Whither our Art? Clinical Wisdom & Evidence-based Medicine

The relationship between evidence-based medicine (EBM) and clinical judgement is the subject of conceptual and practical dispute. For example, EBM and clinical guidelines are seen to increasingly dominate medical decision-making at the expense of other, human elements, and to threaten the art of medicine. Clinical wisdom always remains open to question. We want to know why particular beliefs are held, and the epistemological status of claims based in wisdom or experience. The paper critically appraises a number of claims and distinctions, and attempts to clarify the connections between EBM, clinical experience and judgement, and the objective and evaluative categories of medicine. I conclude that to demystify clinical wisdom is not to devalue it. EBM ought not be conceived as needing to be limited or balanced by clinical wisdom, since if its language is translatable into terms comprehensible and applicable to individuals, it helps constitute clinical wisdom. Failure to appreciate this constitutive relation will help perpetuate medical paternalism and delay the adoption of properly evidence-based practice, which would be both unethical and unwise.

Pea mania: deranged behaviour in cattle grazing a pea crop (Pisum sativum var arvense)

Hypersensitivity to external stimuli, progressing in some animals to manic behaviour, occurred in a cattle herd that grazed a crop of field peas (Pisum sativum var arvense) in the pre-flowering stage. Haematological and biochemical analyses eliminated hypomagnesaemia and ketosis as diagnoses. Other than two steers euthanased due to injuries sustained during manic episodes, all affected animals survived, recovering over 3 days when moved to alternative pasture. No necropsies were conducted. No microbial pathogens or endophytes were found on or in the plants. A previously reported incident in Victoria in 1987 in cattle grazing peas appeared to be of a similar nature. Environmental factors leading to these incidents were not clearly identified.

Possible reasons for variation in Ixodes holocyclus toxicity

Tick paralysis caused by Ixodes holocyclus affects an estimated 20,000 domestic animals each year along the eastern coast of Australia (Stone 1988). Animals are presented with clinical signs ranging from mild paresis to ascending flaccid paralysis and varying degrees of respiratory and cardiac compromise. Mortality rates are significantly increased in animals presented with respiratory compromise compared to those animals without respiratory compromise, regardless of the degree of flaccid paralysis (Atwell et al 2001). Anecdotal evidence of ticks (collected from different sites in northern New South Wales) causing different clinical signs and mortality in hyper-immune dogs used for serum production, suggests that there may be a variation in toxin production and toxin content between individual ticks (Warne, N 2002 pers comm). This literature review suggests that two possible contributing factors to toxin variation may be the genetic variation within the I. holocyclus species and the variation in the host's response to tick feeding.

Porphyrins as early biomarkers for arsenic exposure in animals and humans

We studied the effect of arsenic exposure on the haem biosynthetic pathway in the rat and humans. Significant increases in protoporphyrin IX, coproporphyrin III, coproporphyrin I were observed in the blood, liver and kidney, and in the urine of rats after a single dose of arsenic. The level of increase was dependent on the arsenic species present. Most of porphyrin concentrations in the tissues increased within 24 hr and urinary excretion elevated within 48 hr. In the human study, we collected urine samples from 113 people who live in Xing Ren of Guizhou Province, a coal-borne arsenicosis endemic area in southwest of PR China and from 30 people who live in Xing Yi (about 80 km southwest of Xing Ren) where arsenicosis is not prevalent. We analyzed the urinary porphyrins using HPLC. Results indicate that all urinary porphyrins were higher in the arsenic exposed group than those in the control group. Women, children and older age people spend much of their time indoors, they had greater increases of urinary arsenic and porphyrins. They were the higher risk groups among the study subjects. A positive correlation between the urinary arsenic levels and porphyrin concentrations demonstrated the effect of arsenic on haem biosynthesis. Significant alteration in the porphyrin excretion profiles of the younger age (