Endothelial progenitor cells for diabetic cardiac and kidney disease.

The management of diabetes mellitus and its resultant end organ dysfunction represents a major challenge to global health-care systems. Diabetic cardiac and kidney disease commonly co-occur and are significant contributors to the morbidity and mortality of patients with diabetes, carrying a poor prognosis. The tight link of these parallel end organ manifestations suggests a deeper common underlying pathology. Here, we outline the mechanistic link between diabetic cardiac and kidney disease, providing evidence for the role of endothelial dysfunction in both processes and the potential for cellular therapy to correct these disorders. Specifically, we review the preclinical and clinical evidence for endothelial progenitor cell therapy in cardiac, kidney, and cardio-renal disease applications. Finally, we outline novel approaches to endothelial progenitor cell therapy through cell enhancement and the use of extracellular vesicles, discussing published and future work.

Supine headache and papilledema: A case and review of cerebral venous sinus thrombosis.

Key clinical message: Cerebral venous sinus thrombosis (CVST) should be on the differential for intracranial hypertension, and the preferred diagnostic tests are CT venogram or MR venography. Abstract: Cerebral venous sinus thrombosis (CVST) is a rare cause of stroke and is on the differential for intracranial hypertension. Non-contrast head CT is often normal. CT venogram or MR venography are the preferred diagnostic tests, as was required in our patient. We review the presentation, diagnosis, and management of CVST.

Case Studies of Intradialytic Total Parenteral Nutrition in Nocturnal Home Hemodialysis.

The standard use of intradialytic parenteral nutrition has yielded heterogeneous clinical results. Confounders include patient selection, limited dialysis sessional duration, and frequency. Nocturnal home hemodialysis provides an intensive form of kidney replacement therapy (5 sessions per week and 8 hours per treatment). We present a series of 4 nocturnal home hemodialysis patients who required intradialytic total parenteral nutrition (IDTPN) as their primary source of caloric intake. We describe the context, effectiveness, and complications of IDTPN in these patients. Our patients received a range of 1200 to 1590 kCal (including 60 to 70 g of amino acids) with each IDTPN session for up to 27 months. As the availability of home hemodialysis continues to grow, the role of supplemental or primary IDTPN will require further research for this vulnerable patient population.

Assessing the quality of clinical and administrative data extracted from hospitals: the General Medicine Inpatient Initiative (GEMINI) experience.

OBJECTIVE: Large clinical databases are increasingly used for research and quality improvement. We describe an approach to data quality assessment from the General Medicine Inpatient Initiative (GEMINI), which collects and standardizes administrative and clinical data from hospitals. METHODS: The GEMINI database contained 245 559 patient admissions at 7 hospitals in Ontario, Canada from 2010 to 2017. We performed 7 computational data quality checks and iteratively re-extracted data from hospitals to correct problems. Thereafter, GEMINI data were compared to data that were manually abstracted from the hospital's electronic medical record for 23 419 selected data points on a sample of 7488 patients. RESULTS: Computational checks flagged 103 potential data quality issues, which were either corrected or documented to inform future analysis. For example, we identified the inclusion of canceled radiology tests, a time shift of transfusion data, and mistakenly processing the chemical symbol for sodium ("Na") as a missing value. Manual validation identified 1 important data quality issue that was not detected by computational checks: transfusion dates and times at 1 site were unreliable. Apart from that single issue, across all data tables, GEMINI data had high overall accuracy (ranging from 98%-100%), sensitivity (95%-100%), specificity (99%-100%), positive predictive value (93%-100%), and negative predictive value (99%-100%) compared to the gold standard. DISCUSSION AND CONCLUSION: Computational data quality checks with iterative re-extraction facilitated reliable data collection from hospitals but missed 1 critical quality issue. Combining computational and manual approaches may be optimal for assessing the quality of large multisite clinical databases.

Clinical indications associated with opioid initiation for pain management in Ontario, Canada: a population-based cohort study.

Concerns over prescription opioids contributing to high levels of opioid use disorder and overdose have led policymakers and clinicians to seek means to reduce inappropriate and high-dose initial prescriptions. To inform such efforts, we sought to describe the clinical indications associated with opioid initiation and the characteristics of the initial prescriptions and patients through a retrospective population-based cohort study. Our cohort included Ontarians initiating prescription opioids for pain management between April 1, 2015, and March 31, 2016. We identified the apparent clinical indication for opioid initiation by linking prescription drug claims to procedural and diagnostic information on health service records on the day of, and 5 days preceding prescription. Outcomes included initial opioid type, prescription duration, and daily dose (in milligram morphine equivalents), stratified either by indication or indication cluster. Among 653,993 individuals, we successfully classified 575,512 (88.0%) people initiating opioids into 23 clinical indications in 6 clusters: dental (23.2%); postsurgical (17.4%); musculoskeletal (12.0%); trauma (11.2%); cancer/palliative care (6.5%); and other less frequent indications (17.7%). Individuals with postsurgical pain received the highest daily doses (40.5% with greater than 50 milligram morphine equivalent), and those with musculoskeletal pain received more initial prescriptions with a duration exceeding 7 days (34.2%). Opioids are initiated for a wide range of indications with varying doses and durations; yet, those who initiated opioids for postsurgical and musculoskeletal pain received the greatest doses and durations of therapy, respectively. These findings may help tailor and prioritize efforts to promote more appropriate opioid prescribing.