Impact of a learning health system on acute care and medical complications after intracerebral hemorrhage

Introduction: Patients with stroke often experience pneumonia during the acute stage after stroke onset. Oral care may be effective in reducing the risk of stroke‐associated pneumonia (SAP). We aimed to determine the changes in oral care, as well as the incidence of SAP, in patients with intracerebral hemorrhage, following implementation of a learning health system in our hospital. Methods: We retrospectively analyzed the data of 1716 patients with intracerebral hemorrhage who were hospitalized at a single stroke center in Japan between January 2012 and December 2018. Data were stratified on the basis of three periods of evolving oral care: period A, during which conventional, empirically driven oral care was provided (n = 725); period B, during which standardized oral care was introduced, with SAP prophylaxis based on known risk factors (n = 469); and period C, during which oral care was risk‐appropriate based on learning health system data (n = 522). Logistic regression analysis was performed to evaluate associations between each of the three treatment approaches and the risk of SAP. Results: Among the included patients, the mean age was 71.3 ± 13.6 years; 52.6% of patients were men. During the course of each period, the frequency of oral care within 24 hours of admission increased (P < .001), as did the adherence rate to oral care ≥3 times per day (P < .001). After adjustment for confounding factors, a change in the risk of SAP was not observed in period B; however, the risk significantly decreased in period C (odds ratio 0.61; 95% confidence interval 0.43‐0.87) compared with period A. These associations were maintained for SAP diagnosed using strict clinical criteria or after exclusion of 174 patients who underwent neurosurgical treatment. Conclusions: Risk‐appropriate care informed by the use of learning health system data could improve care and potentially reduce the risk of SAP in patients with intracerebral hemorrhage in the acute stage

Inappropriate implantable cardioverter defibrillator shocks—incidence, effect, and implications for driver licensing

PurposePatients with implantable cardioverter defibrillators (ICDs) have an ongoing risk of sudden incapacitation that may cause traffic accidents. However, there are limited data on the magnitude of this risk after inappropriate ICD therapies. We studied the rate of syncope associated with inappropriate ICD therapies to provide a scientific basis for formulating driving restrictions.MethodsInappropriate ICD therapy event data between 1997 and 2014 from 50 Japanese institutions were analyzed retrospectively. The annual risk of harm (RH) to others posed by a driver with an ICD was calculated for private driving habits. We used a commonly employed annual RH to others of 5 in 100,000 (0.005%) as an acceptable risk threshold.ResultsOf the 4089 patients, 772 inappropriate ICD therapies occurred in 417 patients (age 61 ± 15 years, 74% male, and 65% secondary prevention). Patients experiencing inappropriate therapies had a mean number of 1.8 ± 1.5 therapy episodes during a median follow-up period of 3.9 years. No significant differences were found in the age, sex, or number of inappropriate therapies between patients receiving ICDs for primary or secondary prevention. Only three patients (0.7%) experienced syncope associated with inappropriate therapies. The maximum annual RH to others after the first therapy in primary and secondary prevention patients was calculated to be 0.11 in 100,000 and 0.12 in 100,000, respectively.ConclusionsWe found that the annual RH from driving was far below the commonly cited acceptable risk threshold. Our data provide useful information to supplement current recommendations on driving restrictions in ICD patients with private driving habits

Protocol for a multicentre, prospective observational study of elective neck dissection for clinically node-negative oral tongue squamous cell carcinoma (END-TC study)

Introduction: In early-stage oral tongue squamous cell carcinoma (OTSCC), elective neck dissection (END) is recommended when occult lymph node metastasis is suspected; however, there is no unanimous consensus on the risks and benefits of END in such cases. The management of clinically node-negative (cN0) OTSCC remains controversial. This study, therefore, aimed to evaluate the efficacy of END and its impact on the quality of life (QoL) of patients with cN0 OTSCC. Methods and analysis: This is a prospective, multicentre, nonrandomised observational study. The choice of whether to perform END at the same time as resection of the primary tumour is based on institutional policy and patient preference. The primary endpoint of this study is 3-year overall survival. The secondary endpoint are 3-year disease-specific survival, 3-year relapse-free survival and the impact on patient QoL. Propensity score-matching analysis will be performed to reduce selection bias. Ethics and dissemination: This study was approved by the Clinical Research Review Board of the Nagasaki University. The protocol of this study was registered at the University Hospital Medical Information Network Clinical Trials Registry. The datasets generated during the current study will be available from the corresponding author on reasonable request. The results will be disseminated internationally, through scientific and professional conferences and in peer-reviewed medical journals

Protocol for a multicentre, prospective observational study of elective neck dissection for clinically node-negative oral tongue squamous cell carcinoma (END-TC study)

Introduction In early-stage oral tongue squamous cell carcinoma (OTSCC), elective neck dissection (END) is recommended when occult lymph node metastasis issuspected; however, there is no unanimous consensus on the risks and benefits of END in such cases. The management of clinically node-negative (cN0) OTSCCremains controversial. This study, therefore, aimed to evaluate the efficacy of END and its impact on the quality of life (QoL) of patients with cN0 OTSCC.Methods and analysis This is a prospective, multicentre, nonrandomised observational study. The choice of whether to perform END at the same time as resection of the primary tumour is based on institutional policy and patient preference. The primary endpoint of this study is 3-year overall survival. The secondary endpoints are3-year disease-specific survival, 3-year relapse-free survival and the impact on patient QoL. Propensity score-matching analysis will be performed to reduce selection bias.Ethics and dissemination This study was approved by the Clinical Research Review Board of the Nagasaki University. The protocol of this study was registered at the University Hospital Medical Information Network Clinical Trials Registry. The datasets generated during the current study will be available from the correspondingauthor on reasonable request. The results will be disseminated internationally, through scientific and professional conferences and in peer-reviewed medical journals

Secular Strategies of Religious Communities : Studies of the monasteries in medieval England

平成15年度～平成18年度科学研究費補助金基盤研究（C)研究成果報告書研究概要：本研究は、修道院を利益集団である「企業体」として捉え直し、イングランド東部のイースト・アングリア地方を中心に、アングロ=ノルマン期の社会における宗教的共同体としての修道院の実態とその世俗的戦略の特徴を解明することを目指した。宮城は、11世紀初頭に創設されたベリー・セント・エドマンズ修道院を取り上げ、イースト・アングリア地方の多くの修道院が「ノルマン征服」を通じてその既得権益を侵害・剥奪される中、ベリー・セント・エドマンズ修道院が教会財産の損失を比較的最小限度に止めることが出来たことを明らかにした。そして、ベリー・セント・エドマンズ修道院長ボールドウィンが推進した国王ウィリアム1世との密接な協調関係の利用や教会財産の維持・管理政策における文書記録の積極的な活用といった世俗的な戦略が、「ノルマン征服」後の修道院の既得権益の保全に際して決定的に有利に働いたことを指摘した。山代は、ノリッジ司教ハーバート=ロシンガの港町リンやヤーマスでの修道院建設を分析し、ノリッジ司教座付属修道院の立地戦略的に重要な場所への子院の建設が、イースト・アングリア司教区の統治を目指す政治的合理性を持つ優れて戦略的な政策であったことを明らかにした。山代はまた、アウグスティヌス派律修聖職者達の活動を分析し、彼等による修道院の建設が、カンタベリー大司教やヨーク大司教のみならず、国王や王妃、さらには国王や王妃のチャプレン達といった、聖俗の有力者達をパトロンとして構築された人的ネットワークを戦略的に利用しながら行なわれた事業であったことを究明した。研究概要（欧文）：The research has aimed to clarify a real image of the monasteries as a religious enterprise and some characteristics of their secular strategies in East Anglia at the Anglo-Norman period. Miyagi clarified that the abbey of Bury St Edmunds could keep the damage on its possessions to a minimum, though many monasteries in East Anglia suffered considerable losses in their vested interests through the Norman Conquest. He also pointed out that some secular strategies driven by Baldwin abbot of Bury St Edmunds, such as the use of his personal connection to William the Conqueror and the introduction of the documents into the administration of the estates, enabled the abbey to strive for the maintenance of its possessions after the Norman Conquest. Yamashiro clarified that the foundations of the cells in the important places, such as Bishop's Lynn and Yarmouth, by Herbert Losinga bishop of Norwich were strategic policies to aim the government in the diocese of East Anglia. Yamashiro also made it clear that the monastic foundations by Augustinians were carried out strategically through the using of the personal network constructed between them and many magnates as a patron