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The Spur-thighed tortoise (Testudo graeca) is a long-lived terrestrial reptile listed as 'Vulnerable' on the IUCN Red List and protected under CITES Appendix II. As an ecosystem engineer, it plays a vital role in Mediterranean landscapes, yet it frequently faces anthropogenic pressures in urban environments. This study provides an ecological and ethological assessment of a captive T. graeca population (n = 42) in the historical Münire Madrasa Handicrafts Bazaar in Kastamonu, Türkiye. The methodology integrated spatial carrying capacity modeling (Boullon model), systematic ethogram-based observations (120 h), and ethnozoological surveys (n = 200). Spatial analysis revealed that the population exceeds the corrected Real Carrying Capacity (RCC ≈ 10) by four times (Overcapacity Index: 4.2) within the 70 m2 area. Ethological findings documented chronic stress, with stereotypic pacing (H1) occupying 32% of the time budget, alongside a significant loss of anti-predator mechanisms due to anthropogenic habituation (İ1). While stakeholders (100%, 95% CI: 98.1-100%) perceive the tortoises as cultural symbols of abundance, the biological reality indicates severe welfare risks, including potential metabolic bone disease from a monotonous anthropogenic diet and a disrupted Ca:P ratio. The site is categorized as a 'High-Constraint Interaction Zone'. We propose a management transition toward a monitored 'Urban Wildlife Education Station' to align local cultural values with international animal welfare and conservation standards.

The implantable cardioverter defibrillator (ICD) is an effective therapeutic option for hypertrophic cardiomyopathy (HCM). However, a comprehensive quantitative synthesis in this field remains limited. This study aims to analyze the research landscape of ICD application in HCM from 2000 to 2025. Publications related to ICD use in HCM were retrieved from the Web of Science Core Collection between January 1, 2000, and November 3, 2025. Data were visually analyzed using VOSviewer and CiteSpace. A total of 864 publications from 251 countries/regions met the inclusion criteria, with the United States contributing the most. *Circulation* was identified as the most frequently cited journal in this field. Keyword cluster analysis revealed that research hotspots primarily focused on "hypertrophic cardiomyopathy," "sudden cardiac death," and "implantable cardioverter defibrillator." Furthermore, keyword burst analysis indicated that current research frontiers center on terms such as "outcome" and "association." The field of ICD application in HCM has matured and is now on the verge of a paradigm shift. Future research should focus on refining risk prediction models, evaluating long-term patient outcomes, and addressing challenges posed by novel targeted therapies.

The opioid epidemic has motivated hand surgeons to explore alternatives to postoperative pain management. We retrospectively analyzed patients who declined participation in our double-blind randomized controlled trial (RCT) comparing ibuprofen/acetaminophen to oxycodone after carpometacarpal arthroplasty. The purpose of this study was to analyze patient considerations for declining participation to elucidate perspectives on postoperative pain control. We conducted a retrospective cohort study of eligible preoperative patients approached for our RCT between February 2021 and July 2024. Rationale for declining was recorded, and demographic and clinical characteristics were extracted. Associations between baseline demographic and clinical characteristics and reasons for declining were examined. Out of 102 eligible patients approached, 62 (60.8%) enrolled while 40 (39.2%) declined. Of patients who declined, 20 participants (50.0%) cited opioid side effects or other opioid concerns. Eight patients (20.0%) were not interested in participating in research, and 6 patients (15.0%) wanted to ensure opioid access for effective pain control. Patients also cited side effects of ibuprofen/acetaminophen (2, 5.0%) or other medical concerns (4, 10.0%) when declining. Surgery on the right hand was the only significant association with the decision to enroll (P < .05), while surgery on the dominant hand was not significantly associated (P = .15). Our study identifies a trend in patient beliefs about postoperative pain control following hand surgery with half of the declined cohort referencing opioid-related concerns. Hand surgeons should consider patient perspectives when developing future postoperative pain studies and implementing protocols.

Bibliometric analysis uses citation analysis to assess the impact of the research publications. This analysis investigated the most cited articles that are exclusively on the randomized controlled trials (RCTs) in oral submucous fibrosis (OSF) to help get an overview of the clinical research published to date. Articles were searched on the Scopus database with the terms 'oral submucous fibrosis' and 'randomized controlled trial' till March 2025. The Web of Science was used for citation cross-validation with Scopus. The number of citations, journals, authors, and country of origin were all reviewed. Co-occurrence analysis was carried out with the help of VOSviewer software. The data was collected from 2006 to 2024, with the maximum research papers published in 2015. A highest citation of 129 was recorded with a mean citation of 22 (standard deviation = 30.4627). The 25 articles were published in 16 different journals with the highest impact factor of 3.4, and the majority of which (n = 20) were published by Indian authors. Co-occurrence analysis was carried out for all keywords, and 27 keywords of the total 329 keywords met the threshold. Cooccurrence of author keywords suggested 4 keywords out of a total of 58 keywords that met the need with the minimum number of occurrences of 4. Co-occurrence for index keywords showed 25 keywords meeting the threshold. This analysis shows a paucity of RCTs conducted within the field and will facilitate interpretation of the clinical data and assist researchers in conducting more clinical research in the field.

Peripherally inserted central catheters (PICCs) are vital for long-term intravenous therapy but increase the risk of venous thromboembolism (VTE), a process commonly explained through the conceptual framework of Virchow's Triad: stasis, endothelial injury, and hypercoagulability. The catheter-to-vein ratio (CVR), a key modifiable thrombosis risk factor that primarily influences stasis, lacks a universal definition, causing variability in measurement, thresholds, and clinical use. This study compares the diameter-based approach commonly cited in the literature with the area-based approach later adapted for clinical CVR tools, emphasizing that both gain from standard geometric relationships rather than distinct mathematical formulations. Through mathematical conversion, the analysis reveals that a 45% diameter-based CVR corresponds to approximately a 20% area-based CVR, underscoring substantial discrepancies when assuming equivalence. The study endorses a 20% area-based (45% diameter-based) CVR threshold for oncology patients and a 33% area-based (57% diameter-based) threshold for noncancer patients. A harmonized CVR reference is proposed to bridge the gap between methods. To enhance consistency and patient safety, the study advocates for a standardized CVR definition, consistent vein measurement techniques, and stricter control of confounders in future research. It further recommends developing a next-generation CVR calculator integrating hemodynamic and clotting risk factors to refine VTE risk assessment.

Foster care placement is a far-reaching intervention that can have substantial long-term effects on children and families. Commonly cited lifetime prevalence estimates are based on synthetic cohort life tables, which rely on a stationarity assumption that age-specific rates are stable over time. To estimate lifetime prevalence of foster care placement using a birth cohort life table approach, compare it to synthetic cohort estimates, and explore heterogeneity and dynamics in placement. U.S. children born between 2000 and 2002. We estimate lifetime prevalence for the 2000-2002 birth cohorts using a birth cohort life table approach. These cohorts are observed through age 18, allowing estimation of placement using uncensored childhood spells. Using the birth-cohort approach, an estimated 5.0% of children born between 2000 and 2002 experienced foster care placement by age 18. Risks varied substantially by ethnoracial group (Asian/Pacific Islander: 1.6%; Black: 10.0%; Native American: 12.0%; White: 3.9%). Synthetic-cohort estimates exceeded birth-cohort estimates by 16.7% (an absolute difference of 0.8-0.9 percentage points), with the largest differences at older ages and for placements attributed to child behavioral problems, non-kin family foster care, and congregate care. Substantial interstate heterogeneity was also observed. Birth cohort estimates indicate that 5% of children in the U.S. born between 2000 and 2002 were placed in foster care over their childhoods; synthetic cohort estimates are somewhat higher but are qualitatively similar. Comparisons of the two methods shed light on the changes in the use of different types of foster care over time and across geographies.

Amanda Li works with ecoAmerica to spark climate change conversations and action within local communities.

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Residual cardiovascular risk persists despite intensive statin therapy in patients with established atherosclerotic cardiovascular disease (CVD). Omega-3 fatty acids, particularly high-dose eicosapentaenoic acid (EPA), have been proposed as adjunctive therapy, yet trial results conflict, likely due to formulation differences. We conducted a formulation-focused meta-analysis to determine whether high-dose EPA-dominant supplementation reduces cardiovascular events and to quantify the impact of mixed EPA/docosahexaenoic acid (DHA) regimens on efficacy. Following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020 guidelines, we searched MEDLINE, Embase, CENTRAL, and trial registries through May 2025 for randomized controlled trials, including placebo-controlled and open-label designs, of high-dose EPA-dominant omega-3 (&#x2265;&#xa0;1.8 g/day; &#x2265;&#xa0;50% EPA) in adults with established CVD or other high-risk settings. Six trials (n = 42,738; 31-85% male) were eligible. Random-effects models generated pooled risk ratios (RRs), with I2 assessing heterogeneity; sensitivity analyses excluded mixed EPA/DHA formulations. Imaging surrogate outcomes were summarized narratively when study modalities were not directly comparable. EPA-based therapy significantly reduced hospitalizations for unstable angina (RR 0.75, 95% CI 0.66-0.87; I2 = 0%). Overall effects on recurrent myocardial infarction and revascularization were not statistically significant, but both became significant after exclusion of STRENGTH, the only mixed EPA/DHA cardiovascular outcomes trial. No significant effect was observed for ischemic stroke, cardiovascular death, or high-sensitivity C-reactive protein (hs-CRP). CHERRY and EVAPORATE both suggested attenuation of plaque progression, but these imaging studies were not pooled because intravascular ultrasound and coronary computed tomography angiography-derived measures were not directly comparable. High-dose EPA-dominant therapy was associated with fewer unstable angina hospitalizations, and formulation appeared to modify clinical benefit. Among blinded, placebo-controlled, cardiovascular outcomes trials, 4 g/day icosapent ethyl is the only formulation independently associated with reduced cardiovascular events. Larger formulation-specific trials are needed to clarify the roles of purified EPA, mixed EPA/DHA regimens, and patient selection. PROSPERO identifier number: CRD420251063069.

Comprehensive genomic profiling (CGP) has been reimbursed under Japan's universal health coverage since 2019, yet access remains uneven because designated institutions are concentrated in urban areas. Although CGP can identify actionable alterations, fewer than 10% of patients receive matched therapies, often due to geographic barriers to clinical trial enrollment. This nationwide survey evaluated institutional challenges in CGP implementation and explored the perceived role of telemedicine and decentralized clinical trials (DCTs) in improving equitable access. A web-based questionnaire was distributed to professionals involved in CGP across government-designated hospitals for cancer genomic medicine between December 2024 and February 2025. Respondents provided institutional data and perceptions regarding CGP access, telemedicine use, and barriers to trial participation. A total of 194 professionals from 140 hospitals responded. On average, 23.5% of CGP-tested patients were referred from non-designated hospitals, often requiring multiple in-person visits. Fifty-eight percent of respondents supported telemedicine for both informed consent and result disclosure, citing reduced travel burden, while concerns included digital literacy and institutional workload. Sixty-one percent reported that over half of eligible patients declined genotype-matched trials due to travel distance. Institutions facing higher dropout rates expressed greater support for DCTs (67% "strongly needed"). This nationwide study identified major geographic and logistical barriers to equitable precision oncology in Japan. Most institutions view telemedicine and DCTs as essential to expanding access to genomic testing and clinical trials. Japan's experience may offer insights for other healthcare systems considering integration of telemedicine into national precision oncology frameworks under universal health coverage.

Premenstrual symptoms are common physical, psychological, and behavioural symptoms that occur before the onset of menstruation. Despite their cyclical nature, these symptoms can be severe and burdensome, potentially interfering with daily life. Although interventions are available, help-seeking remains infrequent, raising questions about the barriers to engaging in formal care. This study employed a mixed-methods approach to examine both barriers and facilitators to help-seeking and assess their relative impact. An online survey was developed, incorporating questions about premenstrual symptoms and quantitative and qualitative questions on barriers and facilitators to formal help-seeking. Participants included both previous help-seekers and non-help-seekers to allow for group comparisons. Data were collected from 592 UK-based participants. Quantitative data were analysed descriptively, with group differences assessed using Mann-Whitney U and Chi-square tests, as appropriate. Qualitative responses were analysed using thematic analysis. 42.74% (n&#x2009;=&#x2009;253) had not previously sought formal help for premenstrual symptoms, while 57.26% (n&#x2009;=&#x2009;339) had. Overall, the most common and strongest barrier to help-seeking regarded concerns that healthcare professionals (HCPs) would not take symptoms seriously or would act dismissively. Significant group differences were observed in the barriers endorsed, with non-help-seekers being more likely to think professional care would be ineffective and wanting to solve problems on their own. Previous help-seekers were more likely to endorse previous poor care experiences as a barrier. Qualitative analysis revealed that anticipated HCP knowledge and attitudes, along with lack of awareness and education, were the most frequently reported barriers. Among non-help-seekers, improving education and awareness was commonly cited as a potential facilitator of formal help-seeking. Concerns of being dismissed or not taken seriously by HCPs was the most influential factor in deciding whether to seek help or not. Additionally, lack of awareness and education was identified as a key barrier, including uncertainty about whether symptoms were "severe" enough to justify seeking formal care and doubt regarding the range and efficacy of treatment options. To facilitate help-seeking, efforts should focus on improving education for individuals experiencing premenstrual symptoms and enhancing the quality of care interactions to address concerns about poor care experiences.

Medical trainees in Florida during Hurricane Irma learned firsthand how to fend for themselves during and after a storm.

Advance care planning (ACP) is a process that enables individuals to define and communicate their goals and preferences for future medical care, especially in chronic, progressive illnesses such as Parkinson's disease (PD) and other neurodegenerative disorders. Despite its recognized benefits in improving patient autonomy and end-of-life care outcomes, ACP remains underutilized in India. This study aimed to assess the attitudes and practices of Indian neurologists and geriatricians regarding ACP, identify perceived barriers, and suggest strategies to improve uptake. A mixed-methods approach was employed in this study. In the first phase, a structured online survey was distributed to physicians across India who cared for patients with PD and neurodegenerative disorders. The survey collected demographic information and ACP-related practices, attitudes, and perceived barriers. In the second phase, in-depth qualitative interviews were conducted with a purposively sampled subset of respondents, and inductive thematic analysis was performed to gain deeper insights. A total of 140 physicians participated in this survey. Although 93.6% acknowledged the necessity of ACP, only 25% felt they had sufficient time, and 20% felt they had adequate resources for meaningful discussions. Lack of legal clarity (52.1%), training (16.4%), and institutional support (65.7%) were commonly cited as barriers. Qualitative interviews with 15 respondents revealed additional challenges, such as concerns about provoking hopelessness and denial from patients and families. The interviews also revealed that physicians confused ACP with advanced treatment strategies or treatment of advanced disease. Nevertheless, some physicians shared positive experiences, noting that early personalized discussions improved trust and communication, which could facilitate uptake of ACP. We identified several systemic, professional, and physician-perceived sociocultural barriers that hinder ACP implementation. To bridge this gap, legal reforms, structured ACP training, and public awareness initiatives are necessary. Tailored culturally sensitive models involving multidisciplinary teams may improve ACP adoption within the Indian context. Future research could explore whether alternative terminology, such as 'future care planning', may improve clarity and acceptance in this context and avoid confusion with advanced therapies or treatment of advanced disease.

A frequently cited concern regarding patient-as-own-control trial designs in rare disease is the potential for placebo and related effects to inflate apparent treatment efficacy. Whether this concern is disqualifying or manageable has not been systematically evaluated. We reviewed meta-analyses quantifying placebo effect magnitude by endpoint type, reporter modality, and trial duration and evaluated statistical methods available for post-trial placebo adjustment in own-control designs. Placebo effects depend heavily on endpoint type. For objective endpoints (enzyme activity, serum biomarkers, imaging volumetrics)-which constitute the majority of primary endpoints in approved rare disease therapies-placebo effects are consistently small and in most meta-analyses statistically indistinguishable from zero (standardized mean difference [SMD]&#x2009;<&#x2009;0.10). For subjective endpoints (patient-reported pain, caregiver-rated function), effects are larger (SMD 0.20-0.50) but well-characterized and correctable. Placebo effects peak early and decay over weeks, providing a temporal signature distinguishable from sustained pharmacological effects. Multiple complementary analytical methods-including temporal trajectory modeling, objective-subjective concordance analysis, Bayesian informative priors, extended run-in observation designs, and blinded outcome assessment-are available to quantify and manage placebo contributions. Importantly, the randomized controlled trial's structural advantage in canceling placebo is itself degraded in small samples, where asymmetric allocation of placebo responders can distort between-arm comparisons. The placebo objection to own-control designs is manageable rather than disqualifying. For objective endpoints, correction is minimal. For subjective endpoints, a rich analytical toolkit supports credible decomposition of drug and placebo components. These findings support the broader adoption of own-control designs in rare disease clinical trials.

Patients with Medicaid compared with private insurance have increased difficulty gaining access to orthopedic care. How insurance status affects access to care for young athletes (football; from here, all "young athletes" are football players) with hip labrum tears has yet to be assessed. The purpose of this study was to determine whether there is a difference in insurance acceptance rates for Medicaid versus Blue Cross Blue Shield (BCBS) for young athletes with a hip labral tear. Fifty orthopedic clinics across 10 states were contacted using a standardized script. Each clinic was called twice: once as a young athlete with BCBS and once with a young athlete with Medicaid, requesting an appointment for a hip labral tear. The primary outcome was appointment success. Secondary outcomes included barriers to scheduling and wait times. Statistical analysis was performed using chi-squared and Mann-Whitney U tests. All clinics accepted BCBS insurance, whereas only 16 (32%) accepted Medicaid (P<0.0001). Young athletes with BCBS successfully scheduled an appointment 100% of the time compared with only 24% for young athletes with Medicaid (P<0.0001). Of the 34 clinics that did not accept Medicaid, 22 (65%) cited not accepting the insurance, and 11 (32%) required a referral. Among clinics that accepted both insurance types, there was no significant difference in median wait time (13 vs 14 days, P=0.44). For young athletes with hip labrum tears, it is more difficult to schedule appointments with Medicaid insurance compared with BCBS insurance. The main barrier to care with Medicaid for young athletes is requiring a primary care physician referral.

Drug checking services (DCS) promote drug supply awareness among people who use drugs (PWUD) by detecting adulterants such as fentanyl and xylazine that are associated with overdose morbidity and mortality. However, there is limited research on DCS implementation in Latin America (LA). We conducted a survey of 38 DCS across LA (n=10) and the US (n=28) and compared program characteristics and barriers between these two regions. We also conducted a focus group discussion (FGD) with staff representing six organizations implementing DCS in LA. FGD themes were mapped to constructs quantitatively assessed in the survey. Compared to US DCS, LA DCS more frequently reported funding gaps as a major implementation barrier (80% vs. 54%), law enforcement confiscating DCS supplies (38% vs. 11%), as well as offering supervised drug consumption (30% vs. 4%) and mental health/counseling (40% vs. 18%), but less frequently reported that DCS equipment was legal (44% vs. 75%). DCS on the Mexico-US border focused on people who inject drugs and offered syringe services, supervised consumption, and rapid sexually transmitted infection testing. DCS in central Mexico, Colombia, Peru, and Chile primarily provided DCS for the nightlife community (e.g., attendees of concerts/raves). Barriers to DCS implementation cited by FGD discussants included inadequate funding, DCS legal ambiguities, lack of government support, and cartel violence. DCS in LA would benefit from increased funding, government support, and a more permissive legal environment, thereby strengthening harm reduction efforts and improving safety for PWUD.

Generative artificial intelligence (GenAI) tools are increasingly used in scientific research to support literature searches, evidence synthesis, and manuscript preparation. While these systems promise substantial efficiency gains, concerns have emerged regarding their reliability, particularly their tendency to cite inaccurate, fabricated, or retracted literature. The unrecognized inclusion of retracted studies poses a serious risk to research integrity and evidence-based decision-making. Whether commonly used GenAI tools can reliably detect, exclude, or transparently communicate the retraction status of scientific publications remains unclear. This study aimed to evaluate the ability of freely available GenAI tools to correctly handle retracted scientific articles during literature searches. Primary and secondary outcomes focused on accuracy, reliability, and consistency in recognizing retracted literature. In this pragmatic trial, nine widely used free-access GenAI tools (ChatGPT 4, ChatGPT 5, Claude, Gemini, Perplexity, Microsoft Copilot, SciSpace, ScienceOS, and Consensus) were evaluated. Each tool was asked five predefined, standardized questions addressing topic overview, article identification, article summarization, and explicit assessment of retraction status. Overall, 15 retracted articles (the 10 most cited and 5 most recently retracted as of May 23, 2025) were selected from the Retraction Watch database. All questions were repeated twice to assess intratool consistency. Responses were independently rated as correct or incorrect by 2 researchers. Descriptive statistics summarized performance, and comparisons between general-purpose and research-focused AI tools were conducted using descriptive statistics. Interreviewer agreement was assessed using Cohen kappa coefficient. None of the evaluated AI tools consistently handled retracted articles correctly. No model achieved perfect accuracy across all question sets. ChatGPT 5 performed best, defined by the primary outcome of achieving fully correct responses to all five predefined tasks (5/5) for the highest number of retracted articles, correctly answering all five questions for 8 of 15 articles (53.3%). Research-focused tools (SciSpace, ScienceOS, and Consensus) failed to produce a single fully correct response set. Retracted articles were frequently included in topic overviews without warning, with error rates exceeding 40% in several tools. When specifically asked about retraction status, most systems failed to provide correct or complete information. OpenEvidence only reported data for a subset of our retracted articles as it is only used in health care literature. It demonstrated strong performance in topic overviews but low accuracy in identifying retracted articles. Freely available GenAI tools are currently not able to detect, exclude, or appropriately flag retracted scientific literature. The widespread and confident reproduction of retracted studies represents a substantial threat to research integrity, particularly in medical and evidence-based fields. Until retraction-aware verification mechanisms are systematically integrated, independent source checking remains essential when using AI-assisted literature tools.

Insurance companies and third-party reviewers use the peer review process including prior authorization (PA) and the peer-to-peer (P2P) process to manage healthcare costs and ensure appropriate care, citing principles of value-based care. As the volume of initial denials increases, physicians face notable time burdens and increased administrative costs while patients can incur delays and possibly worse health outcomes. We aim to explore the legal and ethical framework of utilization management; examine the effect on treating physicians, patients, and reviewers; offer suggestions for navigating peer-to-peer reviews; and propose future directions and improvement opportunities.

Digital health solutions and personalized medicine are increasingly promoted as pathways to improve health care delivery in low-resource settings, including Ghana. Drawing on insights from our examination of the published literature and our engagement with digital health research in this context, we present a scholarly viewpoint on how digital health has been positioned in relation to personalized medicine in Ghana, where progress has been uneven and largely oriented toward population-level interventions. We observe that most digital health initiatives in Ghana focus on mobile health apps and health information systems that support service delivery and access, with limited translation toward truly personalized models of care. Although personalized medicine is frequently discussed as a future goal, it remains weakly operationalized in practice, and approaches such as N-of-1 trials-often cited as exemplars of individualized care-are notably absent from the existing literature. Importantly, the limited uptake of personalized approaches does not reflect a lack of relevance in Ghana, but rather the constraints of population-level digital health strategies that, while essential, have shown limited capacity to address individual heterogeneity in treatment responses, adherence, and long-term outcomes. We argue that this absence reflects structural, methodological, and policy-related challenges. At the same time, emerging digital health infrastructure, policy interest, and research capacity present opportunities to reposition digital health as an enabler of personalized medicine. Helping many single individuals through scalable digital personalized approaches may be a valuable innovative approach to public health. This viewpoint articulates key gaps, contextual constraints, and future directions, with the aim of informing researchers, policymakers, and implementers seeking to advance personalized, data-driven care in Ghana and comparable settings.