Elucidating determinants of medication disposal programs at retail pharmacies in North Carolina.

BACKGROUND: Pharmacy-based medication disposal programs is one approach to prevent diversion of unused prescription opioids. OBJECTIVE(S): The objective of this study was to assess the extent to which disposal programs have been implemented by retail pharmacies and identify determinants of implementation using the Consolidated Framework for Implementation Research. METHODS: A sequential mixed-method design was used to examine implementation of medication disposal programs at pharmacies in Pitt County, NC. We conducted environmental scans of all retail pharmacies that served community members (N = 31) to assess the extent to which disposal programs had been implemented. Then, we conducted interviews with pharmacists (n = 15; 48.4%) to identify determinants of implementation. The following pharmacy types were represented in the completed interviews: corporate chain (n = 10), small chain (n = 1), independently owned and operated (n = 1), medical (n = 2), and government (n = 1). RESULTS: We found that 32.3% of pharmacies (n = 10) had a medication disposal box and 12.9% (n = 4) had posted a flyer on medication disposal. Pharmacists perceived that patients benefit from disposal boxes and medication disposal is in their purview. Determinants of implementation included the cost of sustaining the intervention, polices of corporate and regional management, variable local control in the decision-making process to implement a disposal box, and experience with having a medication disposal box. CONCLUSION: Our findings highlight one way in which pharmacists can have a vital role in preventing diversion of opioid analgesics and associated consequences. There is a need to expand disposal boxes at pharmacies to increase community member accessibility and use. Future research is needed to determine the cost-effectiveness of expanding the scale of disposal box implementation in community pharmacies.

Model for end-stage liver disease score predicts left ventricular assist device operative transfusion requirements, morbidity, and mortality.

BACKGROUND: The Model for End-Stage Liver Disease (MELD) predicts events in cirrhotic subjects undergoing major surgery and may offer similar prognostication in left ventricular assist device candidates with comparable degrees of multisystem dysfunction. METHODS AND RESULTS: Preoperative MELD scores were calculated for subjects enrolled in the University of Michigan Health System (UMHS) mechanical circulatory support database. Univariate and multiple regression analyses were performed to investigate the ability of patient characteristics, laboratory data (including MELD scores), and hemodynamic measurements to predict total perioperative blood product exposure and operative mortality. The ability of preoperative MELD scores to predict operative mortality was evaluated in subjects enrolled in the Interagency Registry of Mechanically Assisted Circulatory Support (INTERMACS), and results were compared with those from the UMHS cohort. The mean+/-SD MELD scores for the UMHS (n=211) and INTERMACS (n=324) cohorts were 13.7+/-6.1 and 15.2+/-5.8, respectively, with 29 (14%) and 19 (6%) perioperative deaths. In the UMHS cohort, median total perioperative blood product exposure was 74 units (25th and 75th percentiles, 44 and 120 units). Each 5-unit MELD score increase was associated with 15.1+/-3.8 units (beta+/-SE) of total perioperative blood product exposure. Each 10-unit increase in total perioperative blood product exposure increased the odds of operative death (odds ratio, 1.05; 95% confidence interval, 1.01 to 1.10). Odds ratios, measuring the ability of MELD scores to predict perioperative mortality, were 1.5 (95% confidence interval, 1.1 to 2.0) and 1.5 (95% confidence interval, 1.1 to 2.1) per 5 MELD units for the UMHS and INTERMACS cohorts, respectively. When MELD scores were dichotomized as >or=17 and <17, risk-adjusted Cox proportional-hazard ratios for 6-month mortality were 2.5 (95% confidence interval, 1.2 to 5.3) and 2.5 (95% confidence interval, 1.1 to 5.4) for the UMHS and INTERMACS cohorts, respectively. CONCLUSIONS: The MELD score identified left ventricular assist device candidates at high risk for perioperative bleeding and mortality.

AAV4-mediated expression of IGF-1 and VEGF within cellular components of the ventricular system improves survival outcome in familial ALS mice.

Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disease characterized by motor neuron cell death in the cortex, brainstem, and spinal cord. Extensive efforts have been made to develop trophic factor-based therapies to enhance motor neuron survival; however, achievement of adequate therapeutic delivery to all regions of the corticospinal tract has remained a significant challenge. Here, we show that adeno-associated virus serotype 4 (AAV4)-mediated expression of insulin-like growth factor-1 (IGF-1) or vascular endothelial growth factor (VEGF)-165 in the cellular components of the ventricular system including the ependymal cell layer, choroid plexus [the primary cerebrospinal fluid (CSF)-producing cells of the central nervous system (CNS)] and spinal cord central canal leads to trophic factor delivery throughout the CNS, delayed motor decline and a significant extension of survival in SOD1(G93A) transgenic mice. Interestingly, when IGF-1- and VEGF-165-expressing AAV4 vectors were given in combination, no additional benefit in efficacy was observed suggesting that these trophic factors are acting on similar signaling pathways to modestly slow disease progression. Consistent with these findings, experiments conducted in a recently described in vitro cell culture model of ALS led to a similar result, with both IGF-1 and VEGF-165 providing significant motor neuron protection but in a nonadditive fashion. These findings support the continued investigation of trophic factor-based therapies that target the CNS as a potential treatment of ALS.

Short- and long-term survival of patients transferred to a tertiary care center on temporary extracorporeal circulatory support.

BACKGROUND: Mechanical circulatory support (MCS) with temporary, extracorporeal assist devices restores hemodynamics in patients with refractory cardiogenic shock. These devices are frequently used in community hospitals, with subsequent referral to tertiary care centers. We sought to determine the outcomes of such referrals and identify prognostic variables that may influence management decisions. METHODS: We performed a single-institution retrospective review of 59 consecutive patients transferred on temporary, extracorporeal MCS from 1997 to 2008. Demographics, medical history, laboratory data, and clinical status were obtained, with survival determined from the medical record and the Social Security Death Index. Univariable and multivariable analysis were performed and survival estimates were determined using the Kaplan-Meier method. RESULTS: Median age was 49.6 years (range, 14 to 77 years). Forty-five patients (76%) were supported for postcardiotomy failure, and 34 (58%) required biventricular support. Twenty-five (42%) survived to hospital discharge, 11 after cardiac recovery (44%), 9 with long-term implantable MCS devices (39%), and 5 after heart transplantation (22%). Eight patients discharged with implantable MCS devices underwent heart transplantation and 1 remains alive on long-term implantable MCS support. Survival was 42% +/- 6% at 1 year and 38% +/- 6% at 5 years. Age and renal function were independent predictors of death. CONCLUSIONS: Nearly half of all patients transferred on temporary extracorporeal MCS survive to discharge. Most of the long-term survivors received a heart transplant. Age and renal function were independent predictors of death, suggesting that survival is maximized by considering eligibility for cardiac transplantation.