Wikipedia:Featured article candidates/Buruli ulcer/archive1

Buruli ulcer

 * Nominator(s): Ajpolino (talk) 15:16, 18 November 2020 (UTC)

Ga speakers in southern Ghana have two words for skin wounds: fla for "normal" wounds that heal in weeks to months, and aboabone for "abnormal" wounds that linger and sometimes never heal. More recently we've taken to calling these "abnormal" wounds Buruli ulcer. What begins with a bacterial skin infection can become an enormous yet painless open ulcer. The FARC at Chagas disease earlier this year got me interested in neglected tropical diseases, and this is the first one alphabetically. After a GA review by, extensive commentary from and , and a coat of polish from  and , I think it's ready to shine. I look forward to hearing your thoughts. Ajpolino (talk) 15:16, 18 November 2020 (UTC)
 * Sourcing is compliant with WP:MEDRS and WP:MEDDATE. I have not done a copyvio check, because Ajpolino does fine work at WP:CCI and knows how to paraphrase :) This is a short, readable and interesting medical article that I hope non-medical editors will engage. [[User:SandyGeorgia|SandyGeorgia ]] (Talk) 15:25, 18 November 2020 (UTC)

Image review and comments on sources
ALT text, captions and other aspects are fine. At first glance the article's sourcing is properly and consistently formatted. It seems like all sources except as noted below seem to be WP:MEDRS compliant. No spotchecks done, though. Vincent 2018 is a primary source but using it to elaborate on a case that is mentioned by another, MEDRS-compliant sources seems OK for me. MacCallum 1948 is 70+ old but the way it's used in the article seems like an acceptable use of ancient sources. Röltgen and Pluschke 2020 is in a publication by Frontiers Media, which is a somewhat dodgy source - are folks OK with it? Jo-Jo Eumerus (talk) 17:27, 18 November 2020 (UTC)
 * File:Early signs of BU.png: Source appears to link to a correction rather than the actual source.
 * Fixed. Ajpolino (talk) 17:55, 18 November 2020 (UTC)
 * Just a note to say I can find alternative references for the material currently backed up by the Frontiers article. So if folks feel Frontiers publications are generally untrustworthy, I'm happy to replace. I'll keep that in mind going forward. Ajpolino (talk) 17:55, 18 November 2020 (UTC)
 * Sometimes Frontiers is dodgy; when it is a freely accessible source to things well backed up by other reviews, I have no problem using it, as frequently the authors are well-established and published within their field. Individual evaluation of articles applies ... it can be justified in cases like this. Alternately, you could add an additional source, but I like the freely available for our readers.  Sandy Georgia  (Talk)  18:06, 18 November 2020 (UTC)


 * Image review (ec)
 * I can't verify that the pntd images are available under the stated license. It's not obviously stated on the image page The Journal Information indicates that it is published under a creative commons license, but maybe a no-derivatives one?
 * Other images are OK for licensing (t &#183; c)  buidhe  17:32, 18 November 2020 (UTC)
 * at the bottom of each article there is a statement that "This is an open-access article distributed under the terms of the Creative Commons Attribution License,", linking to CC-BY-4.0. Spicy (talk) 17:38, 18 November 2020 (UTC)
 * Ok, now I found it. (t &#183; c)  buidhe  17:41, 18 November 2020 (UTC)

Comments Support from Spicy
I'll read through the article again and post my comments here over the next few days. Full disclosure: I was involved in the pre-FAC review for this article, and I've made a few edits to it, mostly image changes and minor copyediting. Spicy (talk) 13:04, 19 November 2020 (UTC) Overall the article is very clearly written, concise, and easy to understand - an impressive achievement.
 * Consider linking muscle and tendon. Muscle is debatable but many readers might not be quite sure what a tendon is.'
 * Done.
 * Once in the skin M. ulcerans grows and releases the toxin mycolactone which blocks the normal function of cells, resulting in tissue death... - I would have put a comma after "mycolactone" (possible this is an ENGVAR thing)
 * Done.
 * may involve the bite of an aquatic animal The body of the article seems to say that aquatic insects are more commonly implicated
 * Changed to "aquatic insect".
 * Buruli ulcer occurs in rural areas near slow-moving or stagnant water This feels a bit repetitive since the previous paragraph says "The bacteria live in aquatic environments, particularly in slow-moving or stagnant water." I get why you're reiterating this since it's not always safe to assume there's a one-to-one relationship between where the bacteria live and where cases occur, but maybe this can be rephrased a bit so the wording doesn't duplicate that of the preceding paragraph.
 * Changed the meaning of the first sentence to elaborate on where the bacteria are within water. Better or worse?
 * Better, thanks. Spicy (talk) 21:10, 23 November 2020 (UTC)
 * Is it truly always painless? For example, UpToDate (not the most authoritative source, granted) says "Patients with an initial edematous lesion... tend to have associated pain and low-grade fever". Yotsu et al. (2015) says "no or limited pain".
 * Most sources only remark on painlessness, but some mention that secondary infections of ulcers can cause pain (in particular Kpeli and Yeboah-Manu, 2019, "Background" ...secondary infection should be suspected when a wound develops cellulitis or becomes painful. and Yotsu, et al. 2018, "Description of the condition" A typical ulcer usually has necrotic, undermined edges, and is often painless (unless complicated by secondary infection). I've added a bit to that effect in Signs & symptoms.
 * Fair enough, thanks Spicy (talk) 21:06, 23 November 2020 (UTC)
 * with the ulcer a few centimeters wider underneath the skin than the skin wound itself - is it necessary to specify skin wound, or would just "wound" be okay?
 * Changed.
 * can be replaced by inelastic scar tissue - could "inelastic" be replaced with a simpler word such as "stiff", or would meaning be lost?
 * Removed "inelastic" instead. I think the "immobilizing the body part" bit immediately after should get across the idea that the scar tissue doesn't move well.
 * Might be worthwhile to link contracture somewhere.
 * Sneaky-linked it under "immobilizing the body part".
 * Despite sometimes large ulcers, people with Buruli ulcer tend to remain in otherwise good health - I have some issues with this sentence. I get what you're trying to say - that people rarely die from it or develop life-threatening complications - but there's a large grey area in between "dying" and "in good health". I am not sure "otherwise good health" is a great representation of the sources, which say, for example "Buruli ulcer is a disabling skin infection...leading to functional disability, loss of economic productivity, and social stigma" (UpToDate), "it leads to contractures that cause disfigurement and long-term disability and has a high social stigma" (Guarner, 2019), and "Buruli ulcer, caused by Mycobacterium ulcerans, is a chronic debilitating disease" (WHO factsheet). I would be more specific about what you mean by "good health".
 * I was hoping to get across that folks with ulcers don't tend to have systemic symptoms, which is surprising, since they have a huge open wound. I changed the wording of that sentence. Any better? I'm trying not not to use the word "systemic" since I'm not sure it's broadly understood and Systemic disease isn't very helpful.
 * That's better; I might revise it to something like "symptoms are typically limited to those caused by the wound; the disease rarely affects other parts of the body" just to make it 100% clear Spicy (talk) 21:06, 23 November 2020 (UTC)
 * Done. Ajpolino (talk) 00:48, 25 November 2020 (UTC)
 * Category I describes a single small ulcer that is less than 5 centimetres (2.0 inches). Category II describes ulcers that are larger and can be up to 15 centimetres (5.9 in). - Does having multiple ulcers place you in category II or category III? It's not entirely clear from the phrasing
 * Category III. Clarified.
 * Sec61 inhibition prevents cells from signaling to activate the immune system, resulting in ulcers that lack infiltrating immune cells. - the "resulting in ulcers that..." phrasing seems a bit awkward because, if I've understood the article correctly, the inhibition of signalling causes immunosuppression but doesn't cause the ulcer itself
 * Poor wording on my part. Clarified to "leaving ulcers largely free of immune cells". Better?
 * Yup. Spicy (talk) 21:06, 23 November 2020 (UTC)
 * poor wound care is associated with a higher risk of acquiring Buruli ulcer.[13] Wearing pants and long-sleeved shirts is associated with a lower risk of Buruli ulcer - phrasing is a bit repetitive, could be varied
 * Rephrased. Any better?
 * Yes, that's better.
 * Link mycobacteria
 * Done.
 * This method correctly detects M. ulcerans... In practice microscopy correctly detects M. ulcerans in just... I think "correctly" should be removed here, because someone who is not familiar with the concepts of sensitivity and specificity could get the wrong idea from the way this is phrased. The sources are talking about sensitivity, and (as you know) sensitivity evaluates the test's susceptibility to false negatives, not its susceptibility to false positives. But by saying "correctly detected", you raise the possibility that it could be "incorrectly detected", which implies a false positive result. The sentences already say "...in infected people" which means the positive results are correct.
 * "Correctly"s removed.
 * to biopsy tissue from the ulcer - this may just be personal preference but the use of "biopsy" as a verb feels awkward to me. You could say "to take a tissue sample from the ulcer" instead
 * Changed.
 * Injections of M. ulcerans caused ulcers in... bare past tense seems odd here - why not "have been shown to cause ulcers in"...
 * Changed to present tense.
 * That's better, but (sorry!) I find the phrasing "Injecting M. ulcerans can cause"... awkward; I would have phrased it as "Injections of M. ulcerans can cause..." Spicy (talk) 21:06, 23 November 2020 (UTC)
 * Fair enough. Changed. Ajpolino (talk) 00:48, 25 November 2020 (UTC)
 * I wonder if the "Other names" section wouldn't fit better in the "Society and culture" section, which is currently pretty thin. I also have to wonder why the opening sentence of this nomination, which is very interesting, isn't in the article... :)
 * Moved "Other names".
 * I'm glad you liked it! It's a fascinating tidbit that stuck in my head through all of this. It is just one of many, many ways folks have understood Buruli ulcer (and have drawn lines between the natural and supernatural). Best I can tell, this framing isn't particularly common and is hardly written about. I pulled that example from this paper which covers just one sub-district in southern Ghana. But I haven't seen a normal/abnormal wound classification mentioned elsewhere, and so I don't have any context to put it in. I've got my eyes peeled, so if someone reviews cultural understandings of BU, I'll be ready to add more to the article!
 * Link Mycobacterium bovis
 * Done.
 * Thanks - IIRC the name should be written out in full on first occurrence. Spicy (talk) 21:06, 23 November 2020 (UTC)
 * Done. Ajpolino (talk) 00:48, 25 November 2020 (UTC)

Spotchecks
Since this is a first-time nomination it will need a source spotcheck. I'll consign myself to doing this as I have first-hand experience of how hard it can be to find someone willing to spotcheck a medical article :) Stay tuned. Spicy (talk) 01:34, 21 November 2020 (UTC) Here we go:
 * 1 (Bravo 2019, p. 122) - the figure checks out, but the source doesn't explicitly say the cases are reported to the WHO. The frequency in the infobox is different from that in the lead section, any reason for this?
 * Mea culpa. Changed lead to the 2018 number after Hog Farm and SG's suggestion. Forgot to do the same to the infobox. Now synchronized to 2018 number citing.
 * 2 (WHO 2019) - [a] checks out (see comment above), [b] checks out, the "insect bite" thing is supported by the other source, [c][d][e][f][g] all check out
 * 4 (Guarner 2018, pp. 3-4) - [a][b][c][d] all check out; [e] I don't see where the article explicitly mentions scar tissue, [f] not sure the article is saying this only applies to large ulcers, [g] it seems that plaque and edematous lesions are category II by default - shouldn't this be mentioned? [h][i][j] check out.
 * [e] - I'm attempting a layperson-friendly description of the contractures mentioned in "or the ulcer could extend widely, creating deformities, contractures, and amputations that lead to major disabilities." Perhaps I've over-inserted my own thinking though. I'll look around to see if one of the sources spells things out in more detail.
 * [f] - Not really sure how "large" got in there. Fixed.
 * [g] - Added.
 * 10 (Yotsu et al. 2018, p. 251.) - checks out
 * 16 (Vincent et al. 2018, p. e0006429.) - content checks out; as noted above, this is a primary source, but it's only used as a supplement to information from a review article. I don't understand "p. e0006429" though. This seems to be a document number as far as I can tell, not a page number?
 * The text is cited to the whole paper, i.e. the claim of that sentence is the central finding of the paper. The document number thing does seem fairly inelegant. Perhaps pp=1–17 is better? Changed it to that for now.
 * 20 (Guarner 2018, pp. 4–6.) - [a][b][c] all check out
 * 25 (Guarner 2018, pp. 6–7.) - [a][b][c][d][e] all check out; [f] strictly speaking, the article says that it's recommended but not that it actually works; [g] checks out
 * [f] Earlier the article states "several studies have documented lower odds of acquiring the disease when using cloth barriers (long pants and long-sleeved shirts), using rubbing alcohol or washing minor wounds immediately after these occur, and using insect repellents". Must've got my wires crossed with the page numbers. Fixed.
 * 30 (Zingue et al. 2018, pp. 30–31.) - the article is talking about African countries specifically; I would clarify that
 * Tweaked the wording and swapped to a source that makes the broader claim. Now cited to Yotsu 2015 which notes "However, there are limits to the data collected by the WHO, mainly for the following three reasons: (i) lack of health care and reporting system to the national level where BU is most endemic; (ii) large areas with limited or no control activities for BU resulting in lack of understanding of its true distribution; and (iii) lack of awareness and limited knowledge about BU among community members but also among health practitioners."
 * 33 (Suzuki et al. 2019, pp. 87–88.) - checks out
 * 38 (Bolz & Ruf 2019, p. 159.) -[a][b] both check out
 * 44 (Röltgen & Pluschke 2019, pp. 1–2.) - [a][b][c][d] all check out
 * 51 (MacCallum et al. 1948, pp. 95–98, 103, 117–118.) - primary source, but only used to supplement secondary material. I can't seem to access this one, do you mind sending me an email or posting quotes of the relevant section?
 * It should be criminal to paywall a 72-year-old paper. PDF at this Google Drive link. Let me know when you've got it, and I'll take the link down.
 * got it, thanks. Spicy (talk) 14:25, 25 November 2020 (UTC)
 * [a] and [b] check out. Spicy (talk) 22:07, 27 November 2020 (UTC)
 * 55 (Yotsu, Richardson & Ishii 2018, pp. 6–7.) - [a] and [c] check out. On [b], strictly speaking, "0 to 2%" includes 2%...
 * True! Frankly I hadn't noticed. For anyone following along the source says "recurrence rates reportedly decreased substantially to 0% to 2%", and I have "reduced the rate of ulcer recurrence to fewer than 2% of cases." Since those two are substantially the same, and I prefer my wording, I'm inclined to keep it as is.
 * 57 (Bolz & Ruf 2019, pp. 160–161.) - [a][b] both check out
 * 61 (Bolz & Ruf 2019, p. 163.) - [a][b] both check out.

Random thoughts:
 * Guarner (2018) discusses osteomyelitis at some length; some of the other sources I've checked mention it too. I think it would be worthwhile to mention this in the article.
 * Added to Signs and symptoms (wikilinked as "Bone infection")
 * I think it might be helpful to point out that mycobacteria are also responsible for other diseases of poverty like tuberculosis and leprosy. Most readers won't automatically draw that connection when they see the term "mycobacterial infection". Guarner (2018) mentions "Together with leprosy, BU is one of the most frequent skin mycobacterial diseases worldwide" and a couple of the other sources mention tuberculosis IIRC
 * I've so far stubbornly avoided explicitly linking BU to tuberculosis as I feel authors often do so as a cheap shot to make their favorite mycobacterial disease seem more important than it really is. Comparing BU (thousands of cases) to leprosy (hundreds of thousands of cases) or tuberculosis (billions of cases) seems somewhat unfair. Ditto for the moniker of among the "most frequent skin mycobacterial diseases". It's among the only mycobacterial skin diseases! I realize this falls into the category of "things I have feelings about, but really ought not to". So if folks feel it's important, I can take a chill pill and add mention somewhere. But my preference is to leave it out.
 * Haha, fair enough :p Spicy (talk) 14:34, 25 November 2020 (UTC)
 * Chill pill taken, added a couple of sentences at the top of the Causes section. I'll admit that now that they're there, I think it adds some nice context. So I can see that you were right all along... Ajpolino (talk) 19:59, 20 December 2020 (UTC)
 * I'd link enlarged lymph node.
 * Good idea. Done.
 * The Frontiers source was brought up above, I'm not too concerned about it as the same authors have published on the same subject in more reputable sources.

I haven't fully reviewed the citations for consistency because I'm not any good at that, but I did notice that while a lot of the sources are open access, only a few have the open access icon. I believe you're required to be consistent on whether you use that icon or not.
 * ...I'm not sure where those open access icons even came from. I guess someone added some "free" parameters into the reference templates at some point? I'm agnostic on the value of the lock icon. If folks feel it's useful I'm happy to add it throughout. If not, I'm happy to remove.
 * That is an ever-changing bot issue ... I am happy to leave it to the bot people. Sandy Georgia (Talk)  14:17, 25 November 2020 (UTC)

No copyvio or close paraphrasing concerns. Spicy (talk) 18:33, 23 November 2020 (UTC)
 * Thank you very much for taking the time! Ajpolino (talk) 07:52, 25 November 2020 (UTC)

My concerns have been addressed and I'm happy to support this article for FA status. I will say that I thought the article seemed a bit brief at first, but I've compared it against recent reviews on the subject and found it to be suitably comprehensive for a general audience; I didn't see anything that ought to be covered that wasn't. This is an impressively clearly-written article on an important topic. Many thanks to the nominator. Spicy (talk) 22:25, 27 November 2020 (UTC)

Spot checks 2
For what it is worth, I checked 5 or 6 cites while completing my review and found no issues. Gog the Mild (talk) 22:22, 27 December 2020 (UTC)

Jfdwolff review: SUPPORT
My comments and suggestions organised by section. I think it is a well-written and organised article with good referencing. JFW &#124; T@lk  12:11, 29 November 2020 (UTC) I think that's everything. Thank you very much for taking the time to read and comment. Your feedback is much appreciated. Please feel free to add any additional thoughts and I'll get to it asap. I hope you're staying well! Ajpolino (talk) 19:33, 27 December 2020 (UTC)
 * Introduction:
 * I would start off by saying that this condition is specific to certain geographical areas. The average reader will want to know early on that this is rare in most Western countries. I know this slightly risks systemic bias.
 * That makes sense. I made a somewhat minimal change. Let me know if you think it still flows alright, or if I should do some more hands-on reorganizing of the intro.
 * "Orally" could be changed to "by mouth"
 * Done.
 * Is PLoS authoritative in designating NTDs? Is WHO insufficient?
 * WHO's authority is by far the more substantial here. I've removed mention of PLoS from the lead but left it in the History section (since I do think PLoS NTD's role in popularizing NTDs is important).
 * Signs and symptoms
 * Would recommend using "limbs" rather than "extremities" (second paragraph)
 * Done.
 * Cause
 * Not essential, but perhaps something on the classification of Mycobacterium spp.? How closely related is it to the pathogens for tuberculosis and lepra?
 * My original intention was to clean up Mycobacterium ulcerans alongside this, and have a more detailed description there (to your question, I made a small cladogram there). But after finding fewer sources on the topic than I expected, I mostly ran out of steam. Spicy had asked for something similar, so it's probably worth adding a sentence or two. Will dig through sources on the topic and get back to it shortly. Ajpolino (talk) 16:50, 29 November 2020 (UTC)
 * Still planning to get to this, just a bit strapped for time this week. Ajpolino (talk) 00:55, 3 December 2020 (UTC)
 * Done. Ajpolino (talk) 19:59, 20 December 2020 (UTC)
 * Under "Genetic susceptibility", does the GWAS data suggest why these genes in particular might be required for protection against Buruli ulcer? Similarly, perhaps a few words on the role of beta-defensins?
 * Egads! I mislabeled which genes came from the GWAS study; shame on me. Fixed. I've added just a bit of text to contextualize the gene list. Also added a few words on beta-defensins per your suggestion. I could add more on the individual genes named if you think it'll help. Some (iNOS, IFNG, NOD2) are extensively studied immunity-related genes. The others less so. Ajpolino (talk) 20:27, 20 December 2020 (UTC)
 * Diagnosis
 * "Diagnosis is then confirmed" - presumably only in settings where PCR is available so worth clarifying
 * Added a "Where available" to that sentence, and a couple of sentences on PCR availability later in the paragraph. Ajpolino (talk) 23:34, 20 December 2020 (UTC)
 * Treatment
 * Can anything else be said about wound care? Is it generic or are specific measures needed for a Buruli ulcer? Specialist dressings may be costly.
 * Added the WHO recommendation for generic wound care. One review mentions that specialist dressings have been tried and cites a couple of primary reports, so I added mention of that as well. Ajpolino (talk) 01:41, 21 December 2020 (UTC)
 * Can anything more be said about indications for surgical debridement?
 * I haven't seen any specific guidance. WHO's treatment guideline for healthcare workers says only in vague terms that debridement may be used to speed healing (pg 6 of the linked document). I tweaked the wording to specify that this would be debridement's purpose, and I'll keep my eyes peeled for anything more specific. Ajpolino (talk) 01:41, 21 December 2020 (UTC)
 * Prevention
 * It might be worth pointing out that the BCG vaccine is used to prevent tuberculosis but that there is some cross-protection of other mycobacterial conditions; can anything be said about the level of protection and whether it wanes in adulthood similar to the anti-TB effect?
 * Clarified a bit in the text. If protection exists, it probably wanes as for TB. Reviews are basing their text off the studies listed in this systematic review, and mostly end up with some variation of "BCG may offer some protection, though it is short-lived." No one seems bold enough to extract more specific conclusions on magnitude and timeline of protection. Ajpolino (talk) 19:11, 27 December 2020 (UTC)
 * Other animals
 * Are there any sources discussing the veterinarian treatment of animal Buruli ulcers?
 * Not that I can find. Ulcers are fairly common in some possum populations, but I don't see any record of attempted treatment. Domesticated animal infections have been reported, but are rare enough that no patters or recommendations of treatment have been written up yet. Ajpolino (talk) 19:33, 27 December 2020 (UTC)
 * Society and culture
 * What is meant with "bifurcated"? It is also a clinical term but lay readers may not be familiar with it.
 * Changed to "two simultaneous approaches". Ajpolino (talk) 19:33, 27 December 2020 (UTC)
 * Thanks! Support FA. JFW &#124; T@lk  21:06, 27 December 2020 (UTC)

Support from Gog the Mild
Recusing from coordinator duties to review this.


 * The lead seems a little long. Possibly partly due to some repetition. Eg, "The disease is limited to certain areas of the world, with most cases in Sub-Saharan Africa and Australia" and "Cases are concentrated in sub-Saharan Africa and Australia with fewer in Japan, Papua New Guinea and the Americas." Do we need both of these?
 * Removed the second sentence.
 * It is still, IMO, too long. That duplication was by way of more obvious example, rather than the only issue I had in this respect.


 * "Buruli ulcer is caused by skin infection with Mycobacterium ulcerans. The bacteria live in aquatic environments ..." I think that it should be stated that M ulcerans is a bacteria in the first sentence in which it is mentioned.
 * Done.
 * "Ulcers are most common on the lower limbs (62%)" I think that at first mention the % needs explaining; 62% of what, and, possibly, according to whom?
 * I've expanded a bit. If you feel it deserves further explanation, I can rephrase the sentence instead. The "according to whom" is the source at the end of the sentence. The review authors calculated those estimates from 10 studies from various locations. I felt it was worth including to give the reader a sense of where ulcers appear, but I don't have a clear way of explaining the source of the numbers without muddling the section. I don't feel the numbers are essential, so if you (or others) feel they're hinky, I'm happy to fly without. Ajpolino (talk) 20:05, 27 December 2020 (UTC)
 * No, it needs to go in. It is fine now.


 * "a pathological stress response that results in cell death by apoptosis. This results in tissue death" Optional: Could "results" twice in eight words be avoided?
 * Reworded
 * "Immune cells that do make it to the ulcer". Optional: "make it to" is not (IMO) very encyclopedic. Possibly 'reach' or similar?
 * Switched to "reach". Thank you for the suggestion.
 * "Other ulcerative diseases can appear similarly to Buruli ulcer at its various stages." Should "similarly" be 'similar'?
 * They ring the same to my ear. Not sure if that's regional English, or the fading of my grammar school lessons. Changed to "similar".
 * The lead states that rifampicin is taken orally, while the main article states "The most widely used antibiotic regimen is rifampicin plus twice daily oral clarithromycin" suggesting that it isn't. or at least leaving this unclear.
 * Poor wording on my part. Clarified: rifampicin is taken orally once per day; clarithromycin orally twice per day.
 * "Buruli ulcer can be prevented by avoiding contact with aquatic environments in endemic areas; however, for those living in endemic areas, this may not be possible." Possibly replace the second "endemic" with 'these'?
 * Done.
 * "drives many to seek traditional healers as primary care". "as primary care" → either 'as primary carers' or 'for primary care'.
 * Done. Went with "for primary care."
 * "a bifurcated approach" Would it be possible to rephrase this in more everyday terms?
 * Done: "... with two simultaneous approaches".
 * "and occasionally ineffective, with ulcer recurrence in up to a third of cases" I am not sure that a third of cases can be described as "occasional".
 * Good point. Changed to "often".
 * "the World Health Organization recommended an eight-week course of daily oral rifampicin and injected streptomycin" How does this 8 weeks match with the "temporary worsening of symptoms 3 to 12 weeks"?
 * Both are true. The eight weeks of antibiotics kill the bacteria in the wound (we hope). Typically the wound slowly but steadily heals up. But sometimes the immune system recovers from its mycolactone-induced hangover with ill-temper and causes the ulcer to get worse for a bit before allowing it to return to healing. That immune wakeup can happen while you're still taking antibiotics, or it can happen after. Am I understanding your question correctly? Perhaps I can improve the wording so it doesn't lend itself to misunderstanding? Ajpolino (talk) 20:38, 27 December 2020 (UTC)
 * Ah! OK. Feel free to tweak the wording if you wish, but the confusion was probably as much my preconception as the prose - I withdraw any objections to the current wording.


 * Cairns is duplinked.
 * Fixed.

A very neat article. Gog the Mild (talk) 17:00, 12 December 2020 (UTC)
 * Thank you very much for taking the time to review! Apologies for the slow response. Work has gone from busy to crazy this month, largely keeping me from my (more enjoyable) work here. I'm hoping to carve out a few hours this weekend to get to your comments and JFW's above. If anyone else is considering a review, feel free to pile on the comments and I'll get to them asap. Thank you again! Ajpolino (talk) 06:13, 15 December 2020 (UTC)
 * , glad to see you've been able to get a breather. I have been hesitant to tackle any of this myself, not wanting to mess up your article, but there are some parts I may be able to do considering your sudden real life busy-ness.  Please let me know if you want me to dig in on any of the easier parts, flagging them to my attention, if that will save you time.  Sandy Georgia  (Talk)  20:08, 20 December 2020 (UTC)
 * Thank you very much Sandy. I've got a few quiet hours right now and am working through these. Will let you know if there are any less savory ones I can dump on you. Ajpolino (talk) 20:10, 20 December 2020 (UTC)
 * Done. Happy to address any further comments as well. Thank you for taking the time to read and review. Apologies for the slow responses on my end. I hope you're well and you've had a restful holiday. Ajpolino (talk) 20:38, 27 December 2020 (UTC)


 * OK. Thank you. Looks good. Just the relatively minor issue of slimming the lead a bit, see above. Gog the Mild (talk) 22:28, 27 December 2020 (UTC)
 * I did some further lead slimming. Happy to slim further if you feel it would help. Thanks again. Ajpolino (talk) 19:44, 28 December 2020 (UTC)


 * That looks fine to me. Nice work. Gog the Mild (talk) 20:52, 28 December 2020 (UTC)

Coordinator note
Nearly five weeks in and only one support. No action at all over the past week, despite unaddressed reviewer comments two weeks old. I am aware of "Ask me for anything but time" and that even FAC nominators have lives; nevertheless, the coordinators are going to be getting a bit twitchy and it would be a crying shame for this nomination to be archived after all of the work which has gone into it so far. Gog the Mild (talk) 16:29, 27 December 2020 (UTC)
 * I hope it is only the current perils of working in the health care field that have delayed Ajpolino; I have emailed him. I will be a support as soon as JFW's comments are addressed.  I also could address your commentary mostly myself, but did not want to get in Ajpolino's way.  Sandy Georgia  (Talk)  17:35, 27 December 2020 (UTC)
 * I'm all caught up. Further commentary from anyone is most welcome. Thank you all. Sorry to be the trouble nominator for the month. Ajpolino (talk) 20:38, 27 December 2020 (UTC)


 * As a first time nominator, this is going to need a source spot check. I shall put a request in. Gog the Mild (talk) 22:07, 27 December 2020 (UTC)
 * Spicy did that above. Sandy Georgia (Talk)  22:12, 27 December 2020 (UTC)
 * Drat! Thanks. I noticed them when I first reviewed this - I wondered why I hadn't already put a request in. Too much water under the bridge since then; I focused on Jo-jo's comments at the top and didn't read any further. It looks as if this is close to done then. Gog the Mild (talk) 22:20, 27 December 2020 (UTC)

because this affects Australia, perhaps it will interest you in terms of branching out beyond MILHIST content reviews. Sandy Georgia (Talk)  21:06, 27 December 2020 (UTC)
 * Thanks SG, but with three supports and Gog still to decide, this has probably had enough attention for a first-time nom unless the coords think it needs more. Despite the fact that I am a complete duffer when it comes to anything medical beyond immediate first aid for battle casualties, I am happy to be re-pinged and give it a look if that is the case. Peacemaker67 (click to talk to me) 01:04, 28 December 2020 (UTC)

SandyGeorgia Support
Planning to start in once Ajpolino has finished addressing Gog's comments. Sandy Georgia (Talk)  20:06, 27 December 2020 (UTC)
 * Support. I have followed the development of this article since GAN, and because of my nitpicking MOS fixes, figure as one of the three top editors. Medical editors have reviewed medical content, sourcing is good, all the usual things I check for re MOS are good:  date formatting, endashes/hyphens, two duplicate wikilinks which are not problematic, image captions and punc good, alt text and accessibility dealt with by, convert templates good. I did some minor overuse of however and also redundancy reducing, citations are consistent, clear prose digestible to layperson with no excessive or unexplained jargon, as of dates employed where needed, WP:MEDMOS and WP:MEDRS compliant. This fine effort is ready for promotion.  Sandy Georgia  (Talk)  21:04, 27 December 2020 (UTC)

Ian Rose (talk) 06:59, 30 December 2020 (UTC)