Boston Medical Center

The use of public health vending machines (PHVMs) is an emerging strategy implemented to mitigate drug-related harms via the dispensation of supplies like naloxone and sterile syringes from vending machines that have been documented to reduce transmission of blood borne viruses, support hygiene and basic personal health needs, and prevent overdose. To inform future applications of this technology and performed initially as part of a technical assistance request, we sought to examine PHVM adoption and implementation by conducting semi-structured interviews with 26 individuals from diverse roles and organizations/agencies across the United States in March 2023 about their experiences launching and optimizing PHVMs. We engaged in a secondary thematic analysis of the interview data using both deduction and induction. Using the interview guide as the frame, we broadly organized our findings into themes that are pertinent to consider prior to PHVM implementation ("Pre-implementation") and those that are relevant during implementation ("Implementation and maintenance"). Pre-implementation themes included (1) Motivating factors influencing implementation, (2) Intended PHVM uptake population, (3) Partnership cultivation, (4) Responsiveness to community needs and concerns, and (5) Factors influencing placement of PHVMs. Implementation and maintenance themes included: (1) Operational components of implementation and (2) Tracking consumer use of machines and supply flow. We found that PHVMs have emerged as versatile and central tools to expand and extend critical, life-saving supplies and services to PWUD and other groups within communities throughout the United States, especially to underserved and high-risk populations, such as people of color, young people, rural residents, individuals leaving incarceration, and veterans. We also found that the planning phases of implementation were shaped by local needs, funding opportunities, collaboration, and community engagement, with PHVM placement most often determined by feasibility and willingness of host sites, as well as the perceptions and needs of the community. Operational challenges included unanticipated costs related to maintenance and supply stocking of the PHVMs. Our findings elucidate the local, ground-up, and bold approaches and innovations undertaken by many organizations, agencies, and programs throughout the country in PHVM implementation. Policymakers and government officials should consider passing local ordinances or granting permissions in support of placing PHVMs and securing access to life saving materials.

Left ventricular (LV) dysfunction is a potential cardioembolic source of ischemic stroke, but its role in recurrent stroke risk and treatment response remains unclear. We explore whether LV injury associates with the risk of recurrent stroke and modifies the association between anticoagulation and stroke recurrence using real-world data. We performed a multicenter, retrospective study of Cardiac Abnormalities in Stroke Prevention and Recurrence cohort across 27 US sites. Patients with LV ejection fraction ≥20% were included. LV injury, defined as LV ejection fraction 20% to 40% and wall motion abnormality, was the primary exposure and treatment effect modifier. The treatment of interest was anticoagulant versus antiplatelet therapy. The composite outcome included recurrent stroke, major bleeding, or death. Outcomes were evaluated using unadjusted and inverse probability weighting adjusted Cox proportional hazards models, with treatment effect modification tested by LV injury status. Among 2685 patients enrolled, 2328 with complete data were analyzed (median age, 65 years; 49.8% female; median follow-up, 1.6 years). LV injury was present in 310 patients (13.3%). Overall, 535 events occurred: 258 recurrent ischemic strokes, 28 hemorrhagic strokes, 67 major hemorrhages, and 256 deaths. LV injury was associated with a higher unadjusted risk of the primary outcome (hazard ratio [HR], 1.51 [95% CI, 1.21-1.87]), though nonsignificant after inverse probability weighting adjustment (adjusted HR, 1.29 [95% CI, 0.97-1.70]). In the LV injury subgroup, anticoagulation versus antiplatelet therapy was associated with a lower risk of the primary outcome (adjusted HR, 0.24 [95% CI, 0.10-0.59]), relative to the non-LV injury subgroup (adjusted HR, 1.28 [95% CI, 0.83-1.95]; p[LV-interaction], 0.001). Similar interactions were seen for EF 20% to 40% (versus >40%; adjusted HR, 0.19 [95% CI, 0.04-0.86]; p[LV-interaction], 0.001) and wall motion abnormality (versus no wall motion abnormality; adjusted HR, 0.33 [95% CI, 0.15-0.73]). After cryptogenic stroke, anticoagulation in those with LV injury was associated with lower rates of recurrent stroke, major bleeding, and death. These findings warrant confirmation in a dedicated randomized controlled trial. URL: https://www.clinicaltrials.gov; Unique identifier: NCT06398366.