The US Environmental Protection Agency Focus on Compliant Pharmaceutical Waste Management Now Includes Long-term Care.

The article provides a summary of changes in the US Environmental Protection Agency's (EPA) regulation of hazardous waste pharmaceuticals as they pertain to both long-term care-provider pharmacies and longterm care facilities. The article describes the EPA's Final Rule: Management Standards for Hazardous Waste Pharmaceuticals and Amendment to the P075 Listing for Nicotine, which became effective in some states on August 22, 2019, and is slowly being adopted by states nationwide. The new rule applies to all health care settings, including provider pharmacies and, for the first time, specifically refers to long-term care facilities as regulated entities. A major benefit of the Final Rule is the removal of over-the-counter nicotine gums, lozenges, and patches from regulation as a P-listed hazardous waste, which previously has had a major negative impact on the hazardous waste generation status of health care facilities. Waste-generation parameters are provided to enable both provider pharmacies and consultant pharmacists to evaluate their specific practices to determine applicability. The biggest change is the removal of all hazardous waste pharmaceuticals from the future calculation of generator status, thereby enabling facilities to meet the requirements of Very Small Quantity Generators or Small Quantity Generators of hazardous waste. All Small Quantity and Large Quantity Generators of hazardous waste must notify their state of their generator status once the state adopts the Final Rule by completing Form 8700-12. This article provides a variety of references to provide The American Society of Consultant Pharmacists members with additional resources and information.

Amnion-derived cellular cytokine solution promotes macrophage activity.

Activated macrophages play a significant role in wound healing and infected tissue repair. In this study, we investigate the recruitment of macrophages into the wound, and the effects on the bactericidal/phagocyte activity after exposure to amnion-derived cellular cytokine solution (ACCS). To evaluate the influence of ACCS on the migratory behavior of macrophages, cell migration was assayed quantitatively using a Boyden chamber. Chemotactic migration activity of macrophages through the membrane determined the influence of ACCS. In the presence of ACCS, macrophages demonstrated a statistically significant (P < 0.05) increase in migration as compared with controls. Subsequently, groups of macrophages were exposed to different concentrations of ACCS solution. The killing and phagocytic activity of each group was compared with the control after exposure to Escherichia coli. Macrophage activity following activation by higher concentrations of ACCS demonstrated significantly increased phagocytosis as well as a trend correlation between percentage ACCS concentration and bactericidal activity. These cell types, critical to normal wound healing, may be influenced by ACCS to accelerate migration and enhance bactericidal/phagocytic activity in wounds.

Individualized, targeted wound treatment based on the tissue bacterial level as a biological marker.

BACKGROUND: The use of biologic markers to aid in individualizing wound treatment may help improve outcomes. A biologic marker that has been demonstrated to be predictive of healing in both chronic and acute wounds is wound tissue bacterial level. The objective of this study was to determine whether tissue bacterial level can be used to individualize wound treatment regimens with a stem-like cell-derived product. METHODS: Amnion-derived cellular cytokine solution (ACCS) was topically applied to rat chronic wounds, and healing rates were measured. RESULTS: Experimental wounds treated with ACCS demonstrated accelerated healing regardless of the tissue level of bacteria, compared with saline. As the level of tissue bacteria increased, the frequency of ACCS application required to obtain optimal results increased. CONCLUSIONS: It appears that the biologic characteristic of tissue bacterial level can serve as a marker to predict the response of open granulating wounds treated with ACCS.

Amnion-derived cellular cytokine solution (ACCS) promotes migration of keratinocytes and fibroblasts.

Amnion-derived Multipotent Progenitor cells appear to be useful as adjuvants in wound healing. Amnion-derived multipotent progenitor cells secrete a unique combination of cytokines and growth factors, known as amnion-derived cellular cytokine solution (ACCS). In the skin, a cytokine communication network between mesenchymal and epithelial cells tightly controls keratinocyte and fibroblast migration, proliferation and differentiation-key determinants of wound healing. To evaluate the influence of ACCS on the migratory behavior of keratinocytes and fibroblasts, cell migration was assayed quantitatively using a Boyden chamber. Chemotactic migration activity of fibroblasts or keratinocytes through the membrane determined the influence of ACCS. In the presence of ACCS, fibroblasts and keratinocytes demonstrated a statistically significant (P < 0.05) increase in migration when compared with controls. These cell types, critical to normal wound healing, may be influenced to accelerate migration in wounds, thus accelerating wound repair/healing.

Effect of amnion-derived cellular cytokine solution on healing of experimental partial-thickness burns.

BACKGROUND: Amnion-derived multipotent progenitor (AMP) cells, unlike most stem cells, have been demonstrated to be nontumorigenic and nonimmunogenic. Amnion-derived cellular cytokine solution (ACCS), a secreted product of AMP cells, is a cocktail of cytokines existing at physiological levels and has been used to accelerate epithelialization of experimental partial-thickness burns. METHODS: Using modifications of Zawacki's guinea pig partial-thickness scald burn model, a total of 65 animals were treated with ACCS, ACCS + AMP cells, unconditioned medium (UCM) + AMP cells, or either UCM alone or saline as controls. Dosage times ranged from every other day to once a week. Percent epithelialization was serially determined from acetate wound tracings. Histology was performed on wound biopsies. RESULTS: ACCS, UCM + AMP cells, and ACCS + AMP cells improved epithelialization compared with the two control groups (P < 0.05). When ACCS was delivered more frequently, statistically significant more rapid epithelialization occurred (P < 0.05). By day 7, all groups treated with ACCS had reached at least 90% epithelialization, whereas control groups were only 20-40% epithelialized (P < 0.05). Histology showed excellent regeneration of the epidermis with rete ridge formation. Hair growth occurred in ACCS-treated animals but not in the control group. CONCLUSIONS: Amnion-derived cellular cytokine solution accelerates the healing of experimental partial-thickness burns. Based on these findings, a multicenter clinical trial is underway.

The effect of amnion-derived cellular cytokine solution on the epithelialization of partial-thickness donor site wounds in normal and streptozotocin-induced diabetic swine.

OBJECTIVE: The purpose of this study was to determine whether amnion-derived cellular cytokine solution (ACCS) could improve the quality of epithelialization and accelerate closure of dermatome-created partial-thickness wounds in normal and streptozotocin-induced diabetic pigs. METHODS: Dermatome-created partial-thickness wounds were sealed with wound chambers in healthy and diabetic pigs and were injected with ACCS. Wound fluid was exchanged daily for total protein concentration, and biopsies were taken on days 6, 8, 10, and 12. Epithelialization, thickness of epidermis, number of epidermal cell layers, and rete ridges were evaluated. RESULTS: The macroscopic appearance of the wounds and speed of healing was similar in all groups at each time point. All wounds were healed by day 6. The epidermis was thicker in the ACCS-treated diabetic wounds than in the controls (140.6 microm vs 82.7 microm on day 12 in diabetic pigs). There were more cell layers (13 vs 7.7) in ACCS-treated diabetic pigs on day 12. The number of rete ridges per 2.5 mm was greater on day 12 in the ACCS-treated diabetic wounds (13 vs 8). There was also a significant increase in the number of rete ridges in ACCS-treated nondiabetic pigs but no difference in epidermal thickness or number of cell layers. CONCLUSION: In diabetic pigs, we found a significantly thicker epidermis and more cell layers and rete ridges in the ACCS-treated wounds. Healthy pigs showed more rete ridges but no difference in thickness of epidermis or number of cell layers on day 12.

The use of amnion-derived cellular cytokine solution (ACCS) in accelerating closure of interstices in explanted meshed human skin grafts.

UNLABELLED: Meshed, split-thickness skin grafts, especially when required to be widely spread, do not obtain immediate biologic closure. In patients with burns that cover a large percentage of the body surface area, this leaves the patient at risk for metabolic problems and life-threatening infection. OBJECTIVE: The purpose of this study was to determine whether amnion-derived cellular cytokine solution could improve epithelialization kinetics and accelerate closure of meshed skin graft interstices. METHODS: Human meshed, split-thickness skin grafts were explanted to athymic "nude" rats and treated with 3 different regimens of amnion-derived cellular cytokine solution (groups I, II, and III) or normal saline (group IV) as a control. Serial wound tracings of unepithelialized interstitial wound areas were compared over time. Two different preparations of amnion-derived cellular cytokine solution were also compared with one another, one containing animal components and the other free of animal components. RESULTS: Only 67.03% of interstices in control animals closed by day 9. This compared with 92.2% closure for group I, 83.72% for group II, and 90.64% for group III. Interstices in all 3 groups treated with amnion-derived cellular cytokine solution (with or without animal-derived components) closed faster statistically than in the control animals (P < .05). There were no statistical differences among the 3 amnion-derived cellular cytokine solution-treated groups. CONCLUSIONS: These data suggest that epithelialization kinetics and interstitial closure of meshed skin grafts can be accelerated with the use of amnion-derived cellular cytokine solution, a physiologic cocktail of cytokines, and provide support for a future clinical trial.

The use of amnion-derived cellular cytokine solution to improve healing in acute and chronic wound models.

OBJECTIVE: Growth factors demonstrate mixed results improving wound healing. Amnion-derived multipotent cells release physiologic levels of growth factors and tissue inhibitors of metalloproteinases. This solution was tested in models of acute and chronic wound healing. METHODS: Acute model: Sprague-Dawley rats underwent laparotomy incisions. The midline fascia was primed with phosphate-buffered saline, unconditioned media, or amnion-derived cellular cytokine suspension prior to incision. Breaking strength of laparotomy wounds was tested with an Instron tensiometer. Incisional hernia formation was measured after 28 days. Chronic model: Chronic, infected granulating wounds were produced in rats by excising full thickness burn eschars inoculated with Escherica coli. Granulating wounds were treated with unconditioned media or amnion-derived cellular cytokine suspension. Treatments were applied either on day 0 and day 7 or day 0 and then every other day. Wounds were traced every 72 hours and biopsied for quantitative bacteriology. RESULTS: Acute model: Priming with amnion-derived cellular cytokine suspension increased the breaking strength of laparotomy incisions in comparison with phosphate-buffered saline or unconditioned media (P < .05). Acute wound failure and incisional hernia formation was 100% in the phosphate-buffered saline and unconditioned media groups and 18% in the amnion-derived cellular cytokine suspension-treated group (P <.05). Chronic model: The rate of wound closure was accelerated in amnion-derived cellular cytokine suspension-treated chronic wounds (P < .05). Multidosing improved the effect. CONCLUSIONS: A physiologic solution of cytokines and tissue inhibitors of metalloproteinases improves healing in models of acute and chronic wounds. Such a cocktail can be produced from amnion-derived multipotent progenitor cells.

Amnion-derived multipotent progenitor cells increase gain of incisional breaking strength and decrease incidence and severity of acute wound failure.

OBJECTIVE: Acute wound failure is a common complication following surgical procedures and trauma. Laparotomy wound failure leads to abdominal dehiscence and incisional hernia formation. Delayed recovery of wound-breaking strength is one mechanism for laparotomy wound failure. Early fascial wounds are relatively acellular, and there is a delay in the appearance of acute wound growth factors and cytokines. The objective of this study was to accelerate and improve laparotomy wound healing using amnion-derived multipotent cells (AMPs). AMPs' nonimmunogenic phenotype and relative abundance support its role as a cell therapy. METHODS: AMPs were injected into the load-bearing layer of rat abdominal walls prior to laparotomy, and cell viability was confirmed. Wound mechanical properties were measured over 28 days. The incidence and severity of laparotomy wound failure was measured in an incisional hernia model. RESULTS: AMP cells were viable in laparotomy wounds for at least 28 days and did not migrate to other tissues. Laparotomy wound-breaking strength was increased by postoperative day 7 following AMP therapy. AMP therapy reduced the incidence of hernia formation and the size of hernia defects. Histology suggested stimulated wound fibroplasia and angiogenesis. CONCLUSIONS: AMP cell therapy reduces the incidence of laparotomy wound failure by accelerating the recovery of wound-breaking strength. This results in fewer incisional hernias and smaller hernia defects.

Maternal methyl supplements increase offspring DNA methylation at Axin Fused.

Transient environmental exposures during mammalian development can permanently alter gene expression and metabolism by influencing the establishment of epigenetic gene regulatory mechanisms. The genomic characteristics that confer such epigenetic plasticity upon specific loci, however, have not been characterized. Methyl donor supplementation of female mice before and during pregnancy permanently increases DNA methylation at the viable yellow agouti (A(vy)) metastable epiallele in the offspring. The current study tested whether another murine metastable epiallele, axin fused (Axin(Fu)), similarly exhibits epigenetic plasticity to maternal diet. We found that methyl donor supplementation of female mice before and during pregnancy increased DNA methylation at Axin(Fu) and thereby reduced by half the incidence of tail kinking in Axin(Fu)/+ offspring. The hypermethylation was tail-specific, suggesting a mid-gestation effect. Our results indicate that stochastic establishment of epigenotype at metastable epialleles is, in general, labile to methyl donor nutrition, and such influences are not limited to early embryonic development.

Post-weaning diet affects genomic imprinting at the insulin-like growth factor 2 (Igf2) locus.

IGF2 loss of imprinting (LOI) is fairly prevalent and implicated in the pathogenesis of human cancer and developmental disease; however, the causes of this phenomenon are largely unknown. We determined whether the post-weaning diet of mice affects allelic expression and CpG methylation of Igf2. C57BL/6JxCast/EiJ F1 hybrid mice were weaned onto (1) a standard natural ingredient control diet, (2) a synthetic control diet or (3) a synthetic methyl-donor-deficient diet lacking folic acid, vitamin B(12), methionine and choline. Maternal Igf2 expression in kidney was negligible at birth, but increased to approximately 10% of total expression after 60 days on the natural control diet. By 60 days post-weaning, both synthetic diets caused significant LOI of Igf2 relative to animals weaned onto the natural control diet. Total Igf2 expression was significantly reduced in these groups, however, indicating that the increase in relative maternal Igf2 expression was caused by specific down-regulation of the paternal allele. The LOI induced by the synthetic-deficient diet persisted during a subsequent 100-day 'recuperation' period on natural ingredient diet. There were no group differences in overall or allele-specific CpG methylation in the H19 differentially methylated region (DMR), Igf2 DMR0 or Igf2 DMR1. At 30 and 60 days post-weaning, however, the paternal allele of Igf2 DMR2 was hypermethylated in the kidneys of mice on the control synthetic diet. These results indicate that post-weaning diet can permanently affect expression of Igf2, suggesting that childhood diet could contribute to IGF2 LOI in humans.

Vowel recognition via cochlear implants and noise vocoders: effects of formant movement and duration.

Previous work has demonstrated that normal-hearing individuals use fine-grained phonetic variation, such as formant movement and duration, when recognizing English vowels. The present study investigated whether these cues are used by adult postlingually deafened cochlear implant users, and normal-hearing individuals listening to noise-vocoder simulations of cochlear implant processing. In Experiment 1, subjects gave forced-choice identification judgments for recordings of vowels that were signal processed to remove formant movement and/or equate vowel duration. In Experiment 2, a goodness-optimization procedure was used to create perceptual vowel space maps (i.e., best exemplars within a vowel quadrilateral) that included F1, F2, formant movement, and duration. The results demonstrated that both cochlear implant users and normal-hearing individuals use formant movement and duration cues when recognizing English vowels. Moreover, both listener groups used these cues to the same extent, suggesting that postlingually deafened cochlear implant users have category representations for vowels that are similar to those of normal-hearing individuals.