Yan Luo

Background: Attending school can be emotionally distressing for some children and adolescents. When school attendance becomes difficult for a child and is accompanied by emotional distress, the condition is called school refusal. Contextual factors at the individual, parental, and school levels that interfere with school attendance may complicate school refusal. A 2015 systematic review of psychosocial interventions, including both randomized and non-randomized studies, reported mixed results for treating anxiety in school refusal, while showing promising results for school attendance. No systematic review or meta-analysis restricted to randomized controlled trials, however, has been conducted. We will therefore conduct a systematic review and meta-analysis of randomized controlled trials to determine whether psychosocial interventions reduce anxiety and improve school attendance among school-refusing children and adolescents. Methods: Our protocol followed the PRISMA-P guideline. We will include individually- and cluster-randomized trials in which most children and adolescents are aged 18 years or younger, are enrolled in primary or secondary education, have exhibited school absence, and received psychosocial interventions for school refusal. Our primary aim is to reduce anxiety and increase school attendance. We will search CENTRAL, MEDLINE, PsycINFO, CINAHL, ERIC, ClinicalTrials.gov, and the ICTRP. Two reviewers will independently assess the study selection, data extraction, risk of bias in included studies, and reporting bias. We will also investigate heterogeneity and conduct sensitivity analyses. We will present ‘summary of findings’ tables to show the estimated effects and the certainty of the evidence.Discussion: This will be the first systematic review to include only randomized trials and to broaden the concept of school attendance to capture the child’s engagement with learning in education.

Background: Robotic-assisted radical prostatectomy (RARP) has become the dominant approach for prostate cancer surgery, replacing open and laparoscopic procedures. However, whether the introduction of robotic surgical systems has increased the overall number of radical prostatectomies (RPs) remains unclear, particularly within social health insurance systems. Methods: We conducted a nationwide longitudinal observational study using hospital-level data from Japan between 2016 and 2023. Hospitals performing at least one RP annually and reporting complete data on robotic surgical system status and RP volume across the study period were included in the primary analysis. The primary outcome was the annual number of RPs per hospital. Using a staggered difference-in-differences (DID) design, we compared hospitals that adopted robotic surgical systems with hospitals that had not yet adopted them and estimated the association between adoption and annual hospital-level RP volume. Results: A total of 288 hospitals were categorized as 189 previous adopters, 77 new adopters, and 22 non-adopters. New adopters demonstrated a sustained increase in RP volume, rising from 2608 procedures in 2016 to 4371 in 2023, whereas RP volumes among previous adopters and non-adopters remained stable. Compared with hospitals that had not yet adopted robotic surgical systems, adoption was associated with an increase of 17.4 RPs per hospital per year (95% CI, 10.7 to 24.1). No significant differences were observed between groups during the pre-adoption period, consistent with the parallel trends assumption. Conclusion: In Japan’s social health insurance context, adoption of robotic surgical systems was associated with a significant and sustained rise in RP volume. These findings highlight the need for further research to determine whether the observed increase reflects changes in patient selection, referral patterns, clinical appropriateness, or other mechanisms, as well as the associated clinical and economic implications.

Background: Japan is one of the most rapidly ageing societies in the world and has experienced sustained population decline since 2008. Anticipating how these demographic changes will influence future inpatient demand is essential for planning hospital capacity and health care delivery. Methods: This repeated cross-sectional study used nationwide aggregated data from Japan’s Patient Survey (1999–2023) and population data from the national census and official projections. We modelled age-, sex-, and prefecture-specific inpatient utilization using three approaches: age–period–cohort models, statistical trend models (including linear, log-linear, and spline specifications), and conservative scenario models. Projected utilizations were applied to municipal population projections using indirect standardization, and results were aggregated to prefectural and national levels for 2025–2050. Findings: Between 1999 and 2023, inpatient utilization and the number of inpatients declined despite population ageing. Most models projected continued declines in utilization across age groups. When combined with population projections, total inpatient was projected to decrease toward 2050. Conservative scenarios suggested temporary stabilization or slight increases around 2030, but long-term trends remained downward. Spatial analyses showed increasing concentration of demand in metropolitan and regional centres, while many peripheral municipalities were projected to experience very low inpatient volumes. Interpretation: In Japan, inpatient demand is likely to decline and become increasingly concentrated in urban areas despite continued ageing. These findings highlight the need for region-specific strategies to optimize hospital capacity and adapt health systems to population decline.

Aim: To determine the smallest worthwhile difference (SWD) for lecanemab, a disease‐modifying drug for Alzheimer's disease (AD), among the general Japanese population using a benefit‐harm trade‐off method. Methods: We conducted an online survey with 658 participants to evaluate their preferences for the treatment effect of lecanemab, given its associated risks and high cost. We calculated SWD as the minimum required increase in the possibility of maintaining cognitive function (relative to the 50% without lecanemab) that patients would accept in exchange for the burdens of treatment (adverse effects, costs, other inconveniences). We examined the median SWD for two scenarios: a family member (SWD‐families) and others (SWD‐others), and analyzed subgroup differences. Results: The median SWD revealed a 15% increase for SWD‐families and SWD‐others. This value exceeds the drug's actual efficacy of an 8% increase. Notably, 17% of respondents reported zero SWD, driven by an intense fear of AD and possibly high expectations from media coverage. Including these participants, nearly half of the respondents considered the current effect worthwhile. No noticeable difference was found between the SWD‐families and SWD‐others. Conclusion: Based on Japanese clinical scenarios, the public's median expectation for lecanemab exceeds its efficacy, though its current benefit remains acceptable to nearly half the population. These findings underscore that the SWD is shaped by psychological drivers, including fear and hope, rather than just reasoned evaluation. Clinicians must manage these expectations, accounting for highly heterogeneous treatment preferences. Future research should account for emotional factors that can overshadow a rational assessment of treatment value.

Background: Smartphone-based cognitive behavioral therapy (CBT) programs offer accessible interventions for subthreshold depression, yet engagement needed for meaningful benefit remains unclear. We examined how lesson and worksheet engagement relate to depressive symptom improvements in a behavioral activation (BA) intervention, accounting for time-varying confounders. Methods: This secondary analysis included 298 adults assigned to the BA arm of the RESiLIENT trial, a randomized controlled trial in Japan. Lesson and worksheet completion were treated as time-varying exposures, each yielding four engagement patterns: minimal (Few-Few) , early (Many-Few) , late (Few-Many) , and consistently high (Many-Many). Outcomes were depressive symptom changes measured by the Patient Health Questionnaire-9 (PHQ-9) at weeks 6 and 26. We applied the parametric g-formula to estimate counterfactual PHQ-9 changes under each pattern, adjusting for baseline and time-varying confounders. Results: Early lesson engagement during weeks 0–3 was associated with larger PHQ-9 reductions at both weeks 6 and 26, even when later engagement declined ( Many-Few vs. Few-Few : week 6: −1.47 [95% CI −2.52 to −0.53]; week 26: −1.27 [−2.53 to −0.17]). In contrast, higher worksheet engagement was linked to improved PHQ-9 at week 6, with maximal benefit among consistently high engagers ( Many-Many vs. Few-Few : −1.25 [−2.17 to −0.44]) and late engagers ( Few-Many vs. Few-Few : −1.18 [−2.20 to −0.08]), but not persist to week 26. Conclusions: Greater engagement with smartphone-delivered BA is associated with larger symptom reductions. Early lesson engagement drives sustained benefit, whereas worksheet engagement did not persist. These findings may guide digital CBT design by emphasizing early lesson completion alongside concurrent skill practice.

Introduction The global burden of depression continues to rise despite evidence that prevention is feasible and cost-effective. Building on the Resilience Enhancement with Smartphone in Living ENvironmenTs (RESiLIENT) randomised controlled trial, the Best, Efficient and Affordable Training in Resilience in Constant Evolution (BEATRICE) platform trial evaluates and optimises smartphone-delivered cognitive–behavioural therapy (CBT) for adults with no to subthreshold depression. The primary objective is to minimise the Total Burden of Depression, measured by the integral of weekly to monthly Patient Health Questionnaire-8 (PHQ-8) scores over 12 months, through a living, adaptive platform trial that sequentially tests multiple clinical questions and personalised algorithms. Methods and analysis BEATRICE is a nationwide, digitally centralised, multi-arm platform trial conducted via the ‘Resilience Training App’. Eligible participants are adults (aged ≥18 years) with PHQ-8 ≤14, fluent in Japanese, owning a smartphone and not currently receiving mental health treatment. Recruitment takes place through health-insurance associations, companies, municipalities and online outreach. Participants are randomised centrally to CBT skill modules—behavioural activation, assertion training, behaviour therapy for insomnia, cognitive restructuringor problem-solving—delivered alone or in combination. Assessments are open-label and completed digitally by self-reports. The initial list of clinical questions to be examined in this platform trial includes: external validity of the personalised and optimised algorithm for first-line interventions, strategies to help individuals not on track during initial weeks, second-line interventions at 6 months, development of super-personalised and optimised therapy algorithm, that is, longitudinally personalised and optimised in response to individuals’ responses after the first-line assignment. The primary outcomes, sample sizes and statistical analyses differ depending on the clinical question addressed within the platform trial. Ethics and dissemination Approved by the Ethics Committee of Kyoto University Graduate School of Medicine (C1733). Results will be disseminated via peer-reviewed publications, conferences and public reports. Trial registration number UMIN000058696.

Background: Psychotherapy is proven efficacious for the treatment of alcohol use disorder (AUD). However, the patient-perceived importance of its effect is not fully appreciated in the evidence base. The smallest worthwhile difference (SWD) represents the smallest beneficial effect of an intervention that patients deem worthwhile in exchange for the harms, expenses, and inconveniences associated with the intervention, and facilitates the interpretation of patient perceived worthiness of an intervention. Methods: The proposed study will estimate the SWD of NIAAA recommended psychotherapies for AUD treatment with English-speaking American respondents aged 18 and older. Primary participants will be recruited using the Prolific research crowdsourcing site. The SWD will be estimated using the Benefit-Harm Trade-off Method, presenting survey respondents with variable, hypothetical magnitudes of psychotherapy outcomes to find the smallest acceptable effect over a natural recovery alternative. The overall average SWD, and subgroup distributions by participant AUD treatment experiences and AUD symptomology will be described. Secondary findings will estimate the smallest recommendable risk difference for AUD psychotherapy from providers and criminal justice professionals. Expected Results: We expect to find an estimate of the SWD for AUD psychotherapy. Further, we expect that the SWD will vary between clinical subgroups based on AUD symptomology and treatment experiences. We expect differences in SWDs between the general population and those of providers and criminal justice professionals. Findings from this project will inform the treatment decision process about psychotherapy during the clinical consultation for people with AUD.

Background: The smallest worthwhile difference (SWD) represents the smallest beneficial effect of an intervention that patients deem worthwhile given the harms, expenses and inconveniences of the intervention. The SWD facilitates interpretation of the patient-perceived importance of intervention effects. We previously estimated the SWD for antidepressants for depression, but the SWD for psychotherapy remains unknown. Aims: To estimate the SWD of recommended psychotherapies for depression compared with no treatment. Method: We estimated the SWD through a patient required difference in response rates between psychotherapy and no treatment after 2 months. We recruited using Prolific, an online cross-sectional survey platform, in the UK and USA in January 2025. We also queried a random subset of respondents to replicate our previous SWD estimation for antidepressants. Results: In the primary study, we recruited 526 participants (mean age: 36.7 years (s.d. = 12.5); 54% women and 61% White individuals). Of these, 6% reported that they would not initiate psychotherapy with a 100% treatment response. For those willing to initiate psychotherapy, 87 reported moderate-to-severe depressive symptoms but were not in treatment, 184 were in treatment and 131 reported absent-to-mild symptoms with or without previous treatment. The median SWD for people with moderate-to-severe depressive symptoms, not in treatment and willing to consider psychotherapies was a 20% (interquartile range: 10–35%) difference in response rates comparing psychotherapy with no treatment. This was similar to the SWD for antidepressant drugs (SWD = 20%, interquartile range: 10–30%; n = 104). Participant characteristics were not meaningfully associated with the SWD. Conclusions: Current empirically supported psychotherapy response rates of 15% were sufficient for one in three people to initiate psychotherapy given the burdens, but two in three expected greater treatment benefits or fewer burdens. The SWD for psychotherapy was not materially different from the estimated SWD for antidepressants. Individual patient value judgements and preferences merit greater attention. These findings should be replicated with diverse samples from different geographical locations.

BACKGROUND Alcohol use is one of the largest worldwide contributors to morbidity and mortality, and a major risk factor for esophageal cancer. Reducing or stopping alcohol use results in a significant esophageal cancer risk reduction. A causal factor in alcohol-related esophageal cancer is exposure to acetaldehyde, an alcohol metabolite and established carcinogen. Japanese people have a high proportion of the aldehyde dehydrogenase 2*2 (ALDH2*2) allele, which causes a deficiency in ALDH2 enzyme activity and increases exposure to acetaldehyde, elevating their risks of esophageal cancer. Personalized health information about such risks can be important in developing motivation to moderate alcohol consumption. Fortunately, brief intervention (BI) for unhealthy alcohol use is an effective behavioral intervention that can capitalize on this motivation source but is underused in Japan. OBJECTIVE The proposed project will test the efficacy of an unguided web-based BI using genetic cancer risk education to reduce alcohol consumption in a randomized controlled trial. METHODS Participants will be recruited online and screened for moderate alcohol use and probable ALDH2*2 allele. Included participants will be randomized to an experimental BI condition or sham educational control. The experimental condition will receive an unguided web-based brief video intervention. The intervention will educate participants about their probable genetic risk, how consuming alcohol significantly increases risk of esophageal cancers, and the benefits of reducing or stopping alcohol use. The primary outcome is mean endpoint past 4-week alcohol quantity at 3-months post-randomization. Additionally, secondary main effects will be investigated with alcohol use in grams, severity, motivation to change, health knowledge retention, participant satisfaction, and quality of life. Assessments will be collected at baseline, 1-, 2-, and 3-months post-randomization through a web portal. RESULTS The present study was funded in April 2024. Data collection is projected to occur August 2025 – August 2026 through a Japanese research panel company. Currently, no data has been collected. CONCLUSIONS This intervention is expected to reduce unhealthy alcohol use at a low cost of implementation by using personalized health information as a motivational factor in a general population. Additional group differences are expected to be observed in secondary alcohol use outcomes. CLINICALTRIAL This trial has been registered in University Hospital Medical Information Network Clinical Trials Registry (UMIN000058012).