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.

Analysis of the sequence and expression of a second putative acetylcholinesterase cDNA from organophosphate-susceptible and organophosphate-resistant cattle ticks

The cattle tick, Boophilus microplus, is a major pest of cattle in Australia, Central and South America, and parts of Africa and Asia. Control of ticks with organophosphates (OPs) and carbamates, which target acetylcholinesterases (AChE), led to evolution of resistance to these pesticides. Alleles at the locus studied here, AChE2, from OP-susceptible female ticks from Australia and Mexico differed at 46 of 1689 nucleotide positions (20 putative amino acid differences) whereas alleles from three strains of OP-resistant ticks from Australia differed with the allele from the Australian susceptible ticks at six to 13 nucleotide positions (three to six putative amino acid differences). However, the role, if any, of these polymorphisms in the OP-resistance phenotype is unknown. Certainly none of the polymorphisms correspond to sites in ACK that are involved in catalysis or binding of acetylcholine in other organisms. Both of the AChE loci of B. microplus, AChE1 and AChE2, are apparently expressed in synganglia; AChE1 is also expressed in salivary glands and ovaries, in OP-susceptible and OP-resistant ticks. This seems to contradict studies of enzyme kinetics, which indicated that only one form of AChE was present in the synganglia, the site of the action of OPs, in this species of tick. (C) 2002 Elsevier Science Ltd. All rights reserved.

Species of Stephanostomum Looss, 1899 (Digenea : Acanthocolpidae) from fishes of Australian and South Pacific waters, including five new species

Nine species of Stephanostomum are described from Australian and Southern Pacific marine fishes: Stephanostomum madhaviae n. sp. [syn. S. orientalis of Madhavi ( 1976)] from Caranx ignobilis, off Hope Island, Queensland, with 30-34 circum-oral spines and vitelline fields almost reaching to the posterior extremity of the cirrus-sac; S. bicoronatum (Stossich, 1883) from Argyrosomus hololepidotus, off Southport Broadwater, Queensland; S. votonimoli n. sp. from Scomberoides lysan, off Moorea, French Polynesia ( type-locality) and Western Samoa, with 33-38 circum-oral spines, a uroproct and the vitelline fields not reaching the cirrus-sac; S. nyoomwa n. sp. from Caranx sexfasciatus, off Heron Island, Queensland, with 33-38 circum-oral spines, a uroproct and the vitelline fields reaching the cirrus-sac; S. cobia n. sp. from Rachycentron canadum, off Heron Island, with 36 circum-oral spines, a uroproct and the vitelline fields reaching the cirrus-sac; S. petimba Yamaguti, 1970 from Seriola hippos, off Rottnest Island, Western Australia; S. pacificum ( Yamaguti, 1951) from Pseudocaranx wrighti, off Fremantle, Western Australia; S. aaravi n. sp. from Lethrinus miniatus, off Heron Island, with 36-39 circumoral spines, probably a uroproct and the vitelline fields reaching the ventral sucker; S. pagrosomi ( Yamaguti, 1939) from L. nebulosus, L. miniatus and L. atkinsoni off Heron Island, Pagrus auratus, off Rottnest Island, Western Australia and Gymnocranius audleyi, off Heron Island. A digest of described species of Stephanostomum is included as an appendix.

Voxel-based registration of simulated and real patient CBCT data for accurate dental implant pose estimation

The success of dental implant-supported prosthesis is directly linked to the accuracy obtained during implant’s pose estimation (position and orientation). Although traditional impression techniques and recent digital acquisition methods are acceptably accurate, a simultaneously fast, accurate and operator-independent methodology is still lacking. Hereto, an image-based framework is proposed to estimate the patient-specific implant’s pose using cone-beam computed tomography (CBCT) and prior knowledge of implanted model. The pose estimation is accomplished in a threestep approach: (1) a region-of-interest is extracted from the CBCT data using 2 operator-defined points at the implant’s main axis; (2) a simulated CBCT volume of the known implanted model is generated through Feldkamp-Davis-Kress reconstruction and coarsely aligned to the defined axis; and (3) a voxel-based rigid registration is performed to optimally align both patient and simulated CBCT data, extracting the implant’s pose from the optimal transformation. Three experiments were performed to evaluate the framework: (1) an in silico study using 48 implants distributed through 12 tridimensional synthetic mandibular models; (2) an in vitro study using an artificial mandible with 2 dental implants acquired with an i-CAT system; and (3) two clinical case studies. The results shown positional errors of 67±34μm and 108μm, and angular misfits of 0.15±0.08º and 1.4º, for experiment 1 and 2, respectively. Moreover, in experiment 3, visual assessment of clinical data results shown a coherent alignment of the reference implant. Overall, a novel image-based framework for implants’ pose estimation from CBCT data was proposed, showing accurate results in agreement with dental prosthesis modelling requirements.

Portugal making a difference with children and families: the GADIF model

Portugal is a culture grounded in strong traditions and family. Yet, social changes like women returning to the workforce and a decreas ed national birth rate are impacting the traditional family structure and care giving environments of children. Female employment has been increasing steadily in P ortugal over the last three decades (Galego & Pereira, 2006) and the total fert ility rate decreasing from 4.1 to 2.8 (INE, 2006). Furthermore, extended family me mbers, like grandparents, no longer reside close by to their children and grandc hildren as in the past, because of a changing labor market. Many of the younger gen eration are leaving their rural communities to flock to urban areas because o f job opportunities, leaving behind older relatives who would have otherwise par ticipated in the daily care of children. Given these social and economic changes, children are spending more time in out-of-home care with non-familial caregive rs. Yet, government regulations and guidelines in early care and educat ion (ECCE) and early intervention (EI) are only just emerging; it contin ues to be a work in progress.

On cluster analysis of complex and heterogeneous data

3rd SMTDA Conference Proceedings, 11-14 June 2014, Lisbon Portugal.

La médecine indigène comme instrument normatif social: l’exemple du corps malade navajo

La médecine traditionnelle indigène peut parfois se poser comme un instrument normatif désignant le malade comme celui qui transgresse l‘ordre établi par les ancêtres sacrés et permet à la maladie d‘advenir. Un tiers malveillant ou un sorcier peuvent également être les causes du désordre physiologique et moral du corps social communautaire. L‘étiologie navajo repose sur deux phénomènes : l‘existence de sociosomas (troubles liés à une mauvaise relation à l‘entourage) et de mouvements d‘exclusion ou d‘inclusion du corps étranger, de la conduite déviante. L‘étude de la figure du malade dans les mythes soulignera l‘aspect normatif des thérapeutiques navajo. Enfin, une réflexion sur la justification idéologique de l‘intégration des pratiques ancestrales au protocole de soin montrera dans quelle mesure la collaboration entre praticiens traditionnels et personnels de santé contribue à stigmatiser le malade comme l‘épitome de toutes les déviances : par rapport à la tradition mais aussi au modèle social dominant.

Trypanosoma cruzi strains from triatomine collected in Bahia and Rio Grande do Sul, Brazil

OBJECTIVE Collection of triatomines in domestic, peridomestic and sylvatic environments in states of Bahia and Rio Grande do Sul, Northeastern and Southern Brazil respectively, and isolation of Trypanosoma cruzi strains. METHODS First, the captured triatomines were identified using insect identification keys, then their intestinal content was examined by abdominal compression, and the samples containing trypanosomatid forms were inoculated in LIT medium and Swiss mice. RESULTS Six triatomine species were collected in cities in Bahia, namely Panstrongylus geniculatus (01), Triatoma melanocephala (11), T. lenti (94), T. pseudomaculata (02), T. sherlocki (26) and T. sordida (460), and two in cities in Rio Grande do Sul, namely T. circummaculata (11) and T. rubrovaria (115). Out of the specimens examined, T. cruzi was isolated from 28 triatomine divided into four different species: T. melanocephala (one), T. lenti (one), T. rubrovaria (16) and T. sordida (10). Their index of natural infection by T. cruzi was 6.4%. CONCLUSIONS The isolation of T. cruzi strains from triatomines found in domestic and peridomestic areas shows the potential risk of transmission of Chagas disease in the studied cities. The maintenance of those T. cruzi strains in laboratory is intended to promote studies that facilitate the understanding of the parasite-vector-host relationship.

Medicinal plants: Past and present uses in several communities from the North-eastern Portugal

XX Symposium of Brazilian Medicinal Plants & X International Congress of Ethnopharmacology. S. Paulo, Brasil.

Wild species used in the traditional pharmacopoeia of Trás-os-Montes (Portugal)

XX Symposium of Brazilian Medicinal Plants & X International Congress of Ethnopharmacology. S. Paulo, Brasil.

Evolution of Iberia during the Cenozoic with special emphasis on the formation of the Betic Cordillera and its relation with the western Mediterranean

The extensional process affecting Iberia during the Triassic and Jurassic times change from the end of the Cretaceous and, throughout the Palaeocene, the displacement between the African and European plates was clearly convergent and part of the future Internal Zone of the Betic Cordillera was affected. To the west, the Atlantic continued to open as a passive margin and, to the north, no significant deformation occurred. During the Eocene, the entire Iberian plate was subjected to compression. which caused major deformations in the Pyrenees and also in the Alpujarride and Nevado-Filabride, Internal Betic, complexes. In the Oligocene continued this situation, but in addition, the new extensional process ocurring in the western Mediterranean area, together with the constant eastward drift of Iberia due to Atlantic opening, compressed the eastern sector of Iberia, giving rise to the structuring of the Iberian Cordillera. The Neogene was the time when the Betic Cordillera reached its fundamental features with the westward displacement of the Betic-Rif Internal Zone, expelled by the progressive opening of the Algerian Basin, opening prolonged till the Alboran Sea. From the late Miocene onwards, all Iberia was affected by a N-S to NNW-SSE compression, combined in many points by a near perpendicular extension. Specially in eastern and southern Iberia a radial extension superposed these compression and extension.

Estimation of the Crustal Bulk Properties Beneath Mainland Portugal from P-Wave Teleseismic Receiver Functions

In this work, we present results from teleseismic P-wave receiver functions (PRFs) obtained in Portugal, Western Iberia. A dense seismic station deployment conducted between 2010 and 2012, in the scope of the WILAS project and covering the entire country, allowed the most spatially extensive probing on the bulk crustal seismic properties of Portugal up to date. The application of the H-κ stacking algorithm to the PRFs enabled us to estimate the crustal thickness (H) and the average crustal ratio of the P- and S-waves velocities V p/V s (κ) for the region. Observations of Moho conversions indicate that this interface is relatively smooth with the crustal thickness ranging between 24 and 34 km, with an average of 30 km. The highest V p/V s values are found on the Mesozoic-Cenozoic crust beneath the western and southern coastal domain of Portugal, whereas the lowest values correspond to Palaeozoic crust underlying the remaining part of the subject area. An average V p/V s is found to be 1.72, ranging 1.63-1.86 across the study area, indicating a predominantly felsic composition. Overall, we systematically observe a decrease of V p/V s with increasing crustal thickness. Taken as a whole, our results indicate a clear distinction between the geological zones of the Variscan Iberian Massif in Portugal, the overall shape of the anomalies conditioned by the shape of the Ibero-Armorican Arc, and associated Late Paleozoic suture zones, and the Meso-Cenozoic basin associated with Atlantic rifting stages. Thickened crust (30-34 km) across the studied region may be inherited from continental collision during the Paleozoic Variscan orogeny. An anomalous crustal thinning to around 28 km is observed beneath the central part of the Central Iberian Zone and the eastern part of South Portuguese Zone.

Evidences against a significant role of Mus musculus as natural host for Angiostrongylus costaricensis

Wild rodents have been described as the most important hosts for Angiostrongylus costaricensis in Central America and southern Brazil. Sinantropic rodents apparently do not play a significant role as natural hosts. A search for natural infection failed to document worms in 14 mice captured in the house of a patient with diagnosis of abdominal angiostrongylosis and experimental infection of a "wild" Mus musculus strain and groups of albino Swiss mice were carried out. Mortality was not significantly different and varied from 42% to 80% for Swiss mice and from 26% to 80% for "wild" mice. The high mortality of a "wild" M. musculus infected with A. costaricensis was very similar to what is observed with most laboratory mice strains. These data may be taken as indications that M. musculus is not a well adapted host for A. costaricensis, although susceptibility was apparently higher with "wild" populations of M. musculus as compared to Swiss strain.

The Self-Inflicted Burns - Typology and its Prognostic Relevance in a 14-Year Review of Self-Inflicted Burns in a Tertiary Referral Centre

Self-inflicted burns (SIB) are responsible for 2-6% of admissions to Burn Units in Europe and North America, and for as many as 25% of admissions in developing nations. Recently, a promising new tool was proposed to stratify SIB patients in the following subgroups: "typical", "delirious", and "reactive". However, as far as the authors know, the clinical usefulness of this instrument has not yet been validated by others. We retrospectively reviewed the clinical records of 56 patients admitted to our Burn Unit with the diagnosis of SIB injury in the past 14 years. The following parameters were evaluated: demographic features; psychiatric illness; substance abuse; mechanism of injury; burn depth, total body surface area (TBSA) involved, Abbreviated Burn Severity Index (ABSI); length of hospital stay, and mortality. All patients were followed up by a psychologist and a psychiatrist, and were classified according to the SIB-Typology Tool, into three classes: "typical", "delirious" and "reactive". There was a slight predominance of the "typical" type (44.6%), followed by the "delirious" type (30.4%), and, finally the "reactive" type (25.0%). Mortality was significantly higher in the "typical" subgroup. In conclusion, the SIB-Typology Tool appears to be a valuable instrument in the clinical management of SIB patients.

Barnacle Allergy: Allergen Characterization and Cross-Reactivity with Mites

Background: Barnacles are a type of seafood with worldwide distribution and abundant along the shores of temperate seas. They are particularly appreciated and regularly consumed in Portugal as well as in Spain, France and South America, but barnacle allergy is a rare condition of which there is only one reference in the indexed literature. The molecular allergens and possible cross-reactivity phenomena implicated (namely with mites) have not been established. Objective: To demonstrate the IgE-mediated allergy to barnacle and to identify the proteins implicated as well as possible cross-reactivity phenomena with mites. Methods: We report the clinical and laboratory data of five patients with documented IgE-mediated allergy to barnacle. The diagnosis was based on a suggestive clinical history combined with positive skin prick tests (SPT) to barnacle – prick to prick method. Two barnacle extracts were prepared (raw and cooked barnacle) and sodium dodecylsulphate polyacrylamide gel electrophoresis (SDS-PAGE) and IgE-immunoblotting were performed. An immunoblotting inhibition assay with Dermatophagoides pteronyssinus was also done in order to evaluate cross-reactivity. Results: All patients had mite-related asthma and the allergic rhinoconjunctivitis; they all experienced mucocutaneous symptoms. All of them had positive SPT to barnacle, and the immunoblotting showed several allergenic fractions with a wide molecular weight range (19 – 94 kDa). The D. pteronyssinus extract inhibited several IgE-binding protein fractions in the barnacle extract. Conclusions: We describe five patients with IgE-mediated barnacle allergy. We also describe a group of IgEbinding+ proteins between 30 and 75 kDa as the allergenic fractions of this type of Crustacea. Cross-reactivity with D. pteronyssinus was demonstrated in two cases.