Chlorhexidine Gluconate Bathing Reduces the Incidence of Bloodstream Infections in Adults Undergoing Inpatient Hematopoietic Cell Transplantation.

Bloodstream infections (BSIs) occur in 20% to 45% of inpatient autologous and allogeneic hematopoietic cell transplant (HCT) patients. Daily bathing with the antiseptic chlorhexidine gluconate (CHG) has been shown to reduce the incidence of BSIs in critically ill patients, although very few studies include HCT patients or have evaluated the impact of compliance on effectiveness. We conducted a prospective cohort study with historical controls to assess the impact of CHG bathing on the rate of BSIs and gut microbiota composition among adults undergoing inpatient HCT at the Duke University Medical Center. We present 1 year of data without CHG bathing (2016) and 2 years of data when CHG was used on the HCT unit (2017 and 2018). Because not all patients adhered to CHG, patients were grouped into four categories by rate of daily CHG usage: high (>75%), medium (50% to 75%), low (1% to 49%), and none (0%). Among 192 patients, univariate trend analysis demonstrated that increased CHG usage was associated with decreased incidence of clinically significant BSI, defined as any BSI requiring treatment by the medical team (high, 8% BSI; medium, 15.2%; low, 15.6%; no CHG, 30.3%; P = .003), laboratory-confirmed BSI (LCBI; P = .03), central line-associated BSI (P = .04), and mucosal barrier injury LCBI (MBI-LCBI; P = .002). Multivariate analysis confirmed a significant effect of CHG bathing on clinically significant BSI (P = .023) and MBI-LCBI (P = .007), without consistently impacting gut microbial diversity. Benefits of CHG bathing were most pronounced with >75% daily usage, and there were no adverse effects attributable to CHG. Adherence to daily CHG bathing significantly decreases the rate of bloodstream infection following HCT.

Development of risk models for major adverse chronic renal outcomes among patients with type 2 diabetes mellitus using insurance claims: a retrospective observational study.

Objective: To develop and validate models allowing the prediction of major adverse chronic renal outcomes (MACRO) in patients with type 2 diabetes mellitus (T2DM) using insurance claims data.Methods: The Optum Integrated Real World Evidence Electronic Health Records and Claims de-identified database (10/01/2006-09/30/2016) was used to identify T2DM patients ≥50 years old. Risk factors were assessed over a 12-month baseline period, and MACRO were subsequently assessed until the end of data availability, continuous enrollment, or death. Separate models were built for moderate-to-severe diabetic kidney disease (DKD), end-stage renal disease (ESRD), and renal death. A random split-sample approach was employed, where 70% of the sample served for model development (training set) and the remaining 30% served for validation (testing set). C-statistics were used to assess model performance.Results: A total of 160,031 patients were included. Risk factors associated with MACRO for all models included adapted diabetes complications severity index, heart failure, anemia, diabetic nephropathy, and CKD. C-statistics ranged between 0.70 (moderate-to-severe DKD) and 0.84 (renal death) in the testing set. A substantial proportion (e.g. 88.7% for moderate-to-severe DKD) of patients predicted to be at high-risk of MACRO did not have diabetic nephropathy, proteinuria, or CKD at baseline.Conclusions: The models developed using insurance claims data could reliably predict the risk of MACRO in patients with T2DM and enabled patients at higher-risk of DKD to be identified in the absence of baseline diabetic nephropathy, CKD, or proteinuria. These models could help establish strategies to reduce the risk of MACRO in T2DM patients.

Development of predictive risk models for major adverse cardiovascular events among patients with type 2 diabetes mellitus using health insurance claims data.

BACKGROUND: There exist several predictive risk models for cardiovascular disease (CVD), including some developed specifically for patients with type 2 diabetes mellitus (T2DM). However, the models developed for a diabetic population are based on information derived from medical records or laboratory results, which are not typically available to entities like payers or quality of care organizations. The objective of this study is to develop and validate models predicting the risk of cardiovascular events in patients with T2DM based on medical insurance claims data. METHODS: Patients with T2DM aged 50 years or older were identified from the Optum™ Integrated Real World Evidence Electronic Health Records and Claims de-identified database (10/01/2006-09/30/2016). Risk factors were assessed over a 12-month baseline period and cardiovascular events were monitored from the end of the baseline period until end of data availability, continuous enrollment, or death. Risk models were developed using logistic regressions separately for patients with and without prior CVD, and for each outcome: (1) major adverse cardiovascular events (MACE; i.e., non-fatal myocardial infarction, non-fatal stroke, CVD-related death); (2) any MACE, hospitalization for unstable angina, or hospitalization for congestive heart failure; (3) CVD-related death. Models were developed and validated on 70% and 30% of the sample, respectively. Model performance was assessed using C-statistics. RESULTS: A total of 181,619 patients were identified, including 136,544 (75.2%) without prior CVD and 45,075 (24.8%) with a history of CVD. Age, diabetes-related hospitalizations, prior CVD diagnoses and chronic pulmonary disease were the most important predictors across all models. C-statistics ranged from 0.70 to 0.81, indicating that the models performed well. The additional inclusion of risk factors derived from pharmacy claims (e.g., use of antihypertensive, and use of antihyperglycemic) or from medical records and laboratory measures (e.g., hemoglobin A1c, urine albumin to creatinine ratio) only marginally improved the performance of the models. CONCLUSION: The claims-based models developed could reliably predict the risk of cardiovascular events in T2DM patients, without requiring pharmacy claims or laboratory measures. These models could be relevant for providers and payers and help implement approaches to prevent cardiovascular events in high-risk diabetic patients.

Experimental asbestos studies in the UK: 1912-1950.

The asbestos industry originated in the UK in the 1870s. By 1898, asbestos had many applications and was reported to be one of the four leading causes of severe occupational disease. In 1912, the UK government sponsored an experimental study that reported that exposure to asbestos produced no more than a modicum of pulmonary fibrosis in guinea pigs. In the 1930s, the newly established Medical Research Council, with assistance from industry, sponsored a study of the effects of exposing animals to asbestos by injection (intratracheal and subcutaneous) and by inhalation in the factory environment. Government reports, publications, and contemporary records obtained by legal discovery have been reviewed in the context of the stage of scientific development and the history of the times. Experimenters were engaged in a learning process during the 1912-1950 period, and their reports of the effects of asbestos were inconsistent. Pathologists who studied the effects of asbestos experimentally, at whole animal, tissue and cellular levels, advanced experimental methodology and mechanistic knowledge. In the hands of public relations experts, however, research was exploited to preserve an industry and perpetuate preventable diseases, a practice that continues to this day.

The case for a global ban on asbestos.

BACKGROUND: All forms of asbestos are now banned in 52 countries. Safer products have replaced many materials that once were made with it. Nonetheless, many countries still use, import, and export asbestos and asbestos-containing products, and in those that have banned other forms of asbestos, the so-called "controlled use" of chrysotile asbestos is often exempted from the ban. In fact, chrysotile has accounted for > 95% of all the asbestos used globally. OBJECTIVE: We examined and evaluated the literature used to support the exemption of chrysotile asbestos from the ban and how its exemption reflects the political and economic influence of the asbestos mining and manufacturing industry. DISCUSSION: All forms of asbestos, including chrysotile, are proven human carcinogens. All forms cause malignant mesothelioma and lung and laryngeal cancers, and may cause ovarian, gastrointestinal, and other cancers. No exposure to asbestos is without risk. Illnesses and deaths from asbestos exposure are entirely preventable. CONCLUSIONS: All countries of the world have an obligation to their citizens to join in the international endeavor to ban the mining, manufacture, and use of all forms of asbestos. An international ban is urgently needed. There is no medical or scientific basis to exempt chrysotile from the worldwide ban of asbestos.

The defence of chrysotile, 1912-2007.

The commercial exploitation of asbestos may be dated from the late 1870s, when Canada was the major world source. Reports of severe and fatal respiratory disease in workers in asbestos factories appeared in Britain (1898, 1906), and in France (1906) and Italy (1908). In 1912 the Canadian Department of Labour denied that the health of Quebec's millers and miners was affected. A series of denials appeared for over 40 years, until in 1955 a Thetford Mines medical officer reported finding that between 1945 and 1953, among some 4,000 asbestos workers 128 had asbestosis of various degrees of severity, 121 diagnosed radiographically, and 33 confirmed at autopsy. Although a committee of inquiry into health in the asbestos industry (1976), and a Royal Commission on health and safety arising in the use of asbestos in Ontario (1984) confirmed that disease had occurred, these findings were to have no adverse effects on asbestos exports. Rather, the inquiries constituted elements in the industry's successful public relations exercise that continues to operate to this day. Even when an increasing number of national bodies have legislated for total bans on asbestos use, a policy with which all the international bodies concerned with public health agree, the Canadian PR apparatus continues to be able to call on physicians and scientists prepared to oppose the consensuses reached by the independent advisors to these bodies.

Commentary on effects of exposure to industry influence on ACOEM.

With the assistance of colleagues of like kidney, the authors of an article in this issue have drafted a damning indictment of what purports to be a learned society, as well as casting opprobrium on American Industry and its medical and scientific henchmen. In this they have not been inhibited by a legal system that imperils authors who dare call a knave a knave.

FIOH-sponsored newsletter misrepresents asbestos hazards in Zimbabwe.

The Finnish Institute of Occupational Health (FIOH) has received support from the World Health Organization (WHO) and the International Labor Office (ILO) to publish the African Newsletter on Occupational Health and Safety. The African Newsletter on Occupational Health and Safety should not be a medium for industry propaganda, or the source of misinformation among the workers of Africa. Instead, FIOH should provide the same level of scientific information in Africa that it does in Finland and other developed countries.

Revising the British Occupational Hygiene Society asbestos standard: 1968-1982.

BACKGROUND: In 1968 the British Occupational Hygiene Society (BOHS) published a chrysotile asbestos hygiene standard. As a consequence of acknowledged inadequacies of the data, it underestimated the risks of exposure, but its influence was international and operated for longer than it merited. Five years later, BOHS reported the standard not to be in need of amending, despite its own doubts and no cognizance having been taken of the cancer hazard. Within months, stung by criticism from Dr. Irving J. Selikoff, industry required it to review the standard, which BOHS continued to do for a number of years before giving up. METHODS: Material obtained for the American Courts by means of legal discovery from an asbestos company's archive, provided information on the membership of the new BOHS committees, and on its operation. RESULTS: Alterations in the composition of the new committees included importantly the introduction of certain independent scientists, whose rigor militated against the ready production of a new hygiene standard acceptable to industry. CONCLUSIONS: There was a time in Britain when a learned society might with impunity omit to consult the views of workers or their representatives when making value judgments about their health and safety, but consider it proper to accede to industry's decision as to what hygiene standard it would accept. Health and Safety at Work legislation in 1974, established an organization on which industry and labor were represented, with the onus for recommending hygiene standards. For several years the BOHS Asbestos Sub-Committee continued attempting to reconcile the interests of industry, until finally abandoning hygiene standard setting as its mission.

The last Senior Medical Inspector of Factories and his place in the history of occupational health.

BACKGROUND: Apart from a few industrialists with senses of enlightened self-interest and of ethics, 19th century Occupational Health (OH) in the United Kingdom was essentially in the care of Her Majesty's Factory Inspectorate (HMFI). Two World Wars drew attention to the special health and efficiency needs of workers in the armaments industry, but it required the climate of a Welfare State after the Second for more general provision to be considered. A number of committees made recommendations for enhancing OH that were not implemented, and it was not until 1972 that a political will developed to enhance the State's provision. As a result of a far-sighted senior civil servant, a remarkable Senior Medical Inspector was in post, ready and willing to assist in bringing about change. METHODS: Published official materials have been reviewed in the light of the author's observation of events and persons from 1967 onwards. RESULTS: For a few years, as a consequence of a political will, academic, corporate, and governmental OH burgeoned in Britain, but with a decline in the economy and political change favoring deregulation, it underwent regression. CONCLUSIONS: Any number of committees may meet to discuss OH provision but their reports will moulder until there is a will for implementing their recommendations, at which the requisite funds and persons materialize to establish institutions. When the political climate changes, it will not be difficult to find persons who for a consideration will assist in their demolition.

A report on the health of asbestos, Quebec miners 1940.

BACKGROUND: Twenty years after the start-up of the Canadian asbestos industry, reports began to appear of respiratory disease and deaths in asbestos workers in England and in France. An inquiry from the UK in 1912 as to the health of Quebec miners was met by a denial of ill-health, but the loading of the premiums of asbestos workers in the 1930s indicated that, despite further reassuring health studies on Quebec miners, actuaries had data that gave cause for serious concern. METHODS: A report made to the Canadian asbestos industry by a company doctor in 1940, reviewing the literature and presenting his health findings on some 500 employees, was studied in the context of the published information available at the time, and of unpublished contemporaneous material subsequently obtained by legal discovery. RESULTS: The physician denied that the health and longevity of Quebec's miners and millers were adversely affected, and was dismissive of earlier reports of there being serious health risks associated with working with asbestos. CONCLUSIONS: The methodology employed in his health study was defective and his denial of the literature uninformed. The study was widely circulated, and while it may have boosted Canadian industry morale, it met with a sceptical response from British industry. In denying that conditions in Quebec's asbestos mines and mills disabled and killed workers, the author allied himself to fellow professionals loyal to Government and to industry.