Cardiac rehabilitation is not a luxury intervention. It is a structured chronic disease management program, typically beginning in the hospital and continuing as an outpatient service before transitioning into longer-term community-based secondary prevention. The programs combine supervised exercise, education on healthy living, and stress counselling, and they are designed to improve outcomes for patients recovering from cardiac events or living with ongoing cardiovascular disease. The evidence base is robust: participation reduces mortality by more than 25 percent and hospitalization by nearly 20 percent. Multiple studies have also documented improvements in quality of life and reductions in hospital readmissions. In clinical terms, few interventions in cardiovascular medicine deliver so much benefit for so relatively little cost, which is precisely why the new findings have unsettled the researchers behind them.

The audit identified close to 7,000 cardiac rehabilitation programs across 90 countries. Within that total, 1,233 programs in 40 countries provided detailed information about hybrid and alternative delivery models, which blend clinic-based and home-based care and are generally cheaper to operate and easier for patients to attend. Of those 1,233 programs, only 286 indicated that they received reimbursement from governments or insurance companies for hybrid or alternative delivery. Overall, hybrid and alternative models accounted for roughly one third of all programs offered globally, and only about one quarter of them were reimbursed. For the study’s authors, including York University and University of Toronto Adjunct Professor Gabriela Lima de Melo Ghisi, York Professor Sherry Grace of the Faculty of Health, and graduate student Rachael Carson, the picture is one of under-utilization in the face of proven effectiveness.

Perhaps the most striking pattern in the data is the mismatch between disease burden and program availability when countries are sorted by income classification. In high-income nations, the ratio of programs to cases of ischemic heart disease, while imperfect, reflects at least a meaningful infrastructure. Canada recorded 72,849 cases of ischemic heart disease in 2023 alongside 380 programs. The United States reported 1,144,557 incidents and 2,687 programs. Japan counted 292,531 incidents against 678 programs, and Germany 362,984 incidents against 155 programs. These figures vary considerably in per-case coverage, but they stand in sharp contrast to the situation in low-income countries, where the audit found programs essentially absent despite significant caseloads.

Afghanistan, for example, recorded 34,207 incidents of ischemic heart disease and zero cardiac rehabilitation programs. Ethiopia reported 28,903 incidents and, likewise, no programs. Malawi emerges as an outlier in the dataset, with 3,872 incidents and 23 programs, a small but notable exception that suggests expansion is possible even in resource-constrained settings. The researchers emphasize that the highest levels of chronic cardiac disease now occur in low- and middle-income countries, where roughly 80 percent of global cardiovascular deaths take place. Lima de Melo Ghisi notes that this concentration not only increases economic pressures on those countries but also places further burdens on health-care systems that are often already stretched thin. The absence of rehabilitation capacity in exactly the places where need is greatest amounts to a structural inequity in global cardiovascular care.

The barriers to expansion are neither mysterious nor purely scientific. The study identifies the lack of funding and staffing as the major roadblock, with costs frequently falling on patients themselves, which reinforces inequity. Beyond financing, practical obstacles shape who can actually attend: the distance patients live from program centers, the availability of transportation, particularly in rural areas, and the competing demands of work and family life that leave little room for regular clinic visits. These constraints have driven interest in home-based and hybrid programs, which are less expensive to run, easier for people to access, and, according to existing comparative research, capable of delivering outcomes comparable to clinic- or hospital-based models. Yet even this more flexible tier of service has not grown. Since the pandemic, the number of hybrid and alternative programs has actually decreased, even as more people worldwide survive cardiac events and live longer with cardiovascular disease.

That post-pandemic contraction is one of the study’s most disheartening findings, and the researchers say they were surprised by it. Hybrid models were widely expected to be a growth area, accelerated by the shift toward remote care during COVID-19 lockdowns. Instead, the audit suggests that without committed reimbursement, even the cheaper delivery formats fail to achieve financial sustainability. The reimbursement figures are telling: with only about a quarter of hybrid and alternative programs funded by governments or insurers, the economic case for establishing and maintaining them remains fragile. Where patients must pay out of pocket, uptake drops, and where uptake drops, the programs struggle to justify institutional investment, creating a self-reinforcing cycle of under-provision.

The methodological approach of the audit gives its findings considerable weight. Rather than extrapolating from a handful of national registries, the researchers tallied programs across 90 countries, recorded the level of reimbursement where available, and compared countries by income class, producing a standardized global snapshot that had not existed since before the pandemic. Published as a data and statistical analysis in PLOS One under the title describing delivery of cardiac rehabilitation through hybrid models and alternative settings by country income classification and decade, the study provides a baseline against which future expansion, or continued stagnation, can be measured. The decade-over-decade comparison is what allows the authors to state plainly that availability has not increased worldwide despite rising incidence of cardiovascular disease.

What emerges from the analysis is a clear prescription. The results point to the need not only for increased implementation of cardiac rehabilitation programs but for more sustained reimbursement, which the researchers argue would go a long way toward providing cardiovascular care globally. In practice, that means health systems and insurers recognizing hybrid and home-based delivery as fundable services rather than experimental add-ons, and it means targeted investment in low- and middle-income countries where the disease burden is heaviest and the infrastructure thinnest. Carson’s summary of the paradox is blunt: multiple studies have already shown that cardiac rehabilitation works, playing an outsized role in reducing mortality, hospital readmissions, and improving quality of life, and yet the programs remain under-utilized. Closing that gap, the study suggests, is less a question of clinical science than of policy, financing, and the political will to fund secondary prevention at the scale the global burden of cardiovascular disease now demands.

For the millions of people living with chronic cardiac disease, the stakes of that policy shift are concrete. Every unreimbursed program and every country without services represents patients who could have reduced their risk of death by a quarter but were never given the option. The 2025 Global Audit Update makes the scale of the shortfall measurable for the first time in the post-pandemic era, and it hands clinicians, policymakers, and funders a precise map of where the work must happen next.

Subject of Research: Global availability and reimbursement of cardiac rehabilitation programs compared with rising cardiovascular disease burden

Article Title: Cardiac rehabilitation programs not keeping up with global increases in cardiovascular disease

Article References: Cardiac rehabilitation programs not keeping up with global increases in cardiovascular disease. (n.d.). Original publication

Image Credits: AI Generated

DOI: Not provided

Keywords: cardiac rehabilitation, cardiovascular disease, global health, health equity, hybrid care models, reimbursement, low-income countries, ischemic heart disease, secondary prevention, PLOS One, York University, global audit

The technical backdrop to their argument is a field advancing on multiple fronts simultaneously. A review by Pan and colleagues, published in the same journal, traces how CRISPR-Cas9 and its increasingly refined descendants, including base editing, prime editing, and AI-guided RNA design, are converging with cell and vector engineering to offer potentially curative options for children with rare monogenic diseases. Base editing chemically converts one DNA letter into another without cutting both strands of the double helix, while prime editing allows more precise insertions and deletions with fewer unwanted byproducts. Machine learning tools are accelerating the design of RNA molecules and delivery vehicles, shortening development timelines that once stretched over decades.

The clinical results are no longer theoretical. Several gene therapy products now carry approval from the Food and Drug Administration or the European Medicines Agency for pediatric indications, and dozens more sit in active clinical trials. Diseases once uniformly fatal or progressively disabling, such as spinal muscular atrophy and metachromatic leukodystrophy, now have potentially curative options. The commentary describes this as an inflection point, but one whose promise is fragile, because access for children today and development of new therapies tomorrow hinge on coverage decisions made in insurance boardrooms as much as in laboratories.

Price is the most visible obstacle. Atidarsagene autotemcel, marketed as Lenmeldy, is a one-time therapy for metachromatic leukodystrophy with a list price of 4.25 million dollars, making it among the most expensive medicines ever approved. Onasemnogene abeparvovec, sold as Zolgensma, is a single infusion for spinal muscular atrophy priced near 2.1 million dollars. Exagamglogene autotemcel, known as Casgevy, the first CRISPR-edited cell therapy approved for sickle cell disease, and lovotibeglogene autotemcel, or Lyfgenia, a lentiviral-edited counterpart, list in a similar range. These figures dwarf the cost of conventional orphan drugs and raise immediate questions about affordability for health plans serving children.

Yet the authors caution against reading these prices as simple profiteering. The costs reflect the genuine expense of manufacturing an individualized cell or gene product, a process that involves harvesting a patient’s own cells, engineering them in specialized facilities, performing quality control, and returning them to the patient, all under regulatory scrutiny. Independent health economic assessments have judged several of these therapies cost-effective when measured against the lifetime value of a one-time cure compared with years or decades of standard care, which for conditions like sickle cell disease includes repeated hospitalizations, transfusions, and pain crises. From that perspective, a multimillion-dollar price tag can represent a bargain over a lifetime, even as it creates an acute budget shock for any single insurer.

This tension between long-term value and short-term affordability lies at the heart of the coverage problem. A child treated at age three may remain enrolled with a health plan for only a few years before the family changes jobs or coverage, meaning the insurer that pays for the cure may never capture the savings from avoided care. Economists describe this as a mismatch between who pays and who benefits, and it gives payers a rational incentive to delay or deny coverage in the hope that someone else will bear the cost. For families, the consequence is that access can depend on the accident of which insurance plan covers a child in a given year.

The commentary also examines the frontier of ultra-rare disease, where the economics become even more difficult. Landmark cases such as patient-specific in vivo gene editing for a rare genetic condition and patient-customized oligonucleotide therapy, each developed for a single individual, have demonstrated that bespoke treatments are technically feasible. But therapies designed for one or a handful of patients will never recoup their development costs through sales, no matter how high the price. The authors point to proposed funding approaches for N-of-1 trials of individualized gene-targeted therapies and to efforts to overcome barriers to commercially pre-viable gene and cell therapies for rare and ultra-rare diseases as signs that researchers and policymakers are searching for models that do not depend on conventional market returns.

Regulatory innovation is moving in parallel. The FDA has launched a framework for accelerating the development of individualized therapies for ultra-rare diseases, an acknowledgment that the agency’s traditional pathways were designed for drugs manufactured at scale rather than treatments built for one patient. On the payment side, the Centers for Medicare and Medicaid Services have expanded access to gene therapies through innovative state agreements, and proposals for a national benefit for cell and gene therapies have been advanced in health policy forums. These arrangements, including outcome-based contracts in which manufacturers receive full payment only if a therapy works as promised, represent early attempts to spread risk between manufacturers, payers, and the public.

For the pediatric community, the stakes are unusually high because timing matters in a way it does not in adult medicine. Many of the conditions targeted by gene editing are progressive, and the therapies work best, or only, when administered before irreversible organ damage occurs. Newborn screening programs increasingly identify affected infants in the first days of life, creating a narrow window in which regulatory approval, insurance authorization, manufacturing capacity, and clinical delivery must all align. A delay of months in coverage negotiation can convert a curative intervention into a palliative one, which is why the authors frame payment policy as an integral component of the therapy itself rather than an administrative afterthought.

The commentary closes with a call to build the policy environment deliberately rather than reactively. The authors argue that without coordinated action on coverage, reimbursement, and financing, the remarkable science described by Pan and colleagues will reach only a fraction of the children who could benefit, and that uncertain payment prospects may deter investment in therapies for the rarest conditions of all. The tools of molecular biology have, in their telling, largely been proven; the rulebook that determines who can use them is still being written, and the next chapter will be drafted not by geneticists but by policymakers, insurers, and the families advocating for their children.

Subject of Research: Insurance coverage and reimbursement policy for pediatric gene and cell therapies

Article Title: Editing the rulebook: building the policy environment for children to access gene therapy

Article References: Pulcini, C. D., Chua, K.-P., Conti, R. M., On behalf of the Pediatric Policy Council, Keller, D., Montez, K., Ragavan, M., Lorch, S., Plax, K., Cheng, T., Geme, J. S., Lakshmanan, A., & Mariani, T. J. (2026). Editing the rulebook: building the policy environment for children to access gene therapy. Pediatric Research. https://doi.org/10.1038/s41390-026-05588-y

Image Credits: AI Generated

DOI: 10.1038/s41390-026-05588-y

Keywords: gene therapy, CRISPR, pediatrics, health policy, insurance coverage, drug pricing, rare disease, sickle cell disease, spinal muscular atrophy, reimbursement, base editing, ultra-rare disease

The study, published on 20 September 2026 as a research letter in volume 318 of the journal, takes advantage of a uniquely transparent data resource. Rather than relying on insurance claims, which are often proprietary and difficult to obtain, the team drew on publicly accessible provider-level data hosted by the U.S. Department of Health and Human Services, specifically the Medicaid provider spending datasets available through the department’s open data portal. Because the analysis used only publicly available provider-level information containing no identifiable patient data, the authors note that institutional review board approval was not required, and the work was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

The technical logic behind the approach is worth unpacking. Medicaid, the joint federal-state health insurance program, operates differently across states, and a substantial share of beneficiaries are enrolled in managed care plans rather than traditional fee-for-service arrangements. Fee-for-service data, in which providers bill the program directly for each service rendered, offer a consistent signal of whether a given physician is actually treating Medicaid patients. By tracking participation among surgeons who perform Mohs micrographic surgery, identified through billing for the procedure, the researchers could construct a picture of access trends over time, capturing whether the pool of surgeons willing to accept Medicaid beneficiaries is shrinking, growing, or holding steady.

Why does this matter clinically? Mohs micrographic surgery is a tissue-sparing technique most often used for nonmelanoma skin cancers, particularly basal cell carcinoma and squamous cell carcinoma located on high-risk areas such as the face, ears, and hands. The procedure involves the sequential removal of thin layers of tissue, each examined microscopically at the bedside while the patient waits, allowing the surgeon to map exactly where tumor cells remain. This real-time margin assessment maximizes cure rates while minimizing the removal of healthy tissue, which is why it is favored for tumors in cosmetically and functionally sensitive sites. Skin cancer is among the most common cancers in the United States, and access to this procedure is therefore not a niche concern but a mainstream issue in oncologic dermatology.

The new study does not stand in isolation. It builds on a growing body of literature documenting disparities in dermatologic care for Medicaid beneficiaries. Prior work cited by the authors includes a 2020 study in the Journal of the American Academy of Dermatology by Mazmudar and colleagues, which compared dermatologist appointment access and waiting times across insurance types and found that Medicaid patients faced meaningful barriers to securing care. A 2023 study by Sharma and colleagues examined nonmelanoma skin cancer and the utilization of Mohs micrographic surgery specifically among Medicaid patients, highlighting questions about whether this population receives guideline-concordant surgical treatment at the same rate as privately insured patients.

Perhaps most directly relevant is a 2023 analysis by Beltrami, Hooper, Kodumudi, and colleagues, also published in the Journal of the American Academy of Dermatology, which investigated the association between state-specific reimbursement rates and Medicaid acceptance for Mohs micrographic surgery. That work pointed toward a familiar economic mechanism: when states pay less for a procedure, fewer specialists are willing to accept that insurance. A companion 2022 study by the same group characterized the physicians who do accept Medicaid for Mohs surgery, beginning to sketch a profile of the provider workforce serving this population. The new research letter extends this line of inquiry from static snapshots to longitudinal trends, asking not just who accepts Medicaid today but how participation has shifted across the recent past.

The workforce dimension adds another layer of urgency. A 2025 cross-sectional analysis by Ahn, Yu, Scott, and colleagues sought to define the Mohs micrographic surgery workforce itself, using billing data for the primary tissue-processing code from 2015 to 2020 to estimate how many surgeons perform the procedure nationally. Understanding the size and distribution of that workforce is a prerequisite for understanding access: if the number of Mohs surgeons is limited and only a fraction accept Medicaid, the effective supply of care available to beneficiaries may be far smaller than headline counts of providers suggest. The Mount Sinai team’s trend analysis speaks directly to this concern by measuring the dynamic component, participation, rather than the static component, headcount.

Methodologically, the study is a research letter, a compact format that journals use to disseminate timely findings without the full apparatus of an original article. The authors report that all three contributed to writing the manuscript, with O’Hagan preparing the two figures that accompany the letter. The team declared no conflicts of interest and reported no external funding, and the corresponding author is Lewin, whose department, the Kimberly and Eric J. Waldman Department of Dermatology at Mount Sinai, sits at the intersection of clinical practice and health services research in New York City, a market where insurance dynamics and specialist access are under perpetual scrutiny.

The policy stakes of this line of research are considerable. Medicaid enrollment in the United States has fluctuated dramatically in recent years, swelling during the pandemic-era continuous enrollment period and contracting as states resumed eligibility redeterminations. Each swing shifts the composition of the insured population and, by extension, the demand placed on specialists. If participation in fee-for-service Medicaid among Mohs surgeons is declining even as enrollment rises, the mismatch could translate into longer travel distances, longer waits, or transitions to less tissue-sparing treatments for beneficiaries, outcomes with direct implications for cancer control in a vulnerable population. Reimbursement policy, scope-of-practice debates, and workforce training all intersect here, and granular participation data give policymakers a lever for evaluating interventions such as rate increases or network adequacy requirements.

For readers following the science of health equity, the study is a reminder that access to advanced surgical care is shaped as much by administrative and economic structures as by biology. The technique itself, developed decades ago and refined through generations of surgeons, offers cure rates that few oncologic procedures can match. Whether that benefit reaches patients on public insurance depends on datasets like the ones this team mined, on researchers willing to ask unglamorous questions about billing and participation, and on the willingness of states to align reimbursement with the realities of surgical practice. The full article, including the figures charting participation trends, is available in the Archives of Dermatological Research, and the underlying data remain publicly accessible for other investigators to interrogate, replicate, and extend.

Subject of Research: Trends in fee-for-service Medicaid participation among Mohs micrographic surgery providers in the United States

Article Title: Trends in fee-for-service medicaid participation in Mohs micrographic surgery

Article References: Trends in fee-for-service medicaid participation in Mohs micrographic surgery. (n.d.). https://doi.org/10.1007/s00403-026-04876-1

Image Credits: AI Generated

DOI: 10.1007/s00403-026-04876-1

Keywords: Mohs micrographic surgery, Medicaid, dermatology, health policy, skin cancer, healthcare access, insurance participation, health disparities, reimbursement, workforce, fee-for-service, nonmelanoma skin cancer

The stakes of this question are substantial. According to the study’s framing, 21.8 percent of adults in the United States receive behavioral health treatment in a given year, a figure that underscores how many people stand to be affected by changes in how supportive services are financed. Peer support, in which trained specialists who have navigated their own mental health or substance use challenges help others through recovery, has accumulated a considerable evidence base over recent decades. What has been missing, however, is a sustainable mechanism for paying for these services within the largest public health insurance program for older adults and people with disabilities. The PIN-PS codes were designed to supply exactly that mechanism.

To understand how the new codes are actually landing in the field, researchers led by corresponding author Karen L. Fortuna, PhD, LICSW, of The Dartmouth Institute for Health Policy and Clinical Practice at the Geisel School of Medicine at Dartmouth, conducted an interview study with 20 participants. The group was deliberately broad, encompassing physicians, certified peer support specialists and their leaders, policy professionals, payer representatives, and leaders of behavioral health organizations. This cross-section of stakeholders allowed the team to capture system-level insights rather than the perspective of any single professional group, examining both the barriers and the facilitators that shape early adoption of Medicare-funded peer support.

The barriers the researchers identified cluster around a central problem: unfamiliarity. Participants reported limited knowledge of the Medicare navigation codes themselves, meaning that many clinicians and organizations simply did not know the reimbursement pathway existed or how it worked. Skepticism about the impact of peer support compounded this knowledge gap, with some stakeholders uncertain whether the services would deliver measurable benefit. Even among those inclined to adopt the codes, practical questions loomed large, including how to integrate peer support into existing clinical workflows, limited familiarity with billing requirements, and uncertainty about how to schedule and document PIN-PS encounters in a way that would satisfy Medicare’s rules.

Beyond these foundational uncertainties, the study documented a second tier of structural obstacles. Administrative and billing complexity emerged as a significant deterrent, reflecting the broader reality that Medicare reimbursement carries documentation and compliance demands that smaller organizations and solo peer specialists may struggle to meet. Medicare cost-sharing requirements added another layer of difficulty, since patient financial responsibility can complicate both service delivery and revenue predictability. Constraints in reimbursable service time further narrowed the window in which peer support could be delivered profitably, raising concerns that the codes might only support a compressed version of the work peer specialists actually do.

These findings matter because they illuminate a familiar pattern in health policy: coverage on paper does not automatically translate into services on the ground. When Medicare introduces new billing codes, the intended beneficiaries can only access them if clinicians know the codes exist, understand how to bill them, and can fit the services into workflows that are already stretched thin. The Dartmouth-led study suggests that each of these links in the chain is currently weak. A peer-support provision that remains unused because of administrative friction would fail to deliver the access benefits that motivated its creation, regardless of its theoretical promise.

The study was not uniformly pessimistic. Participants also identified facilitators that could drive adoption, most notably the belief that the codes could expand access to behavioral health care and reduce inappropriate hospitalizations. These perceived benefits align with longstanding arguments for peer support: that specialists with lived experience can engage people who might otherwise disengage from care, provide outreach and navigation between clinical visits, and intervene early in crises that might otherwise escalate to emergency departments or inpatient psychiatric admission. If those outcomes materialize, they could offset program costs and build the case for broader adoption among skeptical clinicians and payers.

The publication of the study in The Annals of Family Medicine, the peer-reviewed journal of the American Academy of Family Physicians, places these findings squarely in front of the primary care audience most likely to encounter the codes in practice. Primary care practices increasingly serve as the front line for behavioral health, and physicians in these settings are the ones who would bill for and coordinate PIN-PS services. The authors suggest that the findings may inform ongoing implementation and policy refinement as Medicare-funded peer support continues to develop, a signal that the research is intended not merely to document problems but to guide the next round of adjustments by the Centers for Medicare and Medicaid Services and by the organizations attempting to use the codes.

The research itself reflects a growing methodological trend in implementation science: studying new reimbursement mechanisms early, through qualitative interviews with the stakeholders who must operationalize them, rather than waiting years for utilization data that may arrive too late to shape policy. By interviewing physicians, peer specialists, payers, and policy professionals simultaneously, the Dartmouth team captured the misalignments that occur when a policy designed at the federal level meets the realities of scheduling software, documentation templates, and billing staff training. Each stakeholder group experienced different facets of the same barrier, which helps explain why a well-intentioned coverage change can stall even when no single actor opposes it.

What happens next will depend on whether the identified barriers can be addressed through targeted education, simplified billing guidance, and workflow support for the practices and organizations considering PIN-PS adoption. The study’s central contribution is a map of where the friction lies: in knowledge, in skepticism, in workflow design, and in the administrative and financial architecture surrounding the codes. As Medicare-funded peer support matures, the experience of these early implementers will likely determine whether the nation’s largest insurer can successfully fold lived-experience expertise into its funded benefit structure, a development that could reshape how millions of Americans access behavioral health support in the years ahead.

Subject of Research: Implementation barriers to Medicare-funded peer support services under the PIN-PS reimbursement codes

Article Title: Integrating peer support into Medicare-funded care faces implementation barriers

Article References: Integrating peer support into Medicare-funded care faces implementation barriers. (n.d.). Original publication

Image Credits: AI Generated

DOI: Not provided

Keywords: Medicare, peer support, behavioral health, PIN-PS codes, implementation science, reimbursement, primary care, mental health policy, qualitative research, Annals of Family Medicine, health care access, billing complexity

The technique itself is worth understanding, because it is more mechanically demanding than it first appears. Warm needle acupuncture combines acupuncture, the insertion of fine needles into specific points on the body, with moxibustion, the burning of dried mugwort near or on the skin to deliver radiant heat. In the warm needle variant, a small ball or cylinder of moxa is attached directly to the shaft of an inserted needle and ignited. Heat travels down the conductive metal shaft to the tip, delivering warmth deep into the tissue at the insertion point. Practitioners regard this as a way of intensifying the stimulation of acupuncture points, particularly for conditions associated with cold sensitivity, chronic pain, and musculoskeletal stiffness. The procedure, however, demands constant attention: the moxa must be sized and positioned correctly, the burning material must not scald the skin, smoke must be managed, and the needle must be monitored until the heat dissipates. Every one of those steps is an opportunity for error, and every one of them takes time.

To map how the profession actually uses this technique, the researchers conducted a web-based survey between September 27 and November 3, 2025, inviting all 28,319 licensed Korean Medicine doctors in the country to participate. A total of 1,076 completed the questionnaire, a sample large enough to support meaningful subgroup analysis across age brackets, career stages, and practice settings. Respondents were asked whether they used warm needle acupuncture, how often, for which conditions, whether they had encountered adverse events, what prevented more frequent use, and what kinds of devices, training, or reimbursement changes they would like to see. The study was reviewed and granted an exemption by the Institutional Review Board of Dongguk University Oriental Hospital and conducted in line with the Declaration of Helsinki, with electronic informed consent from all participants.

The headline finding is that warm needle acupuncture is far from marginal. Among the 1,076 respondents, 68.7 percent reported using it in clinical practice, a striking adoption rate for a procedure that requires hands-on fire management in an era of standardized, single-use needles. The subgroup analyses added an important nuance: utilization rose steadily with both clinical experience and age. Older, more seasoned practitioners were considerably more likely to reach for the moxa and the matches than their younger colleagues. That pattern cuts two ways. It suggests the technique’s value is learned and confirmed through years of practice, but it also hints at a generational drift, in which newer graduates trained in a more proceduralized, risk-averse clinical environment may be quietly letting the skill atrophy.

Then comes the number that will draw the most attention: among the 739 respondents who had actually used warm needle acupuncture, 87.8 percent reported having encountered at least one adverse event related to the technique in their clinical careers. The survey did not report that these events were severe, and in the context of moxibustion-adjacent procedures the most common harms are typically minor burns, blisters, and skin irritation at the treatment site. But the near-universality of the experience is itself the finding. It means that adverse events are not rare outliers in warm needle acupuncture practice; they are a routine, expected feature of the procedure as currently performed. For a modality seeking broader clinical and international adoption, that statistic is a red flag aimed squarely at the equipment rather than the concept.

When the researchers asked what stood in the way of more frequent use, the answers converged on three barriers: procedural complexity, safety concerns, and reimbursement limitations. In other words, the doctors surveyed were not doubting whether warm needle acupuncture helps their patients. The constraints they identified are logistical and systemic. The procedure is fiddly and time-consuming to perform correctly, the risk of burns is baked into the current manual method, and insurance coverage does not adequately reward the extra time and skill the technique demands. This distinction matters, because it reframes the problem. If clinicians believed the therapy was ineffective, the solution would be more trials and, potentially, abandonment. Because they believe it works but find it cumbersome and risky, the solution is engineering, standardization, and payment reform.

The survey’s data on future demand make that reframing explicit. A majority of respondents, 70.7 percent, said the top priority should be the development of user-friendly and safe warm needle devices, and 74.9 percent said they would be willing to adopt dedicated devices in their clinics if such tools became available. When asked which features mattered most, 64.7 percent pointed to improved ease of application and 46.7 percent to enhanced safety. Read together, these figures describe a profession that has effectively issued a product specification to the medical device industry: build a warm needle system that a busy clinician can apply quickly, that controls or eliminates the burn risk, and that integrates cleanly into a modern clinic’s workflow, and adoption will follow. The willingness-to-adopt figure is particularly notable, because surveys of clinicians often reveal resistance to new technology; here the resistance runs the other way, toward a technology that does not yet exist in the form practitioners want.

The authors conclude that the clinical utilization of warm needle acupuncture appears to be influenced primarily by procedural and systemic constraints rather than by doubts about its perceived clinical effectiveness. Their prescription is twofold: the development of standardized, safer devices, and appropriate insurance support to make the procedure economically viable in routine care. They also emphasize that further clinical research is required to strengthen the evidence base on both efficacy and safety, a necessary step if the modality is to travel beyond Korean Medicine clinics into international integrative medicine settings, where regulators and insurers demand controlled trial data before a therapy can be recommended or reimbursed.

The broader significance of the study lies in its methodology as much as its findings. Surveys that capture an entire licensed profession, with response data spanning nearly 29,000 invited practitioners, are rare in complementary and traditional medicine research, where evidence often rests on small case series or practitioner anecdotes. By quantifying who uses the technique, who gets burned by it, and what would make them use it more, the Korean team has converted a diffuse clinical impression into a set of actionable targets for device engineers, health insurers, and trial designers. Whether those targets are met will determine whether warm needle acupuncture remains a niche skill passed between experienced hands, or matures into a standardized, safely deliverable therapy that can be studied, insured, and exported on the same terms as any modern medical device.

Subject of Research: Clinical use, safety, and barriers to adoption of warm needle acupuncture in Korean Medicine practice

Article Title: A survey on the current clinical use and perceptions of warm needle acupuncture among Korean medicine doctors

Article References: Kim, M.-G., Sung, W.-S., Kim, E.-J., & Kim, E.-J. (2026). A survey on the current clinical use and perceptions of warm needle acupuncture among Korean medicine doctors. BMC Complementary Medicine and Therapies. https://doi.org/10.1186/s12906-026-05592-z

Image Credits: AI Generated

DOI: 10.1186/s12906-026-05592-z

Keywords: warm needle acupuncture, Korean Medicine, moxibustion, acupuncture, adverse events, medical devices, complementary medicine, nationwide survey, reimbursement, clinical practice, traditional medicine, safety

The TKI era delivered incremental but real gains. Lenvatinib emerged as a non-inferior first-line alternative to sorafenib, while regorafenib, cabozantinib, and the anti-VEGFR-2 antibody ramucirumab — the latter reserved for patients with alpha-fetoprotein levels of at least 400 ng/mL — extended survival after sorafenib failure. Yet the ceiling was low: median life expectancy on first-line TKI therapy rarely exceeded 12 to 13 months. Progressive liver dysfunction, clinical decompensation, and the difficulty of tolerating TKIs long-term exposed a fundamental limitation. Immune checkpoint inhibitors (ICIs) tested as monotherapy also failed to beat sorafenib in phase III studies, leaving the field at an impasse until combination immunotherapy arrived.

The turning point came with regimens that pair PD-1 pathway blockade with either VEGF inhibition or CTLA-4 inhibition. Median overall survival for untreated advanced HCC patients, once roughly six months, climbed to between 16 and 23 months in contemporary phase III trials — a leap accompanied by higher response rates, better safety profiles, and improved quality of life. Four pivotal trials now define first-line care. IMbrave150 showed atezolizumab plus bevacizumab (A + B) achieved a median overall survival of 19.2 months versus 13.4 months for sorafenib, with an objective response rate of 30% versus 11%, though six grade 5 bleeding events in the combination arm underscored the need for baseline endoscopic varices screening. HIMALAYA demonstrated that a single priming dose of tremelimumab plus monthly durvalumab (the STRIDE regimen) improved median survival to 16.4 months, with striking five-year survival of 19.6% compared with 9.4% for sorafenib.

CheckMate 9DW added a third option, combining ipilimumab induction with nivolumab maintenance against a control arm dominated by lenvatinib. Median overall survival reached 23.7 months versus 20.6 months, with a 36% response rate and a 48-month survival rate of 31% versus 18%. Notably, early deaths from hepatic events caused the survival curves to cross within the first six months, a reminder that close monitoring for liver decompensation is essential. The fourth positive trial, CARES-310, paired camrelizumab with the TKI rivoceranib and achieved the highest hazard ratio benefit (0.64) and a 23.8-month median survival — but with grade 3–4 toxicity in 81% of patients and a predominantly Asian, hepatitis B-driven population, its results are difficult to extrapolate to Europe, where alcohol-related liver disease, hepatitis C, and metabolic dysfunction-associated steatohepatitis (MASH) predominate.

Underlying liver disease aetiology was once thought to blunt immunotherapy efficacy, particularly in MASH-related HCC, but subsequent analyses have been inconsistent, and current European Society for Medical Oncology (ESMO) guidelines recommend the approved regimens regardless of aetiology. A thornier question concerns patients with Child-Pugh B liver dysfunction, who were largely excluded from phase III trials. Evidence from CheckMate 040 cohort 5 — where nivolumab achieved a 12% response rate and 7.6-month median survival in 49 Child-Pugh B7–B8 patients — and from a meta-analysis of 22 studies suggests immunotherapy is not absolutely contraindicated, though survival is markedly worse than in patients with preserved liver function. The authors stress that the cause of hepatic decline, whether tumour burden or decompensated cirrhosis, must be weighed case by case, ideally with refined tools such as the ALBI grade and within multidisciplinary team consensus.

Managing immune-related liver injury has itself become a core clinical skill. Because HCC arises on a backdrop of chronic liver disease, immune-mediated hepatotoxicity occurs earlier and more frequently than in other solid tumours, and diagnosis is complicated by the absence of specific criteria and by baseline liver test abnormalities. Most cases resolve without permanent discontinuation, but fatal hepatic toxicities have been reported, making vigilant monitoring and early multidisciplinary involvement non-negotiable elements of modern care.

What happens after first-line immunotherapy fails remains one of the field’s largest unmet needs. ESMO guidelines recommend only TKIs — sorafenib, lenvatinib, regorafenib, or cabozantinib — or ramucirumab in the second line, regardless of prior immunotherapy exposure. Observational data from the European LEVIATHAN registry favour lenvatinib over sorafenib after A + B failure (progression-free survival of 5.5 versus 2.6 months), and single-arm Asian phase II trials support regorafenib and cabozantinib in this setting. The recent IMbrave251 trial, though negative for its primary endpoint, provided the first randomised phase III benchmark for TKI monotherapy after first-line immunotherapy: 12.5-month overall survival and 4.8-month progression-free survival in the TKI-only arm. Crucially, no immunotherapy agent holds European approval in the second line — a stark contrast with the United States, where pembrolizumab and ipilimumab plus nivolumab are licensed after TKI failure. Off-label immunotherapy use in Europe therefore depends on institutional policies and is often not reimbursed, pushing costs onto hospital budgets, insurers, or patients themselves.

Access inequity emerges as the review’s most provocative theme. Although the European Medicines Agency grants EU-wide marketing authorisation, national reimbursement decisions vary enormously. Atezolizumab plus bevacizumab and the STRIDE regimen are now reimbursed in 23 and 18 European countries respectively, but ipilimumab plus nivolumab — EMA-approved in March 2025 — was, more than a year later, reimbursed in only one country, Germany. During 2016–2021, compliance with the EU’s recommended 180-day reimbursement deadline ranged from 100% in Germany to just 3% in Belgium. Molecular profiling offers little help in personalising choices: no genomic alteration in HCC reaches the top tiers of the ESMO ESCAT framework, and in the French Genomic Programme only 3 of 135 HCC patients were successfully matched to a targeted therapy. Emerging predictors — tumour immune contexture signatures, the CRAFITY score combining AFP and C-reactive protein, radiomic machine-learning models, and gut microbiome profiles — show promise but await prospective validation.

Meanwhile, European practice is quietly diverging from guidelines in the locoregional arena. Trans-arterial chemoembolization remains the standard for liver-confined intermediate-stage disease, and phase II/III trials including EMERALD-1 and LEAP-012 have shown progression-free survival gains from adding PD-1/PD-L1 blockade to TACE — though no overall survival benefit has yet been demonstrated and no European marketing authorisation exists for the combination. Selective internal radiotherapy (SIRT) with yttrium-90 microspheres, once dismissed after the negative SARAH and SIRveNIB trials, has been rehabilitated by the DOSISPHERE-01 study, which showed that personalised dosimetry delivering at least 205 Gy to the tumour significantly improves survival, even in patients with portal vein thrombosis. The prospective French PROACTIF registry of 989 patients reported 21.8-month median survival after SIRT, yet no randomised comparison with immunotherapy exists, leaving a widening gap between routine practice and guideline-endorsed standards.

The authors call for a coordinated, multi-stakeholder response: harmonised reimbursement pathways, prospective evidence for treatment sequencing, validated predictive biomarkers, broader access to clinical trials beyond academic centres through platforms such as the EU’s Clinical Trials Information System, and universal multidisciplinary review — potentially expanded through virtual networks supported by artificial intelligence. With HCC ranking thirteenth by incidence and sixth by mortality in Europe, the science has finally delivered survival gains once thought impossible. The remaining challenge, the review concludes, is no longer inventing effective treatments but ensuring that every European patient can actually receive them.

Subject of Research: Systemic and locoregional treatment paradigms for unresectable and advanced hepatocellular carcinoma in Europe

Article Title: Systemic treatment paradigms for unresectable and advanced hepatocellular carcinoma in Europe

Article References: Pinato, D. J., Alimenti, E., Lombardi, P., Vaz, J., Digklia, A., Edeline, J., Ben Khaled, N., Di Giacomo, E., Scheiner, B., Ramos, J. P., O’Kane, G. M., Cappuyns, S., Tesini, G., & Rimassa, L. (2026). Systemic treatment paradigms for unresectable and advanced hepatocellular carcinoma in Europe. The Lancet Regional Health – Europe, 70, Article 101839. https://doi.org/10.1016/j.lanepe.2026.101839

Image Credits: AI Generated

DOI: 10.1016/j.lanepe.2026.101839

Keywords: hepatocellular carcinoma, immunotherapy, atezolizumab, bevacizumab, durvalumab, tremelimumab, tyrosine kinase inhibitors, EMA, reimbursement, health inequality, locoregional therapy, biomarkers

The stakes are enormous. According to GLOBOCAN 2022 estimates, nearly 20 million new cancer cases occurred worldwide in 2022, and China alone contributed approximately 4.82 million incident cases and 2.57 million deaths annually, representing close to a quarter of the global burden. Japan and South Korea face rising cancer incidence driven primarily by population ageing, while Australia reports among the highest age-standardised incidence rates in the world. Many of the region’s most common malignancies, including lung, breast, colorectal, prostate, and gastric cancers, are already amenable to biomarker-guided treatment, with actionable alterations such as EGFR mutations, ALK fusions, HER2 amplification, BRAF mutations, and mismatch repair deficiency now routinely detectable. Yet the authors emphasise that clinical impact depends on effective health-system implementation rather than technology alone.

The four countries were deliberately selected because they embody complementary implementation archetypes. Japan represents a nationally coordinated public model, in which cancer genomic medicine is embedded within universal health insurance through a three-tier network of Core, Designated, and Cooperative Hospitals operating under mandatory quality standards and compulsory molecular tumour board review. South Korea exemplifies a rapidly evolving but reimbursement-constrained system, where next-generation sequencing capacity has expanded quickly across tertiary hospitals and private laboratories, yet comprehensive genomic profiling often requires substantial out-of-pocket payment. China constitutes a large-scale, innovation- and market-driven ecosystem, propelled by public hospitals and a vast commercial diagnostics sector. Australia operates a research-integrated translational framework, in which broad genomic profiling remains largely confined to research programmes even as the country pioneers trial-linked molecular screening.

Each archetype produces characteristic bottlenecks along the patient pathway. In Japan, comprehensive genomic profiling is reimbursed mainly for patients who have exhausted standard therapies, restricting the clinical value of identifying actionable alterations earlier in the disease course. Indication-based reimbursement and limited off-label pathways create a persistent mismatch between genomic findings and treatment access, even though targeted drugs themselves are broadly available. In South Korea, a December 2023 policy revision raised patient co-payment rates from 50 percent to 80 percent for most cancers, further constraining access despite rapid regulatory approval of targeted agents. China has achieved the widest availability of genomic testing, particularly in urban centres, but most tests are self-funded and provincial variation in insurance coverage produces profound urban-rural inequities. Australia captures the paradox in a single phrase used by the authors: right test, wrong access, describing a system where the Pharmaceutical Benefits Scheme provides broad drug coverage but indication-based rules limit biomarker-driven off-label use.

Molecular tumour boards, the multidisciplinary forums that translate genomic data into treatment decisions, emerge as a second critical determinant. Japan operates one of the most standardised systems globally, with boards convened at all Core and Designated Hospitals and linked directly to reimbursement. South Korea has widely adopted institutional boards, though formats, documentation, and authority vary between hospitals, and boards typically function in an advisory capacity. China exhibits a spectrum of models ranging from academic boards to commercially facilitated services. Australia concentrates board activity in metropolitan research-intensive cancer centres. The South Korean KOSMOS-I pilot study offers a striking demonstration of what coordinated governance can achieve: a nationwide virtual central molecular tumour board spanning 29 sites delivered molecularly guided therapy to 51 percent of enrolled patients between 2021 and 2022, and the ongoing KOSMOS-II trial has expanded the platform to 31 centres with a clinico-genomic database.

Research-integrated ecosystems prove to be the region’s most powerful accelerators. Japan’s SCRUM-Japan programme has enrolled more than 40,000 patients in nationwide genomic screening, and its MONSTAR-SCREEN initiative has conducted 17 investigator-initiated trials across tumour types using multi-omics profiling. Critically, the SCRUM-MONSTAR ecosystem has demonstrated measurable survival benefit: patients receiving genomically matched therapies achieved a median overall survival of 19.1 months compared with 15.3 months for those receiving non-matched therapy, a hazard ratio of 0.767. The accompanying SCRUM-Japan Registry accumulates regulatory-grade real-world data that have even supported drug approvals as external control data. Meanwhile, the BELIEVE/NCCH1901 basket trial, run under Japan’s Patient-Proposed Healthcare Services framework, has enrolled over 290 patients across 18 cohorts, providing genomically guided access to selected off-label agents. South Korea’s K-MASTER programme sequenced approximately 8,000 patients across 55 institutions between 2017 and 2021, while Australia contributes initiatives such as PrOSPeCT, ASPiRATION, and the SUPER-NEXT programme applying whole-genome and transcriptome sequencing to cancers of unknown primary.

Data governance is identified as an emerging strategic inflection point. Japan’s C-CAT platform exemplifies centralised genomic-clinical data collection, complemented by the 2023 Act on the Promotion of Genome Medicine, though interoperability with other national health datasets remains limited. South Korea launched a national cancer clinical and genomic database in 2025 covering roughly 67 percent of cases nationwide, building on the K-CURE project. China operates under the strict constraints of the Personal Information Protection Law and Data Security Law, which are simultaneously driving adoption of federated analytic models that permit collaboration without raw data transfer. Australia has established Genomics Australia, a new national agency finalising the National Health Genomics Policy Framework and Implementation Plan 2026-2030. The authors argue that federated data infrastructures, harmonised standards, and secure cross-border analytic frameworks are essential for building learning health systems while respecting national privacy and sovereignty requirements.

Equity concerns thread through every domain of the analysis. Workforce shortages in molecular pathology, clinical genetics, genetic counselling, and bioinformatics afflict all four countries, reflecting testing expansion that has outpaced training capacity. Geographic disparities persist, from age-related and institutional variation in Japan to the gaps experienced by Aboriginal and Torres Strait Islander peoples and remote communities in Australia. Rare cancers, paediatric malignancies, and patients with uncommon genomic alterations are disproportionately vulnerable because limited case volumes restrict companion diagnostics, specialist expertise, and matched trials. The review also documents divergent approaches to genetic discrimination: South Korea’s Bioethics and Safety Act explicitly prohibits discrimination based on genetic information, Australia enacted legislation in 2026 banning the use of genetic information in life insurance, while Japan and China lack legally binding protections. The authors insist that equity must be treated as a systems-level property shaped by governance and reimbursement policy, not merely a patient-level problem.

Looking forward, the review proposes seven priority actions, from broadening eligibility for comprehensive genomic profiling beyond late-line settings and harmonising molecular tumour board governance, to adaptive health technology assessment, workforce investment, federated data infrastructure, equity-targeted interventions, and structured regional collaboration. Emerging technologies may shift the field upstream: maturing multi-omics platforms, circulating tumour DNA-based minimal residual disease assays, and evidence supporting first-line genomic profiling in untreated metastatic cancers all argue for earlier testing. Artificial intelligence is expected to relieve workforce pressure, with a Japanese national evaluation showing higher concordance between AI-assisted treatment recommendations and expert consensus than conventional molecular tumour board processes. The central lesson, the authors conclude, is that success in precision oncology should be measured not by sequencing capacity but by the ability to connect molecular findings to matched therapies and improved outcomes, a goal that coordinated regional collaboration across the Asia-Pacific could now make achievable at scale.

Subject of Research: A comparative assessment of cancer genomics and precision oncology implementation, access, and policy across Japan, South Korea, China, and Australia.

Article Title: Landscape of cancer genomics and precision oncology in Japan, South Korea, China, and Australia

Article References: Bando, H., Okayama, H., Chang, Y. J., Yu, J., Grimmond, S. M., Kong, S.-Y., Hu, X., Zeps, N., Han, J.-Y., Kim, J.-I., Seguchi, K., Amisaki, M., Sakamoto, Y., Fujisawa, T., Yamashita, R., Kato, K., Kono, K., Johns, A., & Yoshino, T. (2026). Landscape of cancer genomics and precision oncology in Japan, South Korea, China, and Australia. The Lancet Regional Health – Western Pacific, Article 101981. https://doi.org/10.1016/j.lanwpc.2026.101981

Image Credits: AI Generated

DOI: 10.1016/j.lanwpc.2026.101981

Keywords: precision oncology, cancer genomics, comprehensive genomic profiling, molecular tumour boards, SCRUM-MONSTAR, health policy, reimbursement, data governance, health equity, Asia-Pacific, targeted therapy, clinical trials