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.

A new subfamily, Bothriocrotoninae n. subfam., for the genus Bothriocroton Keirans, King & Sharrad, 1994 status amend. (Ixodida : Ixodidae), and the synonymy of Aponomma Neumann, 1899 with Amblyomma Koch, 1844

Evidence suggesting polyphyly of the traditionally recognised tick genus Aponomma Neumann, 1899 is summarized. Continued recognition of this genus in its current concept leaves a polyphyletic genus Aponomma and a paraphyletic genus Amblyomma Koch, 1844. To improve the correlation between our understanding of phylogenetic relationships in metastriate ticks and their classification, a few changes in classification are proposed. The members of the 'indigenous Australian Aponomma' group (sensu Kaufman, 1972), A. auruginans Schulze, 1936, A. concolor Neumann, 1899, A. glebopalma Keirans, King & Sharrad, 1994, A. hydrosauri (Denny, 1843) and A. undatum (Fabricius, 1775), are transferred to Bothriocroton Keirans, King & Sharrad, 1994, which is raised to full generic rank. The remaining members of Aponomma are transferred to Amblyomma. Uncertainty remains on relationships of Bothriocroton to other metastriate lineages and on the systematic position of the two species formerly included in the 'primitive Aponomma' group, A. elaphense Price, 1959 and A. sphenodonti Dumbleton, 1943.

Variation in coumarin 7-hydroxylase activity associated with genetic polymorphism of cytochrome P450 2A6 and the body status of iron stores in adult Thai males and females

The relationships between catalytic activity of cytochrome P450 2A6 (CYP2A6), polymorphism of CYP2A6 gene, gender and levels of body iron stores were analysed in a sample group of 202 apparently healthy Thais, aged 1947 years. Eleven individuals were found to have high activity of CYP2A6, judged by the relatively large amounts (11.2-14.6 mg) of 7-hydroyxcoumarin (7-OHC) excreted 3 h following administration of 15 mg of coumarin. Ten individuals, however, did not excrete any 7-OHC. Of these 10, four were found to have no CYP2A6 gene (whole gene deletion; CYP2A6*4 allele). The frequency of the CYP2A6 alleles; *1A, *1B and *4 in the whole sample group was 52, 40 and 8% while the frequency of the CYP2A6 gene types; *1A/* 1A, *1A/* 1B, *1B/* 1B, *1A/* 4, *1BI* 4, *4/* 4 was 29, 41, 16, 7, 5 and 2%. Subjects having CYP2A6* 1A/* 1B gene-type group were found to have higher rates of coumarin 7-hydroxylation compared with those of the CYP2A6* 1B/* 1B and CYP2A6* 1A/* 4 gene types. The inter-individual variability in CYP2A6 catalytic activity was therefore attributed in part to the CYP2A6 genetic polymorphism. Variation in CYP2A6 activity in this sample group was not associated with gender but, interestingly, it did show an inverse association with plasma ferritin; an indicator of body iron stores. Higher rates of coumarin 7-hydroxylation were found in individuals with low body iron stores (plasma ferritin < 20 μg/l) compared with subjects having normal body iron store status. Subjects (n = 16) with iron overload (plasma ferritin > 300 mug/l) also tended to have elevated rates of coumarin 7-hydroxylation. These results suggest an increased CYP2A6 expression in subjects who have excessive body iron stores. Further investigations into the underlying factors that may lead to increased expression of CYP2A6 in association with abnormal body iron stores are currently in progress in our laboratory. Pharmacogenetics 12:241-249 (C) 2002 Lippincott Williams Wilkins.

The effects of status on subgroup relations

Two experiments were conducted to assess the impact of status differentials on subgroup attitudes and behaviours. In Experiment 1, 73 maths-science students were led to believe they had higher or lower status than humanities students. They then performed a non-interactive decision-making task during which they were categorized exclusively as a university student (superordinate condition), or as a university student and maths-science student simultaneously (subgroups condition). Experiment 2 (N = 98) differed from Experiment I in that perceptions of relative subgroup status were measured rather than manipulated. Consistent with social identity theory, subgroup members tended to categorize themselves more at the superordinate (university) level the lower status they considered their subgroup to be. In Experiment 2, a series of interactions also emerged, showing that status and inter-subgroup bias were positively related when the participants had been categorized exclusively at the superordinate level. When superordinate and subgroup identities were activated simultaneously, perceptions of status had no effect on levels of bias. The results were interpreted in terms of participants' needs for identity enhancement and identity distinctiveness.

Being attuned to intergroup differences in mergers: The role of aligned leaders for low-status groups

The present research focused on responses of low-status group members to a merger with a high-status group. A study was conducted (N = 153) in which the alignment of the leader for the merged group (ingroup vs. outgroup) and leader behavior (equality, outgroup favoritism, ingroup favoritism, complementarity) were manipulated. The authors predicted that the leader, by his or her behavior, would play an important role in defining the new relationship between premerger groups. Overall, low-status ingroup leaders were evaluated more positively than high-status outgroup leaders. Ingroup leaders were evaluated more favorably and were more likely to engender a common identity in the merged group than were outgroup leaders when leaders behaved in an ingroup-favoring or complementary fashion. In contrast, evaluations of ingroup and outgroup leaders did not differ when the leader stressed equality or was outgroup favoring. The findings demonstrate the important role leaders can play in accentuating or de-emphasizing premerger status differences.

Genotypic variation in proanthocyanidin status in the Leucaena genus

The proanthocyanidin (PA) status of 116 accessions from the Leucaena genus representing 21 species, 6 subspecies, 3 varieties and 4 interspecific hybrids was evaluated under uniform environmental and experimental conditions at Redland Bay, Queensland, Australia in October 1997. The PA content of lyophilized youngest fully expanded leaves was measured spectrophotometrically by the butanol/HCl assay referenced to L. leucocephala ssp. glabrata standard PA and expressed as L. leucocephala ssp. glabrata PA equivalents (LLPAE). Considerable interspecific variation in PA concentration existed within the genus, ranging from 0-339 g LLPAE/kg dry matter (DM). Taxa including L. confertiflora, L. cuspidata, L. esculenta and L. greggii contained very high (> 180 g LLPAE/kg DM) PA concentrations. Similarly, many agronomically superior accessions from L. diversifolia, L. pallida and L. trichandra contained extremely high (up to 250 g LLPAE/kg DM) PA concentrations, although these taxa exhibited wide intraspecific variation in PA content offering the potential to select accessions with lower (120-160 g LLPAE/kg DM) PA content. Commercial cultivars of L. leucocephala ssp. glabrata, known to produce forage of superior quality, contained low amounts of PA (33-39 g LLPAE/kg DM). Artificial interspecific hybrids had PA contents intermediate to those of both parents, Lesser-known taxa. including L. collinsii, L. lanceolata, L. lempirana, L. macrophylla, L. magnifica, L. multicapitula, L. salvadorensis and L. trichodes, contained undetectable to low (0-36 g LLPAE/kg DM) quantities of PA and have potential as parents to breed interspecific hybrids of low PA status and superior forage quality. Extractable PA was the dominant PA component, accounting for 91% of total PA within the genus. Regression analysis of accession ranks from different experiments compared to these results indicated that genetic regulation of Leucaena spp. PA content was consistent (P < 0.01) under different edapho-climatic environments. The distribution of PA within the Leucaena genus did not concur with the predictions of various evolutionary and phylogenetic plant defence theories.

Which aspects of socio-economic status are related to health in mid-aged and older women?

A population-based study was conducted to validate gender- and age-specific indexes of socio-economic status (SES) and to investigate the associations between these indexes and a range of health outcomes in 2 age cohorts of women. Data from 11,637 women aged 45 to 50 and 9,5 10 women aged 70 to 75 were analyzed. Confirmatory factor analysis produced four domains of SES among the mid-aged cohort (employment, family unit, education, and migration) and four domains among the older cohort (family unit, income, education, and migration). Overall, the results supported the factor structures derived from another population-based study (Australian Bureau of Statistics, 1995), reinforcing the argument that SES domains differ across age groups. In general, the findings also supported the hypotheses that women with low SES would have poorer health outcomes than higher SES women, and that the magnitude of these effects would differ according to the specific SES domain and by age group, with fewer and smaller differences observed among older women. The main exception was that in the older cohort, the education domain was significantly associated with specific health conditions. Results suggest that relations between SES and health are highly complex and vary by age, SES domain, and the health outcome under study.

Social rules for managing attempted interpersonal domination in the workplace: Influence of status and gender.

The present study utilized a social rules approach to investigate the relative influence of gender and status on managers' self-evaluations of their effectiveness in handling a dominating subordinate. In the first study 84 White middle-class participants identified the prescriptive and proscriptive rules for socially appropriate responding to a stimulus situation involving a pushy subordinate. Four rule sets were identified for female and male managers and subordinates, respectively. Rule-sets shared a number of common rules and showed some variation according to gender roles. In the second study, 91 White middle-class participants rated the individual rules for importance and also rated their personal and managerial effectiveness when responding to the stimulus situation using gender- and status-consistent and gender-and status-inconsistent response strategies. Both men and women rated the female gender and status- consistent strategy as most effective, and rated the status-inconsistent strategy as less effective than a gender-inconsistent response. Results were interpreted as providing more support for a situational gender-related theory of workplace behavior, rather than a traditional gender role perspective.

Effects of BDF 9198 on left ventricular contractility in advanced spontaneously hypertensive rats with heart failure

In the first part of this study, we characterized 24-month-old Wistar Kyoto (WKY) rats and spontaneously hypertensive rats (SHRs), their heart weights, and the responses of the isolated left ventricles to electrical stimulation. In the main part of the study, we tested whether the positive inotropic effects of BDF 9198, which prevents the closure of the cardiac sodium channel, were present in senescence and heart failure. Thus, we studied the effects of BDF 9198 on the left ventricle strips of 24-month-old WKY rats (senescence) and SHRs using contractility methods. In comparison with WKY rats, the left ventricles of 24-month-old SHRs were hypertrophied and had prolonged times to peak contraction. BDF 9198 (10(-8) to 10(-6) m) was a positive inotrope on the left ventricles of WKY rats, with a maximum augmenting effect of 122% with BDF 9198 at 10(-7) m. The magnitude of the augmenting effects of BDF 9198 were reduced in SHR heart failure, with a maximum augmenting effect of 26% at 10(-7) m. BDF 9198 at 10(-6) m attenuated the responses of the SHR left ventricle to electrical stimulation. In conclusion, the potential of drugs that prevent closure of the sodium channel as positive inotropes in the treatment of heart failure should be further considered.