A model based on integration of NM and EBM can lead to instructional tools that integrate clinical epidemiological knowledge with enforced consideration of differing patient and practitioner perspectives. It also may inform avenues for qualitative research into the processes through which such differing perspectives can be productively identified and shared.

IntroductionThere is concern about excessive bleeding when low-molecular-weight heparins (LMWHs) are used for venous thromboembolism (VTE) prophylaxis in renal dysfunction. Our objective was to evaluate whether LMWH VTE prophylaxis was safe and effective in critically ill patients with renal dysfunction by conducting a subgroup analysis of PROTECT, a randomized blinded trial.MethodsWe studied intensive care unit (ICU) patients with pre-ICU dialysis-dependent end-stage renal disease (ESRD; pre-specified subgroup; n = 118), or severe renal dysfunction at ICU admission (defined as ESRD or non-dialysis dependent with creatinine clearance [CrCl] <30 ml/min; post hoc subgroup; n = 590). We compared dalteparin, 5000 IU daily, with unfractionated heparin (UFH), 5000 IU twice daily, and considered outcomes of proximal leg deep vein thrombosis (DVT); pulmonary embolism (PE); any VTE; and major bleeding. Adjusted hazard ratios [HR] were calculated using Cox regression.ResultsIn patients with ESRD, there was no significant difference in DVT (8.3% vs. 5.2%, p = 0.76), any VTE (10.0% vs. 6.9%; p = 0.39) or major bleeding (5.0% vs. 8.6%; p = 0.32) between UFH and dalteparin. In patients with severe renal dysfunction, there was no significant difference in any VTE (10.0% vs. 6.4%; p = 0.07) or major bleeding (8.9% vs. 11.0%; p = 0.66) but an increase in DVT with dalteparin (7.6% vs. 3.7%; p = 0.04). Interaction p-values for comparisons of HRs (ESRD versus not) were non-significant.ConclusionsIn critically ill patients with ESRD, or severe renal dysfunction, there was no significant difference in any VTE or major bleeding between UFH and dalteparin. Patients with severe renal dysfunction who received dalteparin had more proximal DVTs than those on UFH; this finding did not hold in patients with ESRD alone.

Background: The injection of stem cells in the context of acute myocardial infarction (AMI) has been tested almost exclusively by anterograde intra-arterial coronary (IAC) delivery. The retrograde intravenous coronary (IVC) delivery may be an additional route.

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Despite many passing references to contemporary frontiers of thought such as cybernetics and complexity theory, Tarnished Gold, a self-published book, leads the reader towards critical visions of clinical research enterprise that are more linked to the past than to the present or the future. Along the way, Evidence-Based Medicine is taken as the enemy, but is consistently misrepresented. The authors are seriously under-informed regarding contemporary issues and controversies related to the design of clinical research as well as the cognitive aspects of clinical practice. They ignore the relevance of narrative and relationship-centered medicine to those issues and controversies. The actual challenges of healthcare in our time and its relationship to clinical research are largely avoided. As a result, -Tarnished Gold‖ fails to illuminate or inform lessons already learned from the controversies that have occurred since the appearance of EBM. More importantly, the authors fail to observe that the terms of the debate between EBM and its critics have changed in the direction of an integrative approach, based on considerations of not only the logic of scientific inference, but of contemporary understanding of clinical reasoning and of the forms of knowledge that underlie it. Some of those terms are addressed by this review. -One would be remiss to say that EBM and its practice is a product of physicians alone. Technology has had a large role in the advancement of EBM‖ [1].