Looking for rules in a world of exceptions: reflections on evidence-based practice

After more than a decade, evidence-based medicine (EBM) is well established as an important influence in health care. EBM has engendered a wide range of responses from near-evangelical fervor to angered rejection, with supporters convinced of its scientific superiority and detractors of its needless reductionism. EBM is not a philosophical doctrine, and its originators and proponents have, for the most part, ignored critics and foresworn theorizing. However, EBM claims to be a normative guide to being a better physician. The theoretical, practical, and philosophical dimensions of EBM are intimately intertwined. This essay is a sustained reflection on the issues raised by EBM as experienced by a clinician/teacher who has tried to apply the tenets of EBM in clinical care and teaching over the past decade, and who has sought to expand the borders of EBM from a philosophical point of view.     

Endoplasmic reticulum-associated degradation: exceptions to the rule

Quality control mechanisms in the endoplasmic reticulum (ER) ensure that misfolded proteins are recognized and targeted for degradation. According to the current view of ER-associated degradation (ERAD), the degradation does not occur in the ER itself but requires the retrotranslocation of the proteins to the cytosol where they are degraded by proteasomes. Although this model appears to be valid for many different proteins a number of exceptions from this rule suggest that additional proteasome-independent ERAD pathways may exist. In this review, we will summarize what is known about these alternative ERAD pathways.     

The real objective of Mendel's paper: A response to Monaghan and Corcos

Mendel's work in hybridization is ipso facto a study in inheritance. He is explicit in his interest to formulate universal generalizations, and at least in the case of the independent segregation of traits, he formulated his conclusions in the form of a law. Mendel did not discern, however, the inheritance of traits from that of the potential for traits. Choosing to study discrete non-overlapping traits, this did not hamper his efforts.     

Genetics of mammalian sex determination: some unloved exceptions

The genetics of sex determination is a child of the twentieth century, which overturned the previously held view that sex was determined by the environment. The last quarter of the century witnessed an active search for sex-determining genes in mammals. Although successful, the modus operandi of these genes remained unknown, and the relationship between the sex-determining systems of mammals and other vertebrates remained enigmatic. To overcome these problems, scientists in the 21st century should heed William Bateson's counsel to treasure exceptions, for they point the way to progress. One exception to conventional concepts of sex determination is the bilaterally asymmetrical distribution of ovaries and testes in true hermaphroditism. Ovaries favour the left side in humans and the right side in mice. Observations suggesting that a reversal of asymmetry may occur with increasing organ size may point to a possible explanation. A reevaluation is also required regarding the beginning of sex differentiation, in view of mounting evidence of a sex difference in growth rates of early embryos. Another question to be settled is whether the function of SRY is confined to the fetal gonad. The recent demonstration that Sry induces cell proliferation in the fetal mouse gonad (Schmahl et al., 2000) further emphasizes the importance of differential growth in sex determination and differentiation. It is suggested that SRY represents an additional growth-promoting gene sequestered by mammals to enable the XY embryo to undergo male sex differentiation in the female hormonal environment of the uterus. An increased awareness of the relationship between growth and gonadal differentiation should lead to a better understanding of sex determination in mammals and an ability to relate the function of sex-determining genes to the effects of environmental factors. J. Exp. Zool. 290:484-489, 2001.     

Alternative protein-protein interfaces are frequent exceptions

The intricate molecular details of protein-protein interactions (PPIs) are crucial for function. Therefore, measuring the same interacting protein pair again, we expect the same result. This work measured the similarity in the molecular details of interaction for the same and for homologous protein pairs between different experiments. All scores analyzed suggested that different experiments often find exceptions in the interfaces of similar PPIs: up to 22% of all comparisons revealed some differences even for sequence-identical pairs of proteins. The corresponding number for pairs of close homologs reached 68%. Conversely, the interfaces differed entirely for 12-29% of all comparisons. All these estimates were calculated after redundancy reduction. The magnitude of interface differences ranged from subtle to the extreme, as illustrated by a few examples. An extreme case was a change of the interacting domains between two observations of the same biological interaction. One reason for different interfaces was the number of copies of an interaction in the same complex: the probability of observing alternative binding modes increases with the number of copies. Even after removing the special cases with alternative hetero-interfaces to the same homomer, a substantial variability remained. Our results strongly support the surprising notion that there are many alternative solutions to make the intricate molecular details of PPIs crucial for function.     

Seasonal time constraints do not explain exceptions to the temperature size rule in ectotherms

A negative relationship between rearing temperature and adult size is widespread in ectotherms yet its causes remain poorly understood. It has been suggested that summer generations of some aquatic insects provide exceptions to this temperature size rule (TSR). The hypothesis that seasonal time constraints are responsible for these exceptions was tested using the mayfly Cloeon dipterum . Simulating early-season conditions by varying photoperiod and temperature, we found that this species followed the TSR. However, under simulated seasonal time constraints, the species omitted most of its summer adult generation (delaying completion of nymphal development till the next year), which limited the scope and applicability of the hypothesis for this species. Even those animals that completed nymphal development before winter showed no weakening of the negative temperature size relationship that was predicted by the hypothesis. Moreover, these animals did not increase rates of development or growth in response to simulated time constraints. We then analysed further the study that originally indicated aquatic insect exceptions to the TSR and suggest that gaps in the data and/or experimental design can explain the apparent exceptions. From these analyses and a survey of other exceptions, we conclude that time constraints do not account for any reported counter-TSR relationship.     

Highway to the inner nuclear membrane: rules for the road

To enter the nucleus a protein must be chaperoned by a transport factor through the nuclear pore complex or it must be small enough to pass through by diffusion. Although these principles have long described the nuclear import of soluble proteins, recent evidence indicates that they also apply to the import of integral inner nuclear membrane proteins. Here we develop a set of rules that might govern the transport of proteins to the inner nuclear membrane.     

Axon guidance: Robos make the rules

A central feature of the developing nervous system is the midline region, which guides growing axons with both short- and long-range signals. New research shows that a trio of receptors, the Robos, are crucial in allowing axons to interpret these signals, ensuring correct route-finding within the emerging axon scaffold.     

Tumor antigen presentation: changing the rules

 Cell-based tumor vaccines have been developed on the basis of the hypothesis that tumor cells can be genetically modified to present antigen to T lymphocytes directly. Contrary to expectations, cross-priming is the predominant pathway for activation of tumor-specific CD8⁺ T cells, while direct presentation of antigen dominates activation of tumor-specific CD4⁺ T cells. These results pose interesting paradoxes for the generation of immune responses, and have definite implications for the development of anti-cancer vaccines. Received: 10 October 1997 / Accepted 10 January 1998