition which pose the greatest risk to health and Wikipedia itself outlines that prognosis should include information such as "the potential for complications and associated health issues" . Throughout my research I noticed a commonly discussed point for NS relating to prognosis was cardiovascular disease, as this may greatly contribute to mortality in patients with the condition. This was not previously present in the prognosis section of the Wikipedia article, but was discussed in relation to prognosis in both evidence-based synopses I reviewed (BMJ Best Practice and Dynamed) as well as in GeneReviews. Thus, I thought it was necessary to add the sentences "The greatest contributor to mortality..." and "Prognosis is therefore largely dependent on..." to inform the general public on this pertinent aspect of NS. Similarly, the last sentence regarding hypertrophic cardiomyopathy ("Most notably, Noonan syndrome...") was added because of the particular relevance of hypertrophic cardiomyopathy to NS (20-30% of NS patients may have hypertrophic cardiomyopathy ) and the fact that all three sources mentioned earlier outlined an evidence-based association of hypertrophic cardiomyopathy in NS to arguably the most severe consequence of any disease/condition, mortality. To provide comprehensive information regarding the relationship between NS prognosis and cardiovascular disease, it therefore seemed important to include this sentence.

 Controversy and Varied Opinions: 

There does not seem to be any controversy or varied opinion about the information I would like to add to my section. The three reputable, peer-reviewed, evidence-based sources which I used to add this information (evidence-based synopses from BMJ Best Practice and DynaMed as well as the review in GeneReviews) seem to be in agreement over the sentences I added. I also did not encounter conflicting opinions regarding these points when reviewing other sources during the course of my research for this assignment.

 Critique of Source :

GeneReviews article on Noonan Syndrome

The GeneReviews article on Noonan syndrome is a narrative review type of article. As such, I considered the possibility of selection bias since the evidence included can be selectively chosen by the authors of the article. I noticed when reading the GeneReviews article that there is no mention from the author regarding which evidence was reviewed, how thoroughly it was reviewed (eg, what kind of search strategy the author used, what kind of evidence was considered, and whether or not some relevant research articles were not explored), or which papers were included or not. The strengths and weaknesses of included papers/evidence also was not discussed, evaluated, or shared within the article. The lack of clarity regarding which research was used or wasn't used to form the opinions expressed in the narrative review does pose a threat to the validity of the article. Given this, it may thus be possible that the information in the article is based more on personal experience or wisdom of the authors, rather than purely research evidence. From my own research I believe the authors of the Noonan syndrome GeneReviews article to be credible experts in the field of genetics. For example, Dr. Allanson is a clinical geneticist who was once the head of the genetics section of the Ontario Medical Association and has authored multiple clinical textbooks and articles. Additionally, GeneReviews specifies that each of its chapters are written by one or more experts on the specific condition or disease and go through a rigorous editing and peer review process prior to being published online. For this reason, I believe that even if personal experience or wisdom of the authors was used to guide incorrect or inaccurate recommendations within the article, other editors or peer reviewers would have caught the error. Overall, given the credibility of the authors as well as the credibility of the source of the article and it's rigorous editing and peer review (GeneReviews), I decided that this review was still a reliable source to use for gathering information related to prognosis.

Evidence-based synopses: BMJ Best Practice and Dynamed sources

When assessing validity and bias of BMJ BestPractice and Dynamed I considered the 6 AGREE criteria that can be used to assess the quality and usefulness of guidelines. I believe that these two sources meet the criteria for appropriate scope and purpose, stakeholder involvement, clarity of presentation, and applicability as I found the articles to be clearly organized, comprehensive, and relevant to the topic of Noonan syndrome. However, one aspects of the AGREE criteria where these guidelines may have fallen short are in the "rigour of development" section. Similar to what was discussed for the narrative review in GeneReviews, the evidence-based synopses provided by BMJ Best Practice and Dynamed did not outline which evidence was reviewed, how thoroughly it was reviewed (eg, could there be relevant research articles which were unexplored), or which papers were included or not to form the opinions expressed within the clinical practice guidelines. The strengths and weaknesses of the evidence related to prognosis was also not discussed, evaluated, or shared within either the Dynamed or BMJ BestPractice sources. For these reasons, the "rigour of development" aspect of the AGREE criteria is not completely satisfied by these two guidelines. That being said, I did find the information in the prognosis section of these resources to be consistent with each other, as well as with the GeneReviews article. Additionally, each of these resources is rigorously edited, peer reviewed, and come from a credible source and therefore, I believe errors or oversights would likely have been identified. For these reasons, I did decide to use these sources despite the potential for selection bias.

Another important aspect of evidence-based synopsis or guidelines which can threaten their validity are conflicts of interest. Both BMJ BestPractice and DynaMed list potential financial conflicts of interest for each author, editor, or reviewer involved in formation of the article in question which in part, satisfies the last AGREE criteria of "editorial independence". In DynaMed, none of the listed authors or editors for the Noonan syndrome article had any potential conflicts of interest whereas in the BMJ BestPractice article, the main authors and some peer reviewers had conflicts of interest with many pharmaceutical companies or were authors of some of the studies referenced in the article. That being said, the prognosis section on BMJ did not deal with information regarding pharmaceuticals or contain any information taken from studies published by any of these authors or peer reviewers. Therefore, I still used these sources as I did not believe bias from these conflicts of interest may not have affected the information in the prognosis section specifically.

Finally, it may be possible that English language bias occurred in GeneReviews, BMJ BestPractice, and Dynamed since these articles are written in English by North American and English-speaking authors and none of these sources appear to make reference to non-English research studies. This may mean that it is possible that relevant Noonan syndrome studies which were published in another language or not translated to English may have been missed in these articles. It is impossible to speculate as to whether this information truly exists, what it might be, or how it may affect the conclusions of the authors within any of these sources. The potential for this bias thus did not impact my decision to include these sources.