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A bstract In this study, we carry out a non-perturbative approach to a quantum Otto engine, employing an Unruh-DeWitt particle detector to extract work from a quantum Klein-Gordon field in an arbitrary globally hyperbolic curved spacetime. We broaden the scope by considering the field in any quasi-free state, which includes vacuum, thermal, and squeezed states. A key aspect of our method is the instantaneous interaction between the detector and the field, which enables a thorough non-perturbative analysis. We demonstrate that the detector can successfully extract positive work from the quantum Otto cycle, even when two isochoric processes occur instantaneously, provided the detector in the second isochoric process receives a signal from the first interaction. This signaling allows the detector to release heat into the field, thereby the thermodynamic cycle is completed. As a demonstration, we consider a detector at rest in flat spacetime and compute the work extracted from the Minkowski vacuum state.

We analyze a tripartite entanglement harvesting protocol with three Unruh-DeWitt detectors adiabatically interacting with a quantum scalar field in (3+1) -dimensional Minkowski spacetime. We consider linear, equilateral triangular, and scalene triangular configurations for the detectors, all of which remain static. We find that, under the same parameters, more entanglement can be extracted in the linear configuration than the equilateral one, consistent with single instantaneous switching results. No bipartite entanglement is required to harvest tripartite entanglement. Furthermore, we find that tripartite entanglement can be harvested even if one detector is at larger spacelike separations from the other two than in the corresponding bipartite case. We also find that for small detector separations bipartite correlations become larger than tripartite ones, leading to an apparent violation of the Coffman-Kundu-Wootters (CKW) inequality. We show that this is not a consequence of our perturbative expansion but that it instead occurs because the harvesting qubits are in a mixed state.

Both physicians and patients are proactive towards managing seasonal influenza in Japan and six drugs are approved. Although many countries have national influenza surveillance systems, data on nationwide prescription practices of anti-influenza drugs are lacking. Therefore, we aimed to clarify the status of anti-influenza drug use in Japan by analyzing real-world data. This retrospective study analyzed open data from the National Database of Health Insurance Claims and Specific Health Checkups, which covers most claims data from national health insurance. We estimated the annual number of patients prescribed anti-influenza drugs, which drugs they were prescribed, the patients' age and sex distribution, drug costs, and regional disparities for the period 2014-2020. For 2014-2019, an estimated 6.7-13.4 million patients per year were prescribed anti-influenza drugs, with an annual cost of 22.3-48.0 billion JPY (Japanese Yen). In addition, 21.1-32.0 million rapid antigen tests were performed at a cost of 30.1-47.1 billion JPY. In 2017, laninamivir was the most frequently prescribed anti-influenza drug (48%), followed by oseltamivir (36%), while in 2018, the newly introduced baloxavir accounted for 40.8% of prescriptions. After the emergence of COVID-19, the estimated number of patients prescribed anti-influenza drugs in 2020 dropped to just 14,000. In 2018, 37.6% of prescriptions were for patients aged < 20 years compared with 12.2% for those aged [greater than or equal to] 65 years. Prescriptions for inpatients accounted for 1.1%, and the proportion of prescriptions for inpatients increased with age, with men were more likely than women to be prescribed anti-influenza drugs while hospitalized. Based on our clarification of how influenza is clinically managed in Japan, future work should evaluate the clinical and economic aspects of proactively prescribing anti-influenza drugs.

Gastric cancer is a common malignancy with a high incidence in East Asia. Gastric resection ranges from endoscopic resection to open total gastrectomy. However, nationwide data are lacking. This observational study analyzed data from the publicly accessible National Database of Health Insurance Claims and Specific Health Checkups, which includes most national health insurance claims data in Japan. Trends in the types of resection performed for malignant gastric tumors between 2014 and 2021, patients' age and sex distributions, and regional disparities were investigated. The annual number of resections was highest in 2015 (109,000) and lowest in 2020 (90,000) after the COVID-19 pandemic. The proportion of endoscopic resections increased from 47% in 2014 to 57% in 2021 while that of total gastrectomies decreased from 17 to 10%. In 2021, 70% of patients who underwent resection were men. That year, 83.8% of all patients who underwent any type of gastric resection and 87.1% of those who underwent endoscopic submucosal dissection were aged ≥ 65 years. The annual incidence of gastric resection per million population was highest in Tottori (n = 1236) and lowest in Okinawa (n = 251). The proportion of endoscopic resections was highest in Miyagi (66%) and lowest in Aichi (45%) and that of open surgery was highest in Aomori (36%) and lowest in Wakayama (5%). Gastric malignancy is increasingly treated by endoscopic submucosal dissection rather than open total gastrectomy. However, regional disparities remain in resection type. Standardization of treatment and a more even distribution of specialists are needed.

Cognitive behavioral therapy is known to improve the management of chronic pain. However, the components of this therapy are still being investigated and debated. This study aimed to examine the effectiveness of an integrated cognitive behavioral therapy program with new components (attention-shift, memory work, video feedback, and image training) delivered via videoconferencing. This study was unblinded and participants were recruited and assessed face-to-face in the outpatient department. We conducted a randomized controlled trial for chronic pain to compare 16 weekly videoconference-based cognitive behavioral therapy (vCBT) sessions provided by a therapist with treatment as usual (TAU). Thirty patients (age range, 22-75 years) with chronic pain were randomly assigned to either vCBT (n=15) or TAU (n=15). Patients were evaluated at week 1 (baseline), week 8 (midintervention), and week 16 (postintervention). The primary outcome was the change in pain intensity, which was recorded using the numerical rating scale at 16 weeks from the baseline. Secondary outcomes were pain severity and pain interference, which were assessed using the Brief Pain Inventory. Additionally, we evaluated disability, pain catastrophizing cognition, depression, anxiety, quality of life, and cost utility. In the eligibility assessment, 30 patients were eventually randomized and enrolled; finally, 15 patients in the vCBT and 14 patients in the TAU group were analyzed. Although no significant difference was found between the 2 groups in terms of changes in pain intensity by the numerical rating scale scores at week 16 from baseline (P=.36), there was a significant improvement in the comprehensive evaluation of pain by total score of Brief Pain Inventory (-1.43, 95% CI -2.49 to -0.37, df=24; P=.01). Further, significant improvement was seen in pain interference by using the Brief Pain Inventory (-9.42, 95% CI -14.47 to -4.36, df=25; P=.001) and in disability by using the Pain Disability Assessment Scale (-1.95, 95% CI -3.33 to -0.56, df=24; P=.008) compared with TAU. As for the Medical Economic Evaluation, the incremental cost-effectiveness ratio for 1 year was estimated at 2.9 million yen (about US $25,000) per quality-adjusted life year gained. The findings of our study suggest that integrated cognitive behavioral therapy delivered by videoconferencing in regular medical care may reduce pain interference but not pain intensity. Further, this treatment method may be cost-effective, although this needs to be further verified using a larger sample size. University Hospital Medical Information Network UMIN000031124; https://tinyurl.com/2pr3xszb.

Background: Nationwide epidemiologic studies in Scandinavian countries have shown that the incidence of Achilles tendon ruptures (ATRs) has increased, and the rate of surgical treatment has declined markedly in the past decade. However, there is a lack of national-level data on the trend of ATRs and surgical procedures in other regions. Purpose: To clarify the trend in the incidence of ATRs and the proportion of surgery using the nationwide health care database in Japan. Study Design: Descriptive epidemiology study. Methods: Age- and sex-stratified data on the annual number of ATRs and surgical procedures between 2010 and 2017 were obtained from the Japanese national health care database, which includes almost all inpatient and outpatient medical claims nationwide. The Japanese population data were also obtained from the population census. The change in the annual incidence of ATRs per 100,000 people was assessed using a Poisson regression analysis. The trend in the annual proportion of surgeries relative to the occurrence of tendon ruptures was determined using a linear regression analysis. Results: A total of 112,601 ATRs, with men accounting for 67%, were identified over 8 years. Patients aged ≥60 years accounted for 27,106 (24%), while those aged 20 to 39 years and 40 to 59 years accounted for 36,164 (32%) and 49,331 (44%), respectively. The annual incidence of ATR ranged from 12.8/100,000 to 13.9/100,000 (women, 8.2-8.9/100,000; men, 17.2-19.5/100,000), which did not change over the study period (P = .82). Moreover, the annual incidences did not change across sexes and age categories. The annual proportion of surgery increased significantly, from 67% in 2010 to 72% in 2017 (P = .003). The annual proportions increased across sexes and age categories except for women aged 40 to 59 years. Conclusion: The incidence of ATR did not change between 2010 and 2017, according to the Japanese nationwide health care database. Furthermore, the proportion of surgical treatment increased during the study period. Overall, 70% of patients underwent surgical treatment. This study suggested that the trend in ATR and surgery differed across regions.

Aim The mental healthcare system in Japan is transitioning from institution‐based to community‐based treatment. To prevent prolonged hospitalization and community integration of psychiatric patients, mental health social workers (MHSWs) are pivotal in coordinating post‐discharge arrangements for psychiatric inpatients. This study aimed to propose a care model to improve clinical outcomes in psychiatric emergency wards in Japan. Methods We conducted a mail‐in questionnaire survey targeting medical facilities with psychiatric emergency wards. We collected data of the psychiatric care system, including facility profiles, staffing conditions and caseloads, and the provided psychiatric services and treatment options. Using multiple regression analyses, we explored associations between these data and clinical outcomes, focusing on the average number of days for hospitalization and the integration of patients into a community. Results Data were collected from 82 facilities (response rate, 45.8%). The average number of days for hospitalization and community integration were 64.7 and 327.9 days, respectively. The caseloads for MHSWs were significantly associated with longer hospitalization (β = 0.31, p = 0.009) and shorter duration of community living (β = −0.28, p = 0.027). Conclusion The clinical performance in psychiatric emergency wards surpassed the Japanese government's targets regarding these outcomes. We found that heavy caseloads on MHSWs were associated with worse clinical outcomes for patients in psychiatric emergency wards. These findings suggest that reducing MHSW caseloads (≤20 cases) may be a potential interventional strategy to prevent prolonged hospitalization and promote successful community integration of patients. In this study on psychiatric care in Japan, the relationship between mental health social worker (MHSW) caseloads and clinical outcomes was investigated to improve patient care in psychiatric emergency wards. Data from 82 facilities revealed that high MHSW caseloads were linked to longer hospital stays and shorter community integration durations. The study suggests that maintaining MHSW caseloads at or below 20 cases could be an effective strategy to prevent prolonged hospitalization and enhance patient integration into the community.

ObjectivesTo clarify the dissemination status of cognitive behavioural therapy (CBT) in Japan under the national health insurance scheme.DesignRetrospective observational study.SettingNational Database of Health Insurance Claims and Specific Health Checkups of Japan.ParticipantsPatients who received CBT under the national health insurance scheme from fiscal years (FY) 2010 to 2015.Primary and secondary outcome measuresWe estimated the change rate and the standardised claim ratio (SCR) for the number of patients receiving CBT and analysed the association between the CBT status and several regional factors.ResultsWe found that (a) a total of 60 304 patients received CBT during the study period; (b) the number of patients receiving CBT was highest in the first year (−1.8% from FY2010 to FY2015); (c) the number of patients who received CBT per 100 000 population decreased (or remained at zero) in most prefectures (32 out of 47); (d) there was a maximum 424.7-fold difference between prefectures in the standardised claim ratio for CBT and (e) the number of registered CBT institutions was significantly associated with the number of patients who received CBT.ConclusionsThe provision of CBT did not increase in the first 6 years (FY2010–2015) after its coverage in Japan’s national health insurance scheme. Further studies including a questionnaire survey of registered CBT institutions are required to get more detailed information on the dissemination of CBT in Japan.

Physician maldistribution remains a global challenge, with Japan's rural regions facing critical health care shortages. Regional quota programs aim to attract medical students to underserved areas; however, their effectiveness in fostering long-term commitment is uncertain. Community-oriented medical education (COME) programs aim to address this issue by developing students' understanding and dedication to rural health care. This study investigated the impact of an enhanced COME program, featuring increased early clinical exposure and faculty development, on first-year regional quota medical students' perception of community health care at Chiba University. We conducted a cross-sectional qualitative study comparing 2 cohorts, 20 students enrolled from the existing COME course (April-December 2021) and 20 from the revised course (April-December 2022). The revised course included an additional day of community-based clinical exposure supervised by COME-trained attending physicians. Students' written reflections were analyzed using qualitative content analysis and categorized according to the Fink Taxonomy of significant learning, comprising 6 domains, including foundational knowledge, application, integration, human dimension, caring, and learning how to learn. Reflections were synthesized into higher-order themes crosswalked to the Fink domains. Demographics were similar between the 2021 and 2022 cohorts. In 2021, 311 learning codes were identified across foundational knowledge (n=128), application (n=91), integration (n=40), human dimension (n=16), caring (n=30), and learning how to learn (n=6). In 2022, codes increased to 385, with notable growth in caring (n=58) and human dimension (n=57), alongside increases in learning how to learn (n=15) and integration (n=45). Theme-based synthesis identified four overarching themes: (1) community health care as an interconnected, resource-constrained system; (2) patient-centered relationships and trust through communication and teamwork; (3) emerging professional identity and responsibility toward community service; and (4) developing a self-directed learning orientation for community practice. Qualitative analysis revealed that students gained a deeper understanding of patient-centered care, interprofessional collaboration, and social challenges in rural health care. The consistency in the foundational knowledge domain underscored a stable conceptual foundation, while the increase in affective and reflective domains reflected greater emphasis on interpersonal, value-oriented, and reflective learning in the revised cohort. Enhancements of the COME program, including additional early clinical exposure and faculty development, were associated with improved students' perceptions of community health care. The increased focus on the caring and human dimension domains underscores the role of practical experiences in fostering collaboration, communication, and patient-centered care. The theme-based synthesis further suggests that the revised program prompted more frequent reflections on professional identity formation and self-directed learning while maintaining a stable foundation of community health care concepts. Mentorship by community hospital attendings, alongside structured clinical exposure, appears crucial in shaping medical students' understanding and commitment to rural medicine. Ongoing longitudinal evaluations are warranted to assess the sustained impact of COME programs on career trajectories in underserved areas.