tag:theconversation.com,2011:/au/topics/medicine-441/articlesMedicine – The Conversation2024-03-26T17:01:41Ztag:theconversation.com,2011:article/2257152024-03-26T17:01:41Z2024-03-26T17:01:41ZMany drugs are prescribed for conditions they weren’t tested for – here’s what you need to know<p>All prescription drugs need a licence from a regulator to treat a specific condition. But licensed drugs can be prescribed for conditions they haven’t been tested for in a clinical trial. This is known as “off-label” prescribing – and it’s very common.</p>
<p>The UK doesn’t have current figures on overall off-label prescribing, but a <a href="https://pubmed.ncbi.nlm.nih.gov/16682577/">US study</a> found that one in five prescriptions was off label.</p>
<p>It is important to note that off-label medicine use is not the same as experimental use. Legally, once a medicine has obtained a licence, it can be used for any condition in any patient. A licence is evidence a medicine is safe, effective and of good quality. </p>
<p>So why is off-label prescribing so common? This practice is <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6677268/">most common in</a> children, older people, pregnant women and psychiatric patients, usually with changes in dosing and formulations. It is unusual for drugs to have been tested in these groups of patients. </p>
<p>Obtaining a new license for a medicine (to treat a different condition) is time-consuming, often taking up to <a href="https://www.nature.com/articles/3901619#Sec2">eight years</a> to get approval. It is also very expensive, with the new revenue for the additional uses often not being enough to offset the cost of running new clinical trials, marketing and re-labelling the drug.</p>
<p>To determine if a medicine can and should be prescribed off-label, a prescriber may consider several factors. There may be common features in two similar conditions that ensure there should be a degree of cross-effectiveness. For example, a medicine licensed for anxiety might reasonably be used to treat post-traumatic stress disorder. And a drug approved to treat one type of cancer could reasonably be expected to target other types of cancer. </p>
<p>Some off-label uses have been found by accident. <a href="https://www.migraineagain.com/beta-blockers-migraine-prevention/">Beta-blockers</a> were licensed in the 1960s to treat heart conditions. People who were prescribed these drugs and who suffered from migraines found that their migraine symptoms improved after they started taking the drug. Today, these drugs are commonly prescribed for migraine.</p>
<p>On occasion, off-label medicine use can become the primary treatment option for a particular condition. Amitriptyline, an older type of antidepressant, is now often used to treat nerve pain.</p>
<p>Usually, a prescriber will have considered all other medical options for a patient and will have reviewed the evidence to support any off-label prescribing. This includes “evidence summaries” provided by the <a href="https://cks.nice.org.uk/about/">National Institute for Health and Care Excellence</a>. These are available to GPs to support safe decision-making. </p>
<p>The summaries look at current guidelines and reviews as well as research studies, such as clinical trials and observational studies, and expert opinions. Although the guidelines mainly focus on licensed drugs, they also discuss off-label uses that are common in practice. </p>
<p>Some off-label drugs may also be listed in the British National Formulary, a reference book that contains prescribing information about drugs available in the UK.</p>
<h2>Great responsibility</h2>
<p>Whether there is a wealth of evidence or not, there is a greater responsibility for the prescriber when prescribing drugs off label. </p>
<p>One risk is the absence of information from the patient leaflet. The metformin patient leaflet, for instance, discusses its use in diabetes, but there is no information about its alternative use to treat polycystic ovary syndrome, which can confuse patients. </p>
<p>A bigger risk is the incidence of side-effects, which increase when off-label prescribing is not based on strong medical evidence. Alternatively, the drug may not work at all. </p>
<p>Despite being strongly advocated at the time by some doctors and politicians, a <a href="https://www.nature.com/articles/s41467-021-22446-z">2021 review</a> debunked the use of hydroxychloroquine to treat COVID and found an increased risk of death with its use.</p>
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<a href="https://theconversation.com/coronavirus-scientists-promoting-chloroquine-and-remdesivir-are-acting-like-sports-rivals-138051">Coronavirus: scientists promoting chloroquine and remdesivir are acting like sports rivals</a>
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<p>Recently, <a href="https://www.diabetes.org.uk/about-us/news-and-views/ozempic-and-weight-loss-facts-behind-headlines#:%7E:text=People%20with%20type%202%20diabetes%20who%20use%20Ozempic%20can%20lose,you%20stay%20full%20for%20longer.">Ozempic</a> (semaglutide) caused a storm, with celebrities promoting its miraculous weight-loss effects. This off-label prescribing has led to continuing drug shortages affecting people with diabetes. But it also to the development of Wegovy for weight loss.</p>
<h2>No legal duty</h2>
<p>While there is no legal duty to tell a patient they have been prescribed an off-label medicine, prescribers follow professional guidelines. These state it is good practice to tell patients if a drug is being prescribed off label. </p>
<p>Patients should be told information about the medicine, including potential side-effects and the reasons why they have been prescribed an off-label medicine versus a licensed medicine.</p>
<p>A patient who has been told or suspects their medicine is off-label should ask why they have been prescribed this medicine and what the risks versus the benefits are. They could ask what the likelihood is of this medicine working and what might happen if they do not have the medicine. </p>
<p>Off-label drugs do not have the same medical evidence as licensed drugs and inappropriate use could lead to more side-effects. However, for some people, off-label drugs could be the best or only option and they must receive honest and accurate information about their treatment.</p><img src="https://counter.theconversation.com/content/225715/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dipa Kamdar does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>There is no legal duty to tell a patient they have been prescribed a drug ‘off label’.Dipa Kamdar, Teaching Fellow in Pharmacy Practice, Kingston UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2189922024-03-01T13:33:52Z2024-03-01T13:33:52ZThe tools in a medieval Japanese healer’s toolkit: from fortunetelling and exorcism to herbal medicines<figure><img src="https://images.theconversation.com/files/578362/original/file-20240227-20-ng0qz.jpeg?ixlib=rb-1.1.0&rect=0%2C0%2C979%2C466&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">An 'onmyoji,' an expert on yin and yang, performs divination with counting rods in an Edo-period illustration.
</span> <span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Tamamonomae_Onmyoji.jpg">Kyoto University Library/Wikimedia</a></span></figcaption></figure><p>“The Tale of Genji,” often called <a href="https://www.penguinrandomhouse.com/books/530271/the-tale-of-genji-by-murasaki-shikibu/">Japan’s first novel</a>, was written 1,000 years ago. Yet it still occupies a powerful place in the Japanese imagination. A popular TV drama, “Dear Radiance” – “<a href="https://www.nhk.jp/p/hikarukimie/ts/1YM111N6KW/">Hikaru kimi e</a>” – is based on the life of its author, Murasaki Shikibu: the lady-in-waiting whose experiences at court inspired the refined world of “Genji.”</p>
<p>Romantic relationships, poetry and political intrigue provide most of the novel’s action. Yet illness plays an important role in several crucial moments, most famously when one of the main character’s lovers, Yūgao, <a href="https://www.gutenberg.org/cache/epub/66057/pg66057-images.html#page_92">falls ill and passes away</a>, killed by what appears to be a powerful spirit – as later happens <a href="https://www.gutenberg.org/cache/epub/66057/pg66057-images.html#page_250">to his wife, Aoi</a>, as well.</p>
<p>Someone reading “The Tale of Genji” at the time it was written would have found this realistic – as would some people in different cultures around the world today. Records from early medieval Japan document numerous descriptions <a href="https://academiccommons.columbia.edu/doi/10.7916/d8-46cs-wq63">of spirit possession</a>, usually blamed on spirits of the dead. As has been true in many times and places, physical and spiritual health were seen as intertwined.</p>
<p>As <a href="https://ealc.wustl.edu/people/alessandro-poletto">a historian of premodern Japan</a>, I’ve studied the processes its healing experts used to deal with possessions, and illness generally. Both literature and historical records demonstrate that the boundaries between what are often called “religion” and “medicine” were indistinct, if they existed at all.</p>
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<a href="https://images.theconversation.com/files/578356/original/file-20240227-28-gqyl6g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="An intricate illustration of a ceremony attended by people in robes, with the background covered in a golden color." src="https://images.theconversation.com/files/578356/original/file-20240227-28-gqyl6g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/578356/original/file-20240227-28-gqyl6g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/578356/original/file-20240227-28-gqyl6g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/578356/original/file-20240227-28-gqyl6g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/578356/original/file-20240227-28-gqyl6g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/578356/original/file-20240227-28-gqyl6g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/578356/original/file-20240227-28-gqyl6g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">A 17th-century scroll, ‘Maboroshi no Genji monogatari emaki,’ showing the funeral of Genji’s wife, Aoi.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/leaves-of-wild-ginger-from-the-phantom-genji-scrolls-mid-news-photo/1206222207?adppopup=true">Heritage Art/Heritage Images via Getty Images</a></span>
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<h2>Vanquishing spirits</h2>
<p>The government department in charge of divination, the Bureau of Yin and Yang, established in the late seventh century, played a crucial role. Its technicians, known as <a href="https://nirc.nanzan-u.ac.jp/journal/6/issue/186">onmyōji</a> – yin and yang masters – were in charge of divination and fortunetelling. They were also responsible for observing the skies, interpreting omens, calendrical calculations, timekeeping and eventually a variety of rituals.</p>
<p>Today, onmyōji appear as wizardlike figures in <a href="https://books.bunshun.jp/sp/onmyoji">novels</a>, <a href="https://www.viz.com/twin-star-exorcists">manga</a>, <a href="https://www.youtube.com/watch?v=LEiZuDTEq6A">anime</a> and <a href="https://en.onmyojigame.com/">video games</a>. Though heavily fictionalized, there is a historical kernel of truth in these fantastical depictions.</p>
<p>Starting from around the 10th century, Onmyōji were charged with carrying out iatromancy: divining the cause of a disease. Generally, they distinguished between disease caused by external or internal factors, though boundaries between the categories were often blurred. External factors could include local deities known as “kami,” other kami-like entities the patient had upset, minor Buddhist deities or malicious spirits – often revengeful ghosts. </p>
<p>In the case of spirit-induced illness, Buddhist monks would work to winnow out the culprit. Monks who specialized in exorcistic practices were known as “genja” and were believed to know how to <a href="https://www.penguinrandomhouse.com/books/300922/the-pillow-book-by-sei-shonagon">expel the spirit from a patient’s body</a> through powerful incantations. Genja would then transfer it onto another person and force the spirit to reveal its identity before vanquishing it.</p>
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<a href="https://images.theconversation.com/files/578368/original/file-20240227-26-dx583p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A faded picture of a broom, branch with a few leaves, and a fan, as well as Japanese script on top of it." src="https://images.theconversation.com/files/578368/original/file-20240227-26-dx583p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/578368/original/file-20240227-26-dx583p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=665&fit=crop&dpr=1 600w, https://images.theconversation.com/files/578368/original/file-20240227-26-dx583p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=665&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/578368/original/file-20240227-26-dx583p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=665&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/578368/original/file-20240227-26-dx583p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=836&fit=crop&dpr=1 754w, https://images.theconversation.com/files/578368/original/file-20240227-26-dx583p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=836&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/578368/original/file-20240227-26-dx583p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=836&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">A 19th century print by Kubo Shunman shows objects representing the New Year’s ceremony of exorcising demons.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/objects-representing-the-ceremony-of-exorcising-demons-one-news-photo/1338629689?adppopup=true">Heritage Images/Hulton Archive via Getty Images</a></span>
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<h2>Court physicians</h2>
<p>While less common than spirit possessions, the idea that physical factors could also cause illness appears in sources from this period. </p>
<p>Since the late seventh century, the government of the Japanese archipelago had established a bureau in charge of the well-being of aristocratic families and high-ranking members of the state bureaucracy. This <a href="https://rekihaku.repo.nii.ac.jp/records/2657">Bureau of Medications</a>, the Ten’yakuryō, was based on similar systems in China’s Tang dynasty, <a href="https://search.worldcat.org/title/3414658">which Japanese officials</a> adapted for their own culture.</p>
<p>The bureau’s members, whom scholars today often call “court physicians” in English, created medicinal concoctions. But the bureau also included technicians tasked with using spells, perhaps to protect high-ranking people from maladies.</p>
<h2>Not either/or</h2>
<p>Some scholars, both Japanese and non-Japanese, compare the practices of members of the Bureau of Medications with what is now called “traditional Chinese medicine,” or just “medicine.” They typically consider the onmyōji and Buddhist monks, meanwhile, to fall under the label of “religion” – or perhaps, <a href="https://search.worldcat.org/title/7306973">in the case of onmyōji, “magic</a>.”</p>
<p>But I have found numerous signs that these categories do not help people today make sense of early medieval Japan.</p>
<p>Starting in the seventh century, as a centralized Japanese state began to take shape, Buddhist monks from the Korean Peninsula and present-day China brought healing practices to Japan. These techniques, such as herbalism – treatments made of plants – later became associated with court physicians. At the same time, though, monks also employed <a href="https://doi.org/10.1093/acrefore/9780199340378.013.980">healing practices rooted in Buddhist rituals</a>. Clearly, <a href="https://academiccommons.columbia.edu/doi/10.7916/d8-46cs-wq63">the distinction between ritual and physical healing</a> was not part of their mindset.</p>
<p>Similarly, with court physicians, it is true that sources from this period mostly show them <a href="https://rekihaku.repo.nii.ac.jp/records/2657">practicing herbalism</a>. Later on, they incorporated simple needle surgeries and moxibustion, which involves burning a substance derived from dried leaves from the mugwort plant near the patient’s skin.</p>
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<a href="https://images.theconversation.com/files/578349/original/file-20240227-28-9evlnl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A drawing showing the outline of the human body from behind and in front, with one arm outstretched, and Chinese characters written on it." src="https://images.theconversation.com/files/578349/original/file-20240227-28-9evlnl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/578349/original/file-20240227-28-9evlnl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=453&fit=crop&dpr=1 600w, https://images.theconversation.com/files/578349/original/file-20240227-28-9evlnl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=453&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/578349/original/file-20240227-28-9evlnl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=453&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/578349/original/file-20240227-28-9evlnl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=569&fit=crop&dpr=1 754w, https://images.theconversation.com/files/578349/original/file-20240227-28-9evlnl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=569&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/578349/original/file-20240227-28-9evlnl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=569&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">An 18th-century engraving identifying parts of the body treated by moxibustion.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/engraving-of-the-meridian-points-on-the-human-body-which-news-photo/90731089?adppopup=true">Science & Society Picture Library via Getty Images</a></span>
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<p>However, they also incorporated ritual elements from various Chinese traditions: spells, divination, fortunetelling and hemerology, the practice of identifying auspicious and inauspicious days for specific events. For example, moxibustion was supposed to be avoided on certain days because of the position of a deity, <a href="https://cir.nii.ac.jp/crid/1520853832664346880">known as “jinshin</a>,” believed to reside and move inside the human body. Practicing moxibustion on the body part where “jinshin” resided in a specific moment could kill it, therefore potentially harming the patient. </p>
<p>Court physicians were also expected to ritually “rent” a place for a pregnant woman to deliver, <a href="https://doi.org/10.3390/rel12110907">producing talismans</a> written in red ink that were meant to function as “leases” for the birthing area. This was done in order to keep away deities who might otherwise enter that space, possibly because childbirth was believed to be a source of defilement. They also used hemerology to determine where the birthing bed should be placed.</p>
<p>In short, these healing experts straddled the boundaries between what are often called “religion” and “medicine.” We take for granted the categories that shape our understanding of the world around us, but they are the result of complex historical processes – and look different in every time and place.</p>
<p>Reading works like “The Tale of Genji” is not only a way to immerse ourselves in the world of a medieval court, one where spirits roam freely, but a chance to see other ways of sorting human experience at work.</p><img src="https://counter.theconversation.com/content/218992/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alessandro Poletto does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>In medieval Japan, healing might mean taking medicine, undergoing an exorcism or sidestepping harm in the first place by avoiding inauspicious days.Alessandro Poletto, Lecturer in East Asian Religions, Arts & Sciences at Washington University in St. LouisLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2242372024-02-26T01:47:21Z2024-02-26T01:47:21ZWhat is Ryeqo, the recently approved medicine for endometriosis?<figure><img src="https://images.theconversation.com/files/577738/original/file-20240225-24-jk5b3s.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5991%2C3997&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.pexels.com/photo/woman-suffering-from-a-stomach-pain-5938369/">Pexels/Sora Shimazaki</a></span></figcaption></figure><p>For women diagnosed with endometriosis it is often a long sentence of chronic pain and cramping that <a href="https://www.instagram.com/p/CP2i5xKl9tS/">impacts their daily life</a>. It is a condition that is both difficult to diagnose and treat, with many women needing either <a href="https://www.thewomens.org.au/health-information/periods/endometriosis/">surgery or regular medication</a>.</p>
<p>A medicine called Ryeqo has just been approved for marketing specifically for endometriosis, although it was already available in Australia to treat a different condition.</p>
<p>Women who want the drug will need to consult their local doctor and, as it is not yet on the Pharmaceutical Benefits Scheme, they will need to pay the full cost of the script.</p>
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<a href="https://theconversation.com/people-with-endometriosis-and-pcos-wait-years-for-a-diagnosis-attitudes-to-womens-pain-may-be-to-blame-179500">People with endometriosis and PCOS wait years for a diagnosis – attitudes to women’s pain may be to blame</a>
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<h2>What does Ryeqo do?</h2>
<p>Endometriosis <a href="https://www.aihw.gov.au/reports/chronic-disease/endometriosis-in-australia/contents/how-common-is-endometriosis">affects 14% of women of reproductive age</a>. While we don’t have a full understanding of the cause, the evidence suggests it’s due to body tissue that is similar to the lining of the uterus (called the endometrium) growing outside the uterus. This causes pain and inflammation, which reduces quality of life and can also affect fertility.</p>
<p>Ryeqo is a tablet containing three different active ingredients: relugolix, estradiol and norethisterone. </p>
<p>Relugolix is a drug that blocks a particular peptide from releasing other hormones. It is also used in the <a href="https://www.mayoclinic.org/drugs-supplements/relugolix-oral-route/description/drg-20506394">treatment of prostate cancer</a>. Estradiol is a naturally occurring oestrogen hormone in women that helps regulate the menstrual cycle and is used in <a href="https://www.menopause.org.au/health-info/fact-sheets/what-is-menopausal-hormone-therapy-mht-and-is-it-safe">menopausal hormone therapy</a>. Norethisterone is a synthetic hormone commonly used in birth control medications and to <a href="https://www.netdoctor.co.uk/medicines/a8713/norethisterone/">delay menstruation and help with heavy menstrual bleeding</a>.</p>
<p>All three components work together to regulate the levels of oestrogen and progesterone in the body that contribute to endometriosis, alleviating its symptoms. </p>
<p>Relugolix reduces the overall levels of oestrogen and progesterone in the body. The estradiol compensates for the loss of oestrogen because low oestrogen levels can cause hot flushes (also called hot flashes) and bone density loss. And norethisterone blocks the effects of estradiol on the uterus (where too much tissue growth is unwanted).</p>
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Read more:
<a href="https://theconversation.com/a-new-government-inquiry-will-examine-womens-pain-and-treatment-how-and-why-is-it-different-221747">A new government inquiry will examine women's pain and treatment. How and why is it different?</a>
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<h2>Is it really new?</h2>
<p>The maker of Ryeqo claims it is the <a href="https://www.gedeonrichter.com/au/-/media/sites/au/documents/media-release-c_ryeqo-tga-approval_gedeon-richter-australia_final.pdf?rev=1cc37d3726f84e9ca71d4c094c1e3dd6">first new drug for endometriosis in Australia in 13 years</a>.</p>
<p>But individually, all three active ingredients in Ryeqo have been in use since <a href="https://link.springer.com/article/10.1007/s40265-019-01105-0#:%7E:text=Relugolix%20received%20its%20first%20global,with%20uterine%20fibroids%20in%20Japan.">2019</a> or earlier. </p>
<p>Ryeqo has been available in Australia <a href="https://www.tga.gov.au/resources/artg/375414">since 2022</a>, but until now was not specifically indicated for endometriosis. It was originally approved for the treatment of <a href="https://www.ema.europa.eu/en/medicines/human/EPAR/ryeqo">uterine fibroids</a>, which share some <a href="https://www.medicalnewstoday.com/articles/fibroid-vs-endometriosis#similarities">common symptoms</a> with endometriosis and have related causes.</p>
<p>In addition to Ryeqo, current medical guidance lists other drugs that are suitable for endometriosis and some reformulations of these have also only been recently approved. </p>
<p>The oral medicine <a href="https://www.tga.gov.au/resources/artg/336684">Dienogest</a> was approved in 2021, and there have been a number of injectable drugs for endometriosis recently approved, such as <a href="https://www.tga.gov.au/resources/artg/401897">Sayana Press</a> which was approved in a smaller dose form for self-injection in 2023. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/577780/original/file-20240225-28-5t517.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="hands taking pill out of contraceptive blister pack" src="https://images.theconversation.com/files/577780/original/file-20240225-28-5t517.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/577780/original/file-20240225-28-5t517.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/577780/original/file-20240225-28-5t517.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/577780/original/file-20240225-28-5t517.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/577780/original/file-20240225-28-5t517.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/577780/original/file-20240225-28-5t517.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/577780/original/file-20240225-28-5t517.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">You can’t take the contraceptive pill with Ryeqo but the endometriosis drug could replace it.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/contraceptive-pill-174193232">Shutterstock</a></span>
</figcaption>
</figure>
<h2>How to take it and what not to do</h2>
<p>Ryeqo is a once-a-day tablet. You can take it with, or without food, but it should be taken about the same time each day.</p>
<p>It is recommended you start taking Ryeqo within the first five days after the start of your next period. If you start at another time during your period, you may experience initial irregular or heavier bleeding.</p>
<p>Because it contains both synthetic and natural hormones, you can’t use the contraceptive pill and Ryeqo together. However, because Ryeqo does contain norethisterone it can be used as your contraception, although <a href="https://www.ebs.tga.gov.au/ebs/picmi/picmirepository.nsf/pdf?OpenAgent=&id=CP-2023-CMI-01327-1&d=20240224172310101">it will take at least one month of use to be effective</a>. So, if you are on Ryeqo, you should use a non-hormonal contraceptive – such as condoms – for a month when starting the medicine.</p>
<p>Ryeqo may be incompatible with other medicines. It might not be suitable for you if you take medicines for epilepsy, HIV and AIDS, hepatitis C, fungal or bacterial infections, high blood pressure, irregular heartbeat, angina (chest pain), or organ rejection. You should also not take Ryeqo if you have a liver tumour or liver disease.</p>
<p>The possible <a href="https://www.ebs.tga.gov.au/ebs/picmi/picmirepository.nsf/pdf?OpenAgent&id=CP-2022-PI-01955-1">side effects of Ryeqo</a> are similar to those of oral contraceptives. Blood clots are a risk with any medicine that contains an oestrogen or a progestogen, which Ryeqo does. Other potential side effects include bone loss, a reduction in menstrual blood loss or loss of your period.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/whats-a-tens-machine-can-it-help-my-period-pain-or-endometriosis-201389">What's a TENS machine? Can it help my period pain or endometriosis?</a>
</strong>
</em>
</p>
<hr>
<h2>It’s costly for now</h2>
<p>Ryeqo can now be prescribed in Australia, so you should discuss whether Ryeqo is right for you with the doctor you usually consult for your endometriosis. </p>
<p>While the maker has made a submission to the Pharmaceutical Benefits Advisory Committee, it is not yet subsidised by the Australian government. This means that rather than paying the <a href="https://www.pbs.gov.au/info/healthpro/explanatory-notes/front/fee">normal PBS price of up to A$31.60</a>, it has been reported it may <a href="https://www.9news.com.au/national/it-never-stops-new-drug-approved-to-treat-endometriosis-after-decade-of-pain/b51f0e92-6dd8-4812-800a-eadac0d55218">cost as much as $135</a> for a one-month supply. The committee will make a decision on whether to subsidise Ryeqo at its meeting next month.</p>
<hr>
<p><em>Correction: this article has been updated to clarify the recent approval of specific formulations of drugs for endometriosis.</em></p><img src="https://counter.theconversation.com/content/224237/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nial Wheate in the past has received funding from the ACT Cancer Council, Tenovus Scotland, Medical Research Scotland, Scottish Crucible, and the Scottish Universities Life Sciences Alliance. He is a Fellow of the Royal Australian Chemical Institute, a member of the Australasian Pharmaceutical Science Association, and a member of the Australian Institute of Company Directors. Nial is the chief scientific officer of Vaihea Skincare LLC, a director of SetDose Pty Ltd a medical device company, and a Standards Australia panel member for sunscreen agents. Nial regularly consults to industry on issues to do with medicine risk assessments, manufacturing, design, and testing.</span></em></p><p class="fine-print"><em><span>Jasmine Lee does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A drug newly approved by the Therapeutic Goods Administration for endometriosis is available in Australia.Nial Wheate, Associate Professor of the School of Pharmacy, University of SydneyJasmine Lee, Pharmacist and PhD Candidate, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2225682024-02-05T13:29:42Z2024-02-05T13:29:42ZAmid growing legalization, cannabis in culture and politics is the focus of this anthropology course<figure><img src="https://images.theconversation.com/files/572920/original/file-20240201-19-efs8pb.jpg?ixlib=rb-1.1.0&rect=0%2C25%2C3456%2C2214&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Laws that govern cannabis use are changing across the nation.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/marijuana-legalization-high-quality-stock-photo-royalty-free-image/1143280562?phrase=cannabis">Darren415 via Getty Images</a></span></figcaption></figure><figure class="align-right ">
<img alt="Text saying: Uncommon Courses, from The Conversation" src="https://images.theconversation.com/files/499014/original/file-20221205-17-kcwec8.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/499014/original/file-20221205-17-kcwec8.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=375&fit=crop&dpr=1 600w, https://images.theconversation.com/files/499014/original/file-20221205-17-kcwec8.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=375&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/499014/original/file-20221205-17-kcwec8.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=375&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/499014/original/file-20221205-17-kcwec8.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=471&fit=crop&dpr=1 754w, https://images.theconversation.com/files/499014/original/file-20221205-17-kcwec8.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=471&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/499014/original/file-20221205-17-kcwec8.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=471&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
</figcaption>
</figure>
<p><em><a href="https://theconversation.com/topics/uncommon-courses-130908">Uncommon Courses</a> is an occasional series from The Conversation U.S. highlighting unconventional approaches to teaching.</em> </p>
<h2>Title of course:</h2>
<p>Anthropology of Cannabis</p>
<h2>What prompted the idea for the course?</h2>
<p>Whenever I taught my medical anthropology course, I noticed that students were most curious about the section of the course that deals with the uses of plants, fungi and other species for a range of medical purposes. Those purposes included healing, psychological well-being, ritual and spiritual awakening, to name a few.</p>
<p>Once Connecticut, the state where I work, legalized recreational cannabis, I decided it was timely to take the plant section from the original course and expand it to a 14-week course of its own. It was also an opportunity to introduce students to the discipline of anthropology through a topic I knew many of them found interesting. I decided to focus on cannabis instead of the entire panoply of plants and other species, since it was the one plant being legalized in the state at that time.</p>
<h2>What does the course explore?</h2>
<p>Throughout the course, we focus on the different cultural and political significance of cannabis in other geographical contexts. We look at the representation of <a href="https://www.northernstandard.com/a-brief-history-of-cannabis-in-art/">cannabis in art</a>, <a href="https://electricliterature.com/7-lesser-known-stoner-novels-with-suggested-weed-pairings/">literature and pop culture</a>, as well as what the <a href="https://www.nccih.nih.gov/health/cannabis-marijuana-and-cannabinoids-what-you-need-to-know#:%7E:text=The%20cannabis%20plant%20contains%20about,on%20a%20person's%20mental%20state">science of cannabis</a> tells us about its <a href="https://doi.org/10.31887/DCNS.2020.22.3/mcrocq">impact on health and well-being</a>.</p>
<p>We also look at the way stigma and racism impact cannabis users and producers in the United States and elsewhere.</p>
<p>We end the course with students writing letters to themselves in which they imagine how the legal and social landscape for cannabis will be in five years, in the U.S. as well as globally. I plan to send them these letters in 2028.</p>
<h2>Why is this course relevant now?</h2>
<p>While cannabis has long been a part of human existence, the legal and political landscape of cannabis production is rapidly changing. Even if they are not cannabis consumers, students will at least become more aware about the role that cannabis plays in today’s society.</p>
<p>Students may want to know how they can participate in the business side of cannabis. Or they may be interested in doing research on the uses and abuses of the plant.</p>
<p>The course also offers students a way to think about the stigma and discrimination faced by cannabis users and how different cultural systems define and treat behaviors that are deemed deviant. </p>
<h2>What’s a critical lesson from the course?</h2>
<p>My main objective is to have students develop an informed understanding of cannabis as a plant and as a cultural fact. I want them to approach the study of cannabis with an open mind and to walk away with a greater understanding of how harmful stigma can be to individuals in any society. I would hope everyone leaves informed and less inclined to stereotype others. </p>
<h2>What materials does the course feature?</h2>
<p>We read passages from <a href="https://facultyprofile.fairfield.edu/?uname=dcrawford">anthropologist David Crawford</a>’s “<a href="https://rowman.com/ISBN/9781498598187/Dealing-with-Privilege-Cannabis-Cocaine-and-the-Economic-Foundations-of-Suburban-Drug-Culture">Dealing with Privilege: Cannabis, Cocaine, and the Economic Foundations of Surburban Drug Culture</a>,” which challenges the stereotypes that many white people and politicians hold about drug dealing and also explores how drugs became raced and classed entities.</p>
<p>We also read “<a href="https://doi.org/10.1089/can.2022.0251">Understanding and Rebalancing: A Rapid Scoping Review of Cannabis Research Among Indigenous People</a>,” which gives students an opportunity to learn more about Indigenous peoples and cultures alongside learning more about the cannabis plant itself.</p>
<p>And we watch “<a href="https://www.imdb.com/title/tt0028346/">Reefer Madness</a>,” a 1936 film meant to be a cautionary tale about the presumed dangers of marijuana use.</p>
<h2>What will the course prepare students to do?</h2>
<p>Students leave the class better informed about cannabis as a plant and with a better appreciation for the complexity of “drugs” in society. I believe the class also helps students to become more informed citizens, since the laws that govern the use and research on cannabis and other related plants are as much a <a href="https://doi.org/10.1177/0091450919827605">political issue as they are social</a>.</p><img src="https://counter.theconversation.com/content/222568/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Hillary Jeanne Haldane does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Students are invited to imagine how the social, political and legal landscape for cannabis will look in the future.Hillary Jeanne Haldane, Professor of Anthropology, Quinnipiac UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2114702024-01-24T13:29:42Z2024-01-24T13:29:42ZCombining two types of molecular boron nitride could create a hybrid material used in faster, more powerful electronics<figure><img src="https://images.theconversation.com/files/569648/original/file-20240116-15-csiabm.jpg?ixlib=rb-1.1.0&rect=8%2C17%2C5682%2C4471&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Hexagonal boron nitride, also known as 'white graphene.'</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/boron-nitride-monolayer-illustration-royalty-free-image/1161024204?phrase=boron+nitride&adppopup=true">Robert Brook/Science Photo Library via Getty Images</a></span></figcaption></figure><p>In chemistry, structure is everything. Compounds with the same chemical formula can have different properties depending on the arrangement of the molecules they’re made of. And compounds with a different chemical formula but a similar molecular arrangement can have similar properties.</p>
<p><a href="https://www.sciencedirect.com/topics/chemistry/graphene">Graphene</a> and a form of boron nitride called hexagonal boron nitride fall into the latter group. Graphene is made up of carbon atoms. Boron nitride, BN, is composed of boron and nitrogen atoms. While their chemical formulas differ, <a href="https://doi.org/10.1063/PT.3.3297">they have a similar structure</a> – so similar that many chemists call hexagonal boron nitride “white graphene.”</p>
<p>Carbon-based graphene has <a href="https://theconversation.com/graphene-is-a-proven-supermaterial-but-manufacturing-the-versatile-form-of-carbon-at-usable-scales-remains-a-challenge-194238">lots of useful properties</a>. It’s thin but strong, and it conducts heat and electricity very well, making it ideal for use in electronics.</p>
<p>Similarly, hexagonal boron nitride has a host of properties similar to graphene that could improve biomedical imaging and drug delivery, as well as computers, smartphones and LEDs. <a href="https://doi.org/10.1038/nmat2711">Researchers have studied</a> this type of boron nitride for many years.</p>
<p>But, hexagonal boron nitride isn’t the only useful form this compound comes in.</p>
<p>As <a href="https://scholar.google.com/citations?user=S5oLGEgAAAAJ&hl=en">materials engineers</a>, <a href="https://ajayan.rice.edu/">our research team</a> has been investigating another type of boron nitride called cubic boron nitride. We want to know if combining the properties of hexagonal boron nitride with cubic boron nitride could open the door to <a href="https://www.azom.com/article.aspx?ArticleID=78">even more useful applications</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/569649/original/file-20240116-15-c9h3ox.gif?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Molecular structures of molecules, with atoms represented as blue spheres and bonds represented by gray lines connecting them. The left structure is in the shape of the cube, the right in flat sheets of hexagons." src="https://images.theconversation.com/files/569649/original/file-20240116-15-c9h3ox.gif?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/569649/original/file-20240116-15-c9h3ox.gif?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=227&fit=crop&dpr=1 600w, https://images.theconversation.com/files/569649/original/file-20240116-15-c9h3ox.gif?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=227&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/569649/original/file-20240116-15-c9h3ox.gif?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=227&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/569649/original/file-20240116-15-c9h3ox.gif?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=285&fit=crop&dpr=1 754w, https://images.theconversation.com/files/569649/original/file-20240116-15-c9h3ox.gif?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=285&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/569649/original/file-20240116-15-c9h3ox.gif?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=285&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Cubic boron nitride, shown on the left, and hexagonal boron nitride, shown on the right.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Structures_cub_hex_BN.gif">Oddball/Wikimedia Commons</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span>
</figcaption>
</figure>
<h2>Hexagonal versus cubic</h2>
<p>Hexagonal boron nitride is, as you might guess, boron nitride molecules arranged in the shape of a flat hexagon. It looks honeycomb-shaped, like graphene. Cubic boron nitride has a <a href="https://www.azom.com/article.aspx?ArticleID=78">three-dimensional lattice structure</a> and looks like a diamond at the molecular level.</p>
<p>H-BN is thin, soft and used in cosmetics to give them a silky texture. It doesn’t melt or degrade even under extreme heat, which also makes it useful in electronics and other applications. Some scientists predict it could be used to build a <a href="https://doi.org/10.1016/j.cej.2020.127802">radiation shield</a> for spacecraft.</p>
<p>C-BN is hard and resistant. It’s used in manufacturing to make cutting tools and drills, and it can keep its sharp edge even at high temperatures. It can also help dissipate heat in electronics.</p>
<p>Even though h-BN and c-BN might seem different, when put together, <a href="https://doi.org/10.1021/acs.nanolett.3c01537">our research has found</a> they hold even more potential than either on its own.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/566921/original/file-20231220-23-komtmy.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Two white powders, the top labeled 'hexagonal boron nitride' and the bottom labeled 'cubic boron nitride' with a circle between them labeled 'mixed phase boron nitride.' The bottom powder is slightly more brown and more clumpy." src="https://images.theconversation.com/files/566921/original/file-20231220-23-komtmy.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/566921/original/file-20231220-23-komtmy.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=557&fit=crop&dpr=1 600w, https://images.theconversation.com/files/566921/original/file-20231220-23-komtmy.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=557&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/566921/original/file-20231220-23-komtmy.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=557&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/566921/original/file-20231220-23-komtmy.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=700&fit=crop&dpr=1 754w, https://images.theconversation.com/files/566921/original/file-20231220-23-komtmy.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=700&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/566921/original/file-20231220-23-komtmy.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=700&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The two forms of boron nitride have some similarities and some differences, but when combined, they can create a substance with a variety of scientific applications.</span>
<span class="attribution"><span class="source">Abhijit Biswas</span></span>
</figcaption>
</figure>
<p>Both types of boron nitride conduct heat and can provide electrical insulation, but one, h-BN, is soft, and the other, c-BN, is hard. So, we wanted to see if they could be used together to create materials with interesting properties.</p>
<p>For example, combining their different behaviors could make a coating material effective for high temperature structural applications. C-BN could provide strong adhesion to a surface, while h-BN’s lubricating properties could resist wear and tear. Both together would keep the material from overheating.</p>
<h2>Making boron nitride</h2>
<p>This class of materials doesn’t occur naturally, so scientists must make it in the lab. In general, high-quality c-BN has been difficult to synthesize, whereas h-BN is relatively easier to make as high-quality films, using what are called vapor phase deposition methods. </p>
<p>In vapor phase deposition, we heat up boron and nitrogen-containing materials until they evaporate. The evaporated molecules then get deposited onto a surface, cool down, bond together and form a thin film of BN.</p>
<p>Our research team has worked on combining h-BN and c-BN using <a href="https://doi.org/10.1021/nl1022139">similar processes</a> to vapor phase deposition, but we can also <a href="https://doi.org/10.1021/acs.nanolett.3c01537">mix powders of the two together</a>. The idea is to build a material with the right mix of h-BN and c-BN for thermal, mechanical and electronic properties that we can fine-tune.</p>
<p>Our team has found the composite substance made from combining both forms of BN together has a variety of potential applications. When you point a laser beam at the substance, it flashes brightly. Researchers could use this property to create display screens and improve radiation therapies in the medical field. </p>
<p>We’ve also found we can tailor how heat-conductive the composite material is. This means engineers could use this BN composite in <a href="https://doi.org/10.1021/acs.nanolett.3c01537">machines that manage heat</a>. The next step is trying to manufacture large plates made of a h-BN and c-BN composite. If done precisely, we can tailor the mechanical, thermal and optical properties to specific applications.</p>
<p>In electronics, h-BN could <a href="https://doi.org/10.1063/PT.3.3297">act as a dielectric – or insulator – alongside graphene</a> in certain, low-power electronics. As a dielectric, h-BN would help electronics operate efficiently and keep their charge. </p>
<p>C-BN could work alongside diamond to create <a href="https://www.nrel.gov/materials-science/wide-bandgap-semiconductors.html">ultrawide band gap materials</a> that allow electronic devices to work at a much higher power. Diamond and c-BN both conduct heat well, and together they could help cool down these <a href="https://doi.org/10.1002/aelm.201600501">high-power devices</a>, which generate lots of extra heat.</p>
<p>H-BN and c-BN separately could lead to electronics that perform exceptionally well in different contexts – together, they have a host of potential applications, as well. </p>
<p>Our BN composite could improve heat spreaders and insulators, and it could work in energy storage machines like supercapacitors, which are <a href="https://www.azonano.com/article.aspx?ArticleID=6643">fast-charging energy storage devices</a>, and rechargeable batteries.</p>
<p>We’ll continue <a href="https://www.preciseceramic.com/blog/boron-nitride-the-superhero-material-of-the-future.html">studying BN’s properties</a>, and how we can use it in lubricants, coatings and wear-resistant surfaces. Developing ways to scale up production will be key for <a href="https://www.linkedin.com/pulse/global-boron-nitride-market-2024-share-future-trends-d1uwf/?published=t">exploring its applications</a>, from materials science to electronics and even environmental science.</p><img src="https://counter.theconversation.com/content/211470/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Pulickel Ajayan receives funding from the Army Research Laboratory and the Army Research Office. </span></em></p><p class="fine-print"><em><span>Abhijit Biswas does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Two forms of the same boron nitride molecules couldn’t look and act more different – but combining them could lead to applications that have the best of both worlds.Pulickel Ajayan, Professor of Materials Science and NanoEngineering, Rice UniversityAbhijit Biswas, Research Scientist in Materials Science and Nanoengineering, Rice UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2189912024-01-08T13:34:33Z2024-01-08T13:34:33ZEmergency medicine residencies more likely to go unfilled at for-profit and newly accredited programs<p>The number of unfilled positions in emergency medicine residency programs surged in 2022 and 2023, with the trend most pronounced at programs that were recently accredited or under for-profit ownership. That’s the key finding of <a href="https://doi.org/10.1002/aet2.10902">my team’s recent study</a> of the past two match cycles.</p>
<p>A match cycle is when medical students choose a specialty and learn where they will train. It starts when fourth-year medical students interview at residency programs at hospitals around the country. Then, the students rank their preferred training programs, and the programs rank the students. An <a href="https://www.nrmp.org/intro-to-the-match/#:%7E:text=NRMP%20uses%20a%20mathematical%20algorithm,possible%20match%20for%20all%20participants.">algorithm makes matches</a>.</p>
<p>The proportion of medical students applying for emergency medicine residencies dropped by <a href="https://www.acep.org/news/acep-newsroom-articles/joint-statement-match-2023">16.8% from 2021 to 2022</a> and declined another 18.1% from 2022 to 2023. This abrupt decline may degrade the three-to-four-year clinical training experience of emergency medicine residents and affect how the health care system provides emergency care in the future.</p>
<p>But this waning in demand is only half of the story. Deepening the problem is the fact that the number of emergency medicine residency programs has grown at the same time. </p>
<h2>No checks on the for-profit sector</h2>
<p>Over the past five to eight years, <a href="https://www.npr.org/sections/health-shots/2023/02/11/1154962356/ers-hiring-fewer-doctors">more for-profit and private capital-backed firms</a> have bought emergency medicine facilities, taken over staffing contracts in existing hospitals and <a href="https://doi.org/10.1001/jamanetworkopen.2023.12457">created emergency residency programs</a>.</p>
<p>Since they are for-profit entities, these companies have a responsibility to return money to investors. They have been shown to achieve this by <a href="https://doi.org/10.1002/aet2.10786">paying residents less</a> and charging <a href="https://www.bmj.com/content/382/bmj-2023-075244">higher prices</a> on services like imaging and hospitalization.</p>
<p>Currently, there are no limits on the number of residency programs or positions in emergency medicine. The Review Committee for Emergency Medicine <a href="https://www.acgme.org/specialties/emergency-medicine/overview/">automatically approves all proposals for new residency programs</a> that meet requirements. Despite the fact that positions are already going unfilled, <a href="https://apps.acgme.org/ads/Public/Reports/Report/1">eight new emergency medicine residency programs were accredited</a> during the 2022-23 academic year. This accreditation system is currently under review, but any changes will take years to go into effect.</p>
<h2>More positions, lower demand</h2>
<p>I am a physician <a href="https://scholar.google.com/citations?user=KVEHBakAAAAJ&hl=en&oi=ao">who studies the state of emergency care</a>. In our recent paper, my team and I calculated the number of emergency medicine residency programs that filled all positions in the past two match cycles. </p>
<p>Our <a href="https://doi.org/10.1002/aet2.10902">study shows that</a> in 2022, 277 emergency medicine residency programs offered 2,921 positions and had 219 unfilled positions. In 2023, 287 emergency medicine programs offered 3,010 positions and 554 went unfilled. In each of these years, about 30 programs had primary clinical training sites under for-profit ownership. </p>
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<p>The drop in interest in emergency medicine may be driven by well-circulated <a href="https://doi.org/10.1016/j.annemergmed.2021.05.029">forecasts predicting a surplus</a> in the emergency physician workforce by 2030 and <a href="https://doi.org/10.1016/j.annemergmed.2021.05.029">escalating levels of burnout</a> among emergency physicians. </p>
<p>By examining where residents chose to go when there were more than enough programs to choose from, we learned three things. </p>
<p>First, more established programs did better. Emergency medicine residency programs accredited within the past five years had more than double the likelihood of not filling all positions compared with those accredited for more than five years.</p>
<p>Second, in 2023, more opportunities were offered in several metropolitan areas, including Detroit, Miami and Philadelphia, but these programs ended up with many unfilled positions.</p>
<p>Third, emergency medicine residency programs with for-profit clinical sites were less likely to fill all residency positions. These programs had a 50% greater chance of not filling all positions when compared with nonprofit or government-run sites. </p>
<h2>Possible solutions</h2>
<p>It’s not clear whether these trends will continue. In 1996, <a href="https://www.nrmp.org/match-data-analytics/archives/">the anesthesiology specialty</a> saw the proportion of filled residency positions drop to 45%, an all-time low. Yet the specialty rebounded to fill nearly 100% of available positions by 2002.</p>
<p>While it is possible the past two years for emergency medicine are part of the natural ebb and flow of specialty interest among medical students, our findings, the historical literature and the recent <a href="https://www.wsj.com/articles/kkr-backed-envision-healthcare-plans-chapter-11-bankruptcy-filing-2fff4382">bankruptcy filing of Envision</a> – a large, for-profit emergency medicine group that staffs <a href="https://emworkforce.substack.com/p/state-of-the-us-emergency-medicine">several clinical sites and residency programs</a> – all suggest medical students may be recognizing the disadvantages of for-profit emergency medicine residency programs. </p>
<p>There is little data on the quality of these programs. No research yet has evaluated board exam pass rates of emergency medicine residents graduating from newly accredited or for-profit clinic sites. However, <a href="https://doi.org/10.4300/JGME-D-21-01097.1">residents in pediatric programs</a> with a corporate affiliation had lower board exam pass rates.</p>
<p>In addition to reconsidering the persistent opening of new programs, now may be the time for organizations like the <a href="https://www.emra.org/">Emergency Medicine Residents’ Association</a> and the <a href="https://www.acep.org/">American College of Emergency Physicians</a> to address issues that affect recruitment of emergency medicine residents. </p>
<p>Physician burnout could be addressed by reviewing hospital policies designed to maximize profits. For example, many patients are admitted to the hospital, yet <a href="https://www.acep.org/patient-care/policy-statements/boarding-of-admitted-and-intensive-care-patients-in-the-emergency-department">“board”</a> in the hallway of an emergency department for hours. These patients have routinely been shown to have <a href="http://doi.org/10.1001/jamainternmed.2023.5961">worse outcomes</a>, yet hospital leadership frequently attempts to <a href="https://catalyst.nejm.org/doi/full/10.1056/CAT.21.0217">prioritize revenue-generating</a> surgeries and procedures in lieu of assigning beds for admitted patients from the emergency department.</p>
<p>Loan forgiveness and increased salaries could draw more residents to emergency medicine, especially in rural areas where distinct physician shortages exist. And more female residents would be drawn into emergency medicine if disparities in pay and concerns over violence in emergency rooms were systematically resolved.</p><img src="https://counter.theconversation.com/content/218991/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Cameron Gettel receives funding from the National Institute on Aging (NIA) of the National Institutes of Health and the American Board of Emergency Medicine / National Academy of Medicine Fellowship. The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation or approval of the manuscript.</span></em></p>A new study finds more emergency medicine residencies are available, but hundreds of the positions are going unfilled.Cameron Gettel, Assistant Professor of Emergency Medicine, Yale UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2205642024-01-05T14:54:09Z2024-01-05T14:54:09ZNew antibiotic zosurabalpin shows promise against drug-resistant bacteria – an expert explains how it works<figure><img src="https://images.theconversation.com/files/567989/original/file-20240105-24-a6i28q.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5120%2C2880&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Carbapenem-resistant Acinetobacter baumannii is classified as a priority 1 critical pathogen by the World Health Organization</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/medical-science-laboratory-portrait-beautiful-black-1922200124">Gorodenkoff/Shutterstock</a></span></figcaption></figure><p>Researchers have <a href="https://www.nature.com/articles/s41586-023-06799-7">identified</a> an entirely new class of antibiotic that can kill bacteria that are resistant to most current drugs. </p>
<p>Zosurabalpin is highly effective against the bacterium carbapenem-resistant <em>Acinetobacter baumannii</em> (Crab), which is <a href="https://www.who.int/news/item/27-02-2017-who-publishes-list-of-bacteria-for-which-new-antibiotics-are-urgently-needed">classified</a> as a “priority 1” pathogen by the World Health Organization due to its growing presence in hospitals.</p>
<p>Crab <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9137960/">can kill</a> up to 60% of people infected with it. It commonly causes infections of the urinary tract, respiratory tract and blood stream, potentially leading to sepsis. It is responsible for <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6913636/">around 20%</a> of infections in places like hospitals, care homes or other similar healthcare settings.</p>
<p>Antibiotics commonly work by crossing the cell wall that surrounds infectious bacteria to reach the vital machinery inside. Once inside the cell, antibiotics block that machinery in such a way as to either stop the bacteria from growing or to cause cell death. </p>
<p>Crab is a clinical challenge as it has a double-layered cell wall, a feature that microbiologists describe as “<a href="https://www.sciencedirect.com/topics/medicine-and-dentistry/gram-negative-bacteria">gram negative</a>”. This means that antibiotics need to cross both layers to reach the vital machinery inside the bacteria to kill them and treat the infection. </p>
<p>An exception to this rule is penicillin-based antibiotics, where the target is in the cell wall itself. These antibiotics, known as <a href="https://www.bmj.com/content/344/bmj.e3236">carbapenems</a>, were derived from penicillin some 48 years after it was first discovered and still work in the same way. However, they have undergone clever chemical modification to prevent bacteria successfully evolving to resist them. This makes them a vital part of treating infections like those caused by <em>Acinetobacter baumannii</em>. </p>
<p>But Crab, the superbug version of this infection, has developed the ability to break down carbapenems, giving it an evolutionary upper hand, which has led to its rise to supremacy in hospitals. </p>
<h2>Zosurabalpin</h2>
<p>This new class of antibiotic, zosurabalpin, is shown to be highly effective against Crab both in the laboratory and in infected animals. Researchers tested zosurabalpin against more than 100 Crab samples from patients suffering from the infection. The research team, <a href="https://www.nature.com/articles/s41586-023-06799-7">found</a> that zosurabalpin was able to kill all of these bacterial strains. It could also kill the bacteria in the bloodstream of mice infected with Crab, preventing them from developing sepsis. </p>
<p>Crab has the ability to make a toxin called <a href="https://www.sciencedirect.com/topics/neuroscience/lipopolysaccharide">lipopolysaccharide</a> that it uses as part of its weaponry for infecting people and which it normally embeds into its outer cell wall. </p>
<p>Zosurabalpin works by blocking a molecular machine called <a href="https://www.nature.com/articles/s41586-023-06873-0">LptB2FGC</a> that transports the lipopolysaccharide toxin from the inside barrier to the outside one. This makes the toxin build up inside the bacteria, causing the Crab cells to die. Essentially, the bacteria pull the pin out of their own grenade but zosurabalpin stops them from being able to throw it. </p>
<p>This LptB2FGC mechanism is pretty unique to Crab, which has some advantages and disadvantages. The bad news is that zosurabalpin will only kill Crab infections and not those caused by other types of bacteria. This means doctors would need to accurately diagnose patients with this infection to decide if zosurabalpin would be the right drug. </p>
<p>But a major advantage is that the chance of antibiotic resistance emerging is reduced, as this resistance could only emerge from Crab and not other types of bacteria. Hopefully, this could extend the shelf life of this drug. </p>
<p>The researchers say they have already seen some mutations in the drug target, LptB2FGC. However, these only seem to reduce the effectiveness of zosurabalpin, rather than stopping it working entirely. The great news is that this is the first time an antibiotic has been reported to work in this way. It gives microbiologists a new avenue to explore ways to kill our bacterial enemies before they kill us. </p>
<figure class="align-center ">
<img alt="Close up of microscope with lab glassware." src="https://images.theconversation.com/files/568021/original/file-20240105-25-qzeyh5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/568021/original/file-20240105-25-qzeyh5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/568021/original/file-20240105-25-qzeyh5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/568021/original/file-20240105-25-qzeyh5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/568021/original/file-20240105-25-qzeyh5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/568021/original/file-20240105-25-qzeyh5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/568021/original/file-20240105-25-qzeyh5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Zosurabalpin is effective against the bacteria, Crab, which can kill up to 60% of people infected with it.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/microscope-lab-glassware-science-laboratory-research-530971462">totojang1977/Shutterstock</a></span>
</figcaption>
</figure>
<p>Zosurabalpin is now in phase 1 clinical trial for use in patients infected with Crab. This early testing in humans will help the company developing the drug, Roche, to work out any side effects of the drugs as well as potential toxicity. Most importantly, they need to check that the drug works just as well in humans as it did in mice, and look to see if any antibiotic resistance emerges in the trial patients. </p>
<p>It’s early days and the failure rate for new antibiotic development is high, but scientists are rising to the challenge. This discovery offers significant opportunities to the scientific field as a whole and a vital lifeline in the fight against antibiotic-resistant infections.</p><img src="https://counter.theconversation.com/content/220564/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jonathan Cox receives research funding from UKRI, charities and industry.
He is Co-Director of the Antibiotic Discovery Accelerator (ABX) Network </span></em></p>Zosurabalpin is highly effective against dangerous bacterium Crab, which can kill up to 60% of people infected with it.Jonathan Cox, Senior Lecturer in Microbiology, Aston UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2167132023-12-24T08:30:30Z2023-12-24T08:30:30ZHow AI could dramatically improve cancer patients’ prognosis<p>With 1.2 million deaths in the 2020, or 23% of the total number of deaths, cancer is the <a href="https://ec.europa.eu/eurostat/statistics-explained/index.php?title=Cancer_statistics#Deaths_from_cancer">second biggest killer in the European Union</a>.
The figure is all the more tragic given 40% of these cancers could be prevented through <a href="https://www.macmillan.org.uk/cancer-information-and-support/worried-about-cancer/causes-and-risk-factors">early detection and lifestyle change</a> such as not smoking or regular exercise. </p>
<p><a href="https://theconversation.com/the-future-of-medicine-50-year-forecast-offers-hope-for-hiv-and-cancer-patients-and-predicts-climate-change-to-increasingly-set-agenda-215510">Research on the future of medicine</a> offers hope, however, with significant progress forecast in the prevention and treatment of the disease in the decades to come. The rise of Artificial Intelligence (AI), among others, is one of the significant causes for optimism. </p>
<h2>What exactly does AI in healthcare involve?</h2>
<p>Many <a href="https://bmcmededuc.biomedcentral.com/articles/10.1186/s12909-023-04698-z">recent research articles</a> show that AI has the potential to <a href="https://www.esmo.org/newsroom/press-releases/the-potential-of-ai-to-improve-cancer-care-is-only-going-to-grow">transform healthcare</a> by offering new ways to improve the prevention, diagnosis, treatment and management of cancer across many therapeutic areas - oncology, cardiology, and ophthalmology in particular- and across the value chain, from research, development, production down to marketing. Overall, patients stand to enjoy much better care.</p>
<p>Glancing over market figures, the growth of AI in healthcare is evident from the large number of players. Leaving aside the flourish of AI startups, 18 out of the 47 multinationals providing AI currently offer <a href="https://www.calameo.com/read/002049284916ecbd5d8db?view=book&page=">healthcare solutions</a>. Out of these, 80% offer innovative solutions related strictly to treatment, while 20% produce efficiency-based tools to optimise resources and hone healthcare technology. </p>
<p>AI is set to contribute to <a href="https://www.symplr.com/blog/digital-health-ai-transform-healthcare">six areas in particular</a>:</p>
<ul>
<li><p><strong>Medical research</strong>: AI can accelerate the development of new treatments by analysing large bulks of data to identify promising chemical compounds and predict their efficacy. The technology is set to have a major impact on drug development, speeding up clinical research by identifying patients who are eligible for clinical trials and <a href="https://www.forbes.com/sites/greglicholai/2023/07/13/ai-poised-to-revolutionize-drug-development/?sh=128fd37d7ca4">analysing data generated by these trials</a> </p></li>
<li><p><strong>Medical diagnosis</strong>: AI can help doctors make faster and more accurate diagnoses by analysing medical data (X-ray images, lab results, specific medical histories, for example). AI algorithms can detect early signs of disease and help identify the most appropriate treatment. Among many other examples, the Wisconsin Breast Cancer used a specific machine learning algorithm which was successfully applied to diagnose breast cancer and achieved <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9885935/#:%7E:text=AI%2Dbased%20algorithms%20are%20an,diagnosis%20of%20patients%20%5B76%5D">98.53% classification accuracy</a>. </p></li>
<li><p><strong>Surgery assistance</strong>: AI can help surgeons plan and perform complex surgical procedures, including preoperative planning, intra-operative approaches, and prediction of postoperative complications. AI-assisted surgical robots allow for greater precision and <a href="https://www.mdpi.com/2673-4095/4/1/10#:%7E:text=AI%20has%20the%20potential%20to%20significantly%20improve%20the%20safety%20and,precision%20of%20the%20surgical%20procedure.">quicker post-operative recovery for patients</a>.</p></li>
<li><p><strong>Patient monitoring</strong>: AI can be used to monitor patients’ vital signs, including heart rate, blood pressure or blood sugar level, and alert healthcare professionals in the event of abnormalities. This is predicted to be game-changing for patients with chronic diseases, enabling thorough monitoring and early intervention should they experience complications.</p></li>
<li><p><strong>Personalised treatment</strong>: AI can take into consideration vast amounts of medical data to determine the most targeted treatment for patients, factoring in their genetic profile, medical history, lifestyle and a host of other specific traits. </p></li>
<li><p><strong>Medical record management</strong>: AI can automate electronic medical record management, thereby making medical record management more efficient and accurate while ensuring the confidentiality and security of patient information.</p></li>
</ul>
<h2>Diagnostic announcement procedure</h2>
<p>Out of the areas outlined above, the market for AI-assisted medical diagnosis is faring particularly well. Worth $1.3 billion today, it is expected to see an annual growth rate of over <a href="https://www.marketsandmarkets.com/Market-Reports/artificial-intelligence-medical-diagnostics-market-22519734.html">23% in the next five years to reach $3.7 billion in 2028</a>. There is already strong demand for cloud-based medical image analysis software in particular. Fields such as mammography, CT-scans or MRIs are set to be among the <a href="https://www.nature.com/articles/s43856-022-00199-0">first to be benefit from the technology</a>.</p>
<p>In practice, however, many hospital centres are grappling with a lack of technological resources, making it difficult for them to tap into AI’s potential. Take the pathology slides on the basis of which biological anomalies are analysed: although all of them should be digitised to train AI models, the vast majority of European institutions currently lack the equipment to do so.</p>
<h2>Treatment management, support and post-treatment monitoring</h2>
<p>AI can be used at every stage of cancer care, allowing healthcare professionals to focus on high value-added tasks such as direct patient care and psychological support, critical technical decision-making, and clinical trials. This can lead to improved patient outcomes and a more efficient healthcare system.</p>
<p>Five areas stand in particular to <a href="https://www.calmedica.com/lintelligence-artificielle-dans-le-domaine-de-la-sante/">benefit from the technology</a>:</p>
<ul>
<li><p><strong>organisational management tools</strong>, which save your doctor much time in routine tasks. Some of these might help monitor patient flow, slash the administrative burden, and record notes thanks to automated transcription software to complete medical records.</p></li>
<li><p><strong>predictive analytic tools</strong>, which mine and analyse large quantities of patient data and determine which health categories a patient belongs to. This allows for a more personalised and efficient treatment.</p></li>
<li><p><strong>AI-powered surgical assistance tools</strong>, based on medical robotics. These technologies are still too often used for simple surgical procedures, such as stitching. </p></li>
<li><p><strong>Remote monitoring</strong> allows medical professionals to use digital medical devices to remotely interpret patients’ health data collected in their homes and make decisions about their care. Remote monitoring systems aim to improve patients’ health through regular monitoring.</p></li>
<li><p><strong>Chatbots</strong> can also be included in a wide range of applications (Messenger, Slack). They can be utilised throughout the patient care pathway, but are especially helpful during the monitoring period, in which continued <a href="https://www.msdconnect.fr/innovation-sante/organisation-systeme-de-sante/chatbot-sante-assistant-medical-aujourdhui-medecin-demain/">support is crucial</a>.</p></li>
</ul>
<h2>The limits of AI in healthcare</h2>
<p>For all those exciting prospects, we will nevertheless need to overcome a set of challenges before we can enjoy the full range of benefits of AI-assisted healthcare.</p>
<p>For one, AI has yet to become more sophisticated from a technical viewpoint. For example, the current absence of a universal format for data health makes it tricky to clean it up and transfer it from one software or computer to the next. The vast majority of AI solutions also require to be trained by humans - and not any humans. In collaboration with healthcare professionals, engineers will need to carefully listen to the medical community’s needs and reflect them in emerging AI. </p>
<p>It’s no secret sociocultural and ethical questions will also need to be taken into consideration. Data protection remains a real issue for many citizens even though the European Union’s 2018 framework regulation for processing data, the General Data Protection Regulation (GDPR), has handed more power to individuals to dictate how companies handle their personal information. The <a href="https://www.europarl.europa.eu/RegData/etudes/STUD/2020/641530/EPRS_STU(2020)641530_EN.pdf">EU AI Act</a>, the world’s first comprehensive legislation to regulate AI machines posing risks to health, human rights and safety, should also go some way in alleviating those concerns. </p>
<hr>
<p><em>This article was co-written with Prof Frédéric Jallat’s former student, Rym Aouchiche, who currently works as a Life Sciences & Strategy Associate Consultant at IQVIA.</em></p><img src="https://counter.theconversation.com/content/216713/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Frédéric Jallat ne travaille pas, ne conseille pas, ne possède pas de parts, ne reçoit pas de fonds d'une organisation qui pourrait tirer profit de cet article, et n'a déclaré aucune autre affiliation que son organisme de recherche.</span></em></p>From helping surgeons to carry out complex procedures to monitoring the heartbeat of the chronically ill, the use of AI in cancer care is set to be game-changing.Frédéric Jallat, Professor of Marketing and Academic Director of MSc. in Biopharmaceutical Management, ESCP Business SchoolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2169802023-12-21T21:37:49Z2023-12-21T21:37:49ZThe Douglas-Bell Canada Brain Bank: a goldmine for research on brain diseases<figure><img src="https://images.theconversation.com/files/557356/original/file-20231005-26-rmh9lm.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C4000%2C1508&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The experimental methods available today allow us to break the brain down into its elementary components in order to understand its functions and dysfunctions.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Human beings have always been fascinated by the brain. </p>
<p>Although scientific knowledge about this 1.3 kg of fragile substance embedded in our cranium has long been incomplete, dazzling technical breakthroughs made in recent years are now ushering in a Golden Age of molecular neuroscience. </p>
<p>These breakthroughs have been made possible partly thanks to brain banks, which preserve human brains in the best possible conditions for scientific research. Here in Montréal, we have one of the world’s largest such banks, the Douglas-Bell Canada Brain Bank (DBCBB), <a href="https://douglasbrainbank.ca">founded in 1980 at the Douglas Hospital</a>. </p>
<p>The DBCBB, which receives several brains each month, has collected over 3,600 specimens to date. Every year, its team processes dozens of tissue requests from scientists in Québec, Canada and abroad, preparing some 2,000 samples for research. </p>
<p>Over the past 40 years, these efforts have led to a considerable number of discoveries about different neurological and psychiatric diseases. </p>
<p>As a full professor in the department of psychiatry at McGill University, researcher at the Douglas Research Centre and director of the DBCBB since 2007, I work in close collaboration with <a href="https://www.mcgill.ca/psychiatry/gustavo-turecki">Dr. Gustavo Turecki</a>, co-director of the DBCBB and responsible for the component devoted to psychiatric illnesses and suicide.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/552153/original/file-20231004-17-mdh992.jpg?ixlib=rb-1.1.0&rect=14%2C2%2C1535%2C1231&q=45&auto=format&w=1000&fit=clip"><img alt="cerebral hemisphere" src="https://images.theconversation.com/files/552153/original/file-20231004-17-mdh992.jpg?ixlib=rb-1.1.0&rect=14%2C2%2C1535%2C1231&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/552153/original/file-20231004-17-mdh992.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=475&fit=crop&dpr=1 600w, https://images.theconversation.com/files/552153/original/file-20231004-17-mdh992.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=475&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/552153/original/file-20231004-17-mdh992.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=475&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/552153/original/file-20231004-17-mdh992.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=596&fit=crop&dpr=1 754w, https://images.theconversation.com/files/552153/original/file-20231004-17-mdh992.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=596&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/552153/original/file-20231004-17-mdh992.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=596&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The Douglas-Bell Canada Brain Bank, which receives several brains each month, has collected over 3,600 specimens to date.</span>
<span class="attribution"><span class="source">(Naguib Mechawar)</span>, <span class="license">Fourni par l'auteur</span></span>
</figcaption>
</figure>
<h2>A brief history of research on the human brain</h2>
<p>Scientists only began to identify the microscopic elements that make up the human brain in the second half of the 19th century. </p>
<p>That was when brains were preserved for the first time in formalin, a solution that preserves biological tissue so that it can be handled more easily and stored over a longer term.</p>
<p>At the same time, precision instruments and protocols were being developed that made it possible to examine the microscopic characteristics of nervous tissue.</p>
<p>Until the middle of the 20th century, researchers were mainly satisfied with preserving the brains of patients, taken during autopsies, so they could use them to identify possible macroscopic or microscopic changes linked to either neurological or psychiatric symptoms.</p>
<p>This is in fact what the German neurologist Alois Alzheimer did when he analyzed the brain of one of his patients suffering from dementia. In 1906, he described, for the first time, the microscopic lesions which characterize the disease that now bears his name.</p>
<p>Until the end of the 1970s, numerous collections of brain specimens preserved in formalin were built in hospital environments, a bit like the cabinets of curiosities of olden days.</p>
<p>Towards the end of the 20th century, new experimental approaches were developed allowing the high-resolution analysis of cells and molecules within biological tissues.</p>
<p>It then became necessary to collect and preserve human brains, obtained with the consent of the individual or his or her family, in conditions compatible with modern scientific techniques.</p>
<p>Researchers began freezing one of the cerebral hemispheres in order to measure its various molecular components. The other hemisphere was preserved in formalin to be used for macroscopic and microscopic anatomical studies.</p>
<p>This was the context in which the Douglas-Bell Canada Brain Bank was created.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/552154/original/file-20231004-25-z5k7jp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="The DBCBB premises" src="https://images.theconversation.com/files/552154/original/file-20231004-25-z5k7jp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/552154/original/file-20231004-25-z5k7jp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/552154/original/file-20231004-25-z5k7jp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/552154/original/file-20231004-25-z5k7jp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/552154/original/file-20231004-25-z5k7jp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/552154/original/file-20231004-25-z5k7jp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/552154/original/file-20231004-25-z5k7jp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Montréal is home to one of the world’s largest brain banks, the Douglas-Bell Canada Brain Bank, which was founded in 1980 at the Douglas Hospital.</span>
<span class="attribution"><span class="source">(Naguib Mechawar)</span>, <span class="license">Fourni par l'auteur</span></span>
</figcaption>
</figure>
<h2>New experimental approaches are yielding results</h2>
<p>Leading researchers from many universities around the world now use DBCBB samples to advance their research. This, of course, includes a number of teams in Québec.</p>
<p>For example, with his team from the Douglas Research Centre, which is affiliated with McGill University, <a href="https://douglas.research.mcgill.ca/judes-poirier/">Judes Poirier</a> discovered that the APOE4 gene is a <a href="https://doi.org/10.1016/0140-6736(93)91705-Q">risk factor for Alzheimer’s disease</a>. More recently, the team of <a href="https://crhmr.ciusss-estmtl.gouv.qc.ca/en/researcher/gilbert-bernier">Gilbert Bernier</a>, professor in the department of neuroscience at Université de Montréal, discovered that the lesions characteristic of this disease are associated with <a href="https://doi.org/10.1038/s41598-018-37444-3">abnormal expression of the BMI1 gene</a>.</p>
<p>With regard to psychiatric illnesses, and more specifically depression, major progress has been made recently by the <a href="https://douglas.research.mcgill.ca/mcgill-group-suicide-studies-mgss/">McGill Group for Suicide Studies</a>. </p>
<p>Using cutting-edge methods to isolate and analyze human brain cells, Turecki’s team has succeeded in precisely identifying the cell types whose function is affected in men <a href="https://doi.org/10.1038/s41593-020-0621-y">who have suffered from major depression</a>, and then discovering that the cell types involved in this illness differ <a href="https://doi.org/10.1038/s41467-023-38530-5">between men and women</a>. </p>
<p>These experimental approaches generate huge data sets that can be examined in subsequent studies. This is the case, for example, of work carried out in my laboratory, which identified signs of persistent changes in neuroplasticity within the prefrontal cortex of people with a history of <a href="https://doi.org/10.1038/s41380-021-01372-y">child abuse</a>. In fact, the studies mentioned above enabled us to discover at least one of the cell types involved in this phenomenon. </p>
<p>In short, the experimental methods we have today allow us to break the brain down into its elementary components in order to understand its functions and dysfunctions.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/552155/original/file-20231004-27-62uc6y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Cerebral hemispheres preserved in formalin" src="https://images.theconversation.com/files/552155/original/file-20231004-27-62uc6y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/552155/original/file-20231004-27-62uc6y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/552155/original/file-20231004-27-62uc6y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/552155/original/file-20231004-27-62uc6y.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/552155/original/file-20231004-27-62uc6y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/552155/original/file-20231004-27-62uc6y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/552155/original/file-20231004-27-62uc6y.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Leading researchers from many universities around the world benefit from Douglas-Bell Canada Brain Bank samples to advance their research.</span>
<span class="attribution"><span class="source">(Naguib Mechawar)</span>, <span class="license">Fourni par l'auteur</span></span>
</figcaption>
</figure>
<h2>Identify, prevent, screen and treat</h2>
<p>Thanks to the hard work and dedication of the entire DBCBB team, as well as the unfailing support of all its partners, patrons (often anonymous) and funding bodies — particularly the FRQS research fund and Québec’s suicide research network, the <a href="https://reseausuicide.qc.ca">Réseau québécois sur le suicide, les troubles de l'humeur et les troubles associés</a> — this invaluable resource has not only managed to survive, but to grow and become one of the largest brain banks in the world. </p>
<p>There is every reason to believe that, in the years to come, the DBCBB will play an important role in the increasingly precise identification of the biological causes of brain diseases, and, as a result, will contribute to the identification of new targets for better approaches to prevention, screening and treatment.</p><img src="https://counter.theconversation.com/content/216980/count.gif" alt="La Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Naguib Mechawar has received funding from CIHR, NSERC, HBHL (CFREF) and FQRS (NEURON ERA-NET and RQSHA).</span></em></p>Montréal is home to one of the world’s largest brain banks, the Douglas-Bell Canada Brain Bank, where discoveries about different neurological and psychiatric diseases are made.Naguib Mechawar, Neurobiologiste, Institut Douglas; Professeur titulaire, Département de psychiatrie, McGill UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2169782023-12-07T22:50:53Z2023-12-07T22:50:53ZCould visiting a museum be the secret to a healthy life?<figure><img src="https://images.theconversation.com/files/557354/original/file-20231016-28-1a079n.jpg?ixlib=rb-1.1.0&rect=5%2C1%2C986%2C655&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Does the simple fact of being in contact with art have any specific effects?</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>It’s Saturday morning. You are barely awake, with a cup of coffee in your hand, and your gaze wanders to the window. It’s raining. So you make up your mind. This afternoon, you will go to a museum.</p>
<p>But what if, without realizing it, you just made a good decision for your health?</p>
<p>That’s the hypothesis put forward by the <a href="https://www.medecinsfrancophones.ca/a-propos/lassociation/">Association des Médecins francophones du Canada</a> in 2018, when it launched the <a href="https://www.mbam.qc.ca/en/news/museum-prescriptions/">museum prescriptions program</a> in partnership with the Montreal Museum of Fine Arts. The project, now completed, has enabled thousands of patients to get a doctor’s prescription to visit a museum, either on their own or accompanied. The aim of the prescription was to promote the recovery and well-being of patients with chronic illnesses (hypertension, diabetes), neurological conditions, cognitive disorders or mental health problems. The decision to write the prescription was left to the discretion of the doctor.</p>
<p>Five years in, this pioneering initiative has inspired other innovative projects. So we are now seeing an increasing number of museum-based wellness activities ranging from <a href="https://museumlondon.ca/yoga-at-the-museum">museum yoga</a> to <a href="https://agakhanmuseum.org/programs/mindfulness-and-education-sessions">guided meditations</a> with works of art, as well as the practice of <a href="https://www.gallery.ca/magazine/your-collection/the-art-of-slow-looking-a-painting-by-jean-paul-riopelle?_gl=1*ys4kk2*_ga*MTY5MjQ1NTg3Mi4xNjk5NTUxNTQ3*_ga_83BW334MD2*MTY5OTU1MTU0Ni4xLjAuMTY5OTU1MTU0Ni4wLjAuMA..">slow contemplation</a> or “slow looking.” </p>
<p>There’s no shortage of possibilities, and they all help to reinforce the same idea, that art is good for us.</p>
<h2>Beyond first impressions</h2>
<p>These initiatives have recently made headlines in national media on both sides of the Atlantic, in <a href="https://www.radiofrance.fr/franceculture/museotherapie-je-crois-que-nous-sommes-dans-un-moment-de-bouillonnement-2414180">France</a> and <a href="https://www.cbc.ca/news/canada/montreal/montreal-museum-fine-arts-medecins-francophone-art-museum-therapy-1.4859936">Canada</a>, and are gaining in visibility in the general public. Because of the popularity of these activities, more and more claims are being made that a visit to the museum can have “powerful anti-stress properties,” be a “miracle cure for stress,” or have other “incredible benefits.”</p>
<p>Talk about enthusiasm!</p>
<p>Yet, as a certified neuroscientist, I can’t help but wonder why, given the extraordinarily relaxing effects that are being claimed, crowds aren’t flocking to our museums every day. </p>
<p>And that gives us all the more reason to look at the scientific reports and studies that have recently been published on the subject.</p>
<h2>Is art good for you? From intuition to observation</h2>
<p>In 2019, the World Health Organization published an extensive report compiling evidence on the role of arts and cultural activities <a href="https://apps.who.int/iris/handle/10665/329834">in promoting health and well-being</a>. The authors of this report attempted to move away from the sweeping claim that the benefits of art could constitute a universal solution to health problems, like a type of home remedy. </p>
<p>Instead, they encourage new, more precise and rigorous approaches to looking at the question, based on observation of the psychological, physiological and behavioural responses induced by certain specific components of artistic activity (aesthetic engagement, sensory stimulation, physical activity, etc.).</p>
<h2>Actor or spectator?</h2>
<p>What’s specific about a museum visit is that it is a so-called receptive artistic activity – in other words, it is not about producing art (painting, drawing, composing). It does, however, have the advantage of being accessible and already well established in our collective habits, making it a good candidate for health prevention.</p>
<p>The question is whether art exposure, alone, is enough to reap its benefits. In other words, does the simple fact of being in contact with art have specific effects?</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/554091/original/file-20231016-15-yh6rw2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="woman in a museum" src="https://images.theconversation.com/files/554091/original/file-20231016-15-yh6rw2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/554091/original/file-20231016-15-yh6rw2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/554091/original/file-20231016-15-yh6rw2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/554091/original/file-20231016-15-yh6rw2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/554091/original/file-20231016-15-yh6rw2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/554091/original/file-20231016-15-yh6rw2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/554091/original/file-20231016-15-yh6rw2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Could exposure to art lead to healthier aging?</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<h2>Healthier consumers of culture</h2>
<p>Research has been carried out in England on samples of several thousand individuals whose long-term health indicators were monitored, and who were asked for 10 years to report on their habits in terms of <a href="https://www.elsa-project.ac.uk">cultural and artistic activities</a>.</p>
<p>This research shows that individuals who regularly (every two or three months, or more) visit cultural venues (theatres, opera houses, museums, galleries) have a 50 per cent lower risk of <a href="https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/cultural-engagement-and-cognitive-reserve-museum-attendance-and-dementia-incidence-over-a-10year-period/0D5F792DD1842E97AEFAD1274CCCC9B9">dementia</a> and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6429253/">depression</a>, and a 40 per cent lower risk of developing a <a href="https://academic.oup.com/psychsocgerontology/article/75/3/571/5280637">geriatric frailty syndrome</a> (age-related decline in health and loss of functional independence).</p>
<p>Does that mean that exposure to art could lead to healthier aging?</p>
<p>Perhaps, but whether cultural involvement is the cause of the improvement in health markers observed in these studies, has yet to be confirmed. To do this, cohort studies and <a href="https://cihr-irsc.gc.ca/e/48952.html">randomized controlled trials</a> are required. However, this type of study has yet to be done.</p>
<h2>In search of the active ingredients</h2>
<p>There is one other question, and it’s a big one! It’s the question of <em>why</em>.</p>
<p>Why would art, and visual art in particular, do me good? What happens in my body when I encounter a work of art, and how does this contact transform me and help to keep me healthier – if this is the case?</p>
<p>This was the question Mikaela Law, a psychology researcher at the University of Auckland in New Zealand, and her colleagues asked in 2021. They <a href="https://bmjopen.bmj.com/content/11/6/e043549.abstract">reviewed the scientific literature</a> for studies on the physiological response to the visual arts and its effect on self-reported stress. </p>
<p>Some of the studies listed in her work show that contact with artwork can lower blood pressure, heart rate and the cortisol secreted in saliva. Such changes reflect a reduction in the body’s state of guardedness, also called stress. This change appears to be perceived by the individual, reflected by the reduction in the stress he or she feels after exposure.</p>
<p>Other studies, on the other hand, have observed no effects. </p>
<p>So, if contact with visual art is likely to bring about physical and psychological relaxation for the viewer, it may not be a sufficient condition for improved health.</p>
<p>This conclusion invites us to qualify our conclusions and reflect more deeply on what happens at the moment of an encounter with a work that might condition its effects on an individual’s psyche.</p>
<p>Today is Saturday…</p>
<p>You’ve decided you’re going to the museum. </p>
<p>This decision will likely be good for your health. </p>
<p>It’s also likely to depend on the museum you choose, and how you visit it. </p>
<p>However one thing’s certain: going to a museum means you will greatly increase your chances of having a pleasant day!</p><img src="https://counter.theconversation.com/content/216978/count.gif" alt="La Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Emma Dupuy works in partnership with the Montreal Museum of Fine Arts and has received funding from MITACS, the Université de Montréal and the Fonds de Recherche du Québec.</span></em></p>Can a trip to a museum help cure mental dullness? Here’s what the science has to say.Emma Dupuy, Postdoctoral researcher, cognitive neuroscience, Université de MontréalLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2148952023-11-30T17:23:43Z2023-11-30T17:23:43ZBuvidal: is it really a ‘game changer’ in the treatment of problematic opioid use?<p>To overcome problematic opioid use, traditional forms of opioid substitution therapy, such as <a href="https://www.nhs.uk/medicines/methadone/">methadone</a> and <a href="https://www.nhs.uk/medicines/buprenorphine-for-pain/">oral buprenorphine</a>, have become valuable tools. <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD002209.pub2/full?highlightAbstract=opioid">Research</a> shows that patients receiving substitution therapy are more likely to stay in treatment and stop using heroin than patients receiving treatments that do not involve substitutes – such as counselling or group therapy.</p>
<p>But not all those on substitute medication are able to stop using illicit opioids. Some continue to use them in addition to the substitute. One <a href="https://www.sciencedirect.com/science/article/abs/pii/S0376871621001460">barrier</a> to success is the need to attend a clinic or pharmacy every day, or every few days, to obtain the substitute. </p>
<p>In early 2019, a new form of substitute treatment, long-acting injectable buprenorphine, was approved for use in the UK. Unlike methadone and oral buprenorphine, <a href="https://www.nice.org.uk/advice/es19/evidence/evidence-review-pdf-6666819661#:%7E:text=Buprenorphine%20prolonged%2Drelease%20injection%20is,buprenorphine%20prolonged%2Drelease%20injection%20subcutaneously.">long-acting injectable buprenorphine</a> is administered via an injection either weekly or monthly. The treatment – also known by its brand names Buvidal or Sublocade – has been heralded as a “<a href="https://nation.cymru/news/welsh-university-carries-out-game-changer-drug-treatment-research/">game changer</a>” by both doctors and patients. </p>
<h2>Opioids</h2>
<p>In 2021, nearly 5,000 drug-related deaths were <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsrelatedtodrugpoisoninginenglandandwales/2021registrations">registered</a> in England and Wales. About half of those involved an opioid. </p>
<p>Opioids are a class of drugs that include substances derived from the opium poppy. They include <a href="https://www.nhs.uk/medicines/morphine/">morphine</a> and <a href="https://www.emcdda.europa.eu/publications/drug-profiles/heroin_en">heroin</a>, as well as synthetic alternatives that mimic the effects of naturally occurring opioids such as <a href="https://www.nhs.uk/medicines/tramadol/">tramadol</a> and <a href="https://bnf.nice.org.uk/drugs/fentanyl/">fentanyl</a>.</p>
<p>Opioids work in the brain to produce a variety of effects, including pain relief. They also produce feelings of euphoria, joy and pleasure. Opioids have a depressant effect on the body, so if someone overdoses, they can stop breathing and may die. Overdose is a particular risk for those who use illegally obtained opioids of unknown strength, such as heroin.</p>
<p>Often people are unable to stop using opioids despite the risk of death and the serious negative health and social consequences. Such drugs are hard to give up, partly because stopping causes painful physical and psychological withdrawal symptoms.</p>
<h2>Opioid substitution therapy</h2>
<p>An effective form of treatment for problematic opioid use is opioid substitution therapy, where illegally obtained opioids are substituted for prescribed alternatives. </p>
<p>Providing a legal substitute of known purity is useful in many ways. Most notably, it removes the need to buy and use illicit opioids. This reduces the risk of <a href="https://www.bmj.com/content/357/bmj.j1550">overdose</a> and the need to commit crimes like <a href="https://academic.oup.com/bjc/article-abstract/49/4/513/2747197">theft and shoplifting</a> to get money to pay for drugs.</p>
<p>But while daily attendance and supervised consumption may help to minimise the risk of misuse, it also has its drawbacks. For example, it can bring patients into regular contact with their former drug-using networks and can require time-consuming journeys that interfere with employment, education and other responsibilities.</p>
<p>Long-acting injectable buprenorphine does not have these drawbacks. It is not unlike <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8369037/">long-acting</a> forms of contraception, in that the medicine releases slowly over time, thereby avoiding the peaks and troughs associated with oral formulations.</p>
<p>When the pandemic broke and the UK went into lockdown, <a href="https://www.emcdda.europa.eu/publications/topic-overviews/covid-19-and-people-who-use-drugs_en">concerns</a> were raised by experts that daily attendance at clinics or pharmacies for opioid substitution medication might increase the risk of COVID transmission. </p>
<p>Keen to stop the spread of the virus while also providing safe and continuous treatment to patients, the Welsh government <a href="https://committees.parliament.uk/writtenevidence/107535/pdf/">agreed</a> to fund the roll-out of long-acting injectable buprenorphine to drug services across Wales. </p>
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<figcaption><span class="caption">Two doctors discuss Buvidal from the perspective of lived experience.</span></figcaption>
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<p>That decision was supported by <a href="https://pilotfeasibilitystudies.biomedcentral.com/articles/10.1186/s40814-023-01348-5">emerging evidence</a> of the effectiveness of the medication from a drug service in south Wales that had been piloting the medicine before the pandemic. </p>
<h2>Results</h2>
<p>While the primary aim at that time was to stop the spread of COVID, it quickly became clear that the medication was benefiting patients in many other ways. </p>
<p>Patients taking part in a <a href="https://kaleidoscope68.org/app/uploads/2022/05/Kaleidoscope-Peer-led-Buvidal-Review..pdf">survey</a> about the new medication reported reductions in cravings, lower levels of anxiety, reductions in offending and abstinence from illicit opioids. They described rebuilding their lives, getting jobs, reconnecting with family members and heralded long-acting injectable buprenorphine as a “game changer”, “life changing” and even a “miracle”. </p>
<p>Positive results have also been reported in <a href="https://www.jsatjournal.com/article/S0740-5472(22)00058-7/fulltext">systematic reviews</a> that summarise the findings of the currently small, and not very robust, body of evidence on the effectiveness of the medication.</p>
<p>However, alongside the reports of success, less positive <a href="https://kaleidoscope68.org/app/uploads/2022/05/Kaleidoscope-Peer-led-Buvidal-Review..pdf">stories</a> have emerged suggesting that the treatment may not be a silver bullet. Some patients have found the transition onto the medication challenging because it required them to be in full withdrawal before their first dose. </p>
<p>Others have been overwhelmed with emotions because the medication made them feel so clear-headed that their past traumas – suppressed by years of illicit opioid use – had begun to resurface. There have also been <a href="https://kaleidoscope68.org/app/uploads/2022/05/Kaleidoscope-Peer-led-Buvidal-Review..pdf">reports</a> of an increase in crack cocaine use among some patients and concerns about the reduced amount of contact (from daily to monthly) with drug services.</p>
<p>Even though there is a “<a href="https://pubmed.ncbi.nlm.nih.gov/16764215/">ceiling effect</a>” that reduces the risk of overdose, this medication still carries a risk of respiratory depression. This risk is <a href="https://pubmed.ncbi.nlm.nih.gov/15957155/">greater</a> among those using alcohol, benzodiazepines or other opioids such as heroin.</p>
<p>Long-acting injectable buprenophine is still in its infancy worldwide, so the evidence for its effectiveness is slim. To determine if it really is a “game changer”, experts will need to look at its impact across a wider range of outcomes, over longer periods and with larger samples than have been considered to date.</p><img src="https://counter.theconversation.com/content/214895/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Katy Holloway receives funding from Welsh Government and is a member of Welsh Government's National Implementation Board for Drug Poisoning Prevention. </span></em></p><p class="fine-print"><em><span>Fabrizio Schifano receives funding from Welsh Government. Currently a World Health Organization (WHO) member of the Expert Committee on Drug Dependence (ECDD; 2023). Previously, Schifano was a member of the ACMD UK and an expert advisor of the European Medicines Agency (EMA) for Psychiatry. </span></em></p>Long-acting injectable buprenorphine is also known by the brand names Buvidal or Sublocade.Katy Holloway, Professor of Criminology, University of South WalesFabrizio Schifano, Chair in Clinical Pharmacology and Therapeutics, University of HertfordshireLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2165402023-11-20T00:54:20Z2023-11-20T00:54:20ZHow can you define a ‘drug’? Nobody really knows<p>What’s a medical drug? Ask someone on the street and they’re likely to tell you it’s the kind of thing you take when you’re unwell.</p>
<p>This understanding is wrong, as we will see. But after a thorough investigation, my colleagues and I found no other potential definitions are any better. </p>
<p>Despite their centrality to medicine, we have no idea what medical drugs are. We can’t even tell the difference between drugs and food, let alone drugs and so-called “natural” alternatives.</p>
<h2>A Goldilocks definition</h2>
<p>In a <a href="https://academic.oup.com/jmp/advance-article/doi/10.1093/jmp/jhad035/7206006">recent article</a> in the Journal of Medicine and Philosophy, my colleagues (Sara Linton, a pharmacist, and Maureen O’Malley, a philosopher of biology) and I tried to nail down a viable definition of medical drugs.</p>
<p>A viable definition should be broad enough to include everything classified as a drug. To get a sense of this “everything”, we used the <a href="https://go.drugbank.com/about">drug bank</a> compiled by the Canadian Institutes for Health Research, which lists more than 16,000 substances.</p>
<p>A definition should also be narrow enough to exclude substances not typically considered drugs. Take food, for example. Eating a sandwich is usually never thought of as taking a drug.</p>
<p>In short, a viable definition of what drugs are should occupy a “Goldilocks” zone between these two demands: big enough to include all drugs, small enough to exclude everything else.</p>
<p>Based on an initial study of pharmacology textbooks, we found three broad ways to define drugs: in terms of what they are, how they work and what they’re used for.</p>
<p>Unfortunately, none of these options fall within the Goldilocks zone. </p>
<h2>Are drugs specific chemicals?</h2>
<p>If all drugs were a particular type of chemical, then defining drugs would be easy. But this idea is hopeless: there is nothing, chemically speaking, all drugs have in common.</p>
<p>It is also tempting to think drugs are “artificial” chemicals, made in a lab, whereas “natural” supplements come from nature, and that’s the difference.</p>
<p>But many drugs are “natural” in this sense. Aspirin, for instance, is derived from willow bark.</p>
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Read more:
<a href="https://theconversation.com/modern-medicine-has-its-scientific-roots-in-the-middle-ages-how-the-logic-of-vulture-brain-remedies-and-bloodletting-lives-on-today-213702">Modern medicine has its scientific roots in the Middle Ages − how the logic of vulture brain remedies and bloodletting lives on today</a>
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<p>This has immediate implications for so-called “natural” supplements, such as fish oil. </p>
<p>If “drugs” are chemically indistinguishable from “natural” supplements, supplements should not be considered a “safe” alternative. Supplements are no less, and no more, safe than many drugs. </p>
<h2>Do drugs perform a specific function?</h2>
<p>Perhaps drugs can be defined in terms of what they do. This idea initially seems promising, as many drugs work by binding to receptor molecules in the body. </p>
<p>Think of a lock and key: the receptor molecule is the lock, and the drug is the key that opens it. </p>
<p>The discovery of receptor molecules is significant. For some, it is the “big idea” of the science of pharmacology. </p>
<p>But this definition of medical drugs is also hopeless. Many drugs don’t bind to receptors. Antacids, for instance, work simply by changing the level of acidity (pH) in a person’s body.</p>
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Read more:
<a href="https://theconversation.com/explainer-what-is-the-placebo-effect-and-are-doctors-allowed-to-prescribe-them-55219">Explainer: what is the placebo effect and are doctors allowed to prescribe them?</a>
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<p>Many placebos also bind to receptors. Placebos are often contrasted with drugs, but defining drugs as “things that bind to receptor molecules” would include many placebos in the definition. So this definition won’t work either.</p>
<p>Is there a way to define placebos that clearly distinguishes them from drugs? This is not obvious, since defining placebos is also quite hard.</p>
<p>For instance, one might think placebos are substances that have no therapeutic effects. But placebos can have therapeutic effects (the so-called placebo effect), so this definition won’t work. A number of other definitions face similar problems.</p>
<p>Our research paves the way toward an explanation of why it is so hard to define placebos. To properly define placebos, we need to differentiate them from drugs, which we can’t do without a definition of what drugs are.</p>
<h2>Drugs make me better</h2>
<p>This brings us back to wellness. On this view, a medical drug is just any chemical substance used in medical treatment. </p>
<p>This does better: it captures the full range of substances used as drugs in medical contexts.</p>
<p>But now there is absolutely no hope of keeping food and nutrients out. </p>
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Read more:
<a href="https://theconversation.com/poison-or-cure-traditional-chinese-medicine-shows-that-context-can-make-all-the-difference-163337">Poison or cure? Traditional Chinese medicine shows that context can make all the difference</a>
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<p>Consider, for example, total parenteral nutrition. This is a chemical infusion given to people who have trouble absorbing nutrients in the normal way.</p>
<p>Total parenteral nutrition is used in medical treatment. But what it does for your body isn’t really different from what a good sandwich does.</p>
<p>Any treatment-based account of drugs inevitably wipes out the contrast with food.</p>
<h2>So what?</h2>
<p>In our day-to-day lives, we make choices that rely on an implicit understanding of what drugs are. </p>
<p>For instance, we take paracetamol because it is a drug. Many of us may also take fish oil precisely because we believe it isn’t a drug.</p>
<p>Without an account of what drugs are, we risk making serious mistakes.</p>
<p>We might take substances we think are “inert” (placebos) because they are “natural” (like fish oil) when in fact they are active drugs. </p>
<p>Similarly, all legal regulation of medical drugs assumes we already know what a drug is. </p>
<p>But we don’t: our understanding is clearly evolving. This means regulation must also continually change. Substantial resources must therefore be devoted to reworking legislation as we continue to rethink what medical drugs are, as the <a href="https://www.sbs.com.au/news/article/mdma-and-psilocybin-will-be-come-legal-from-1-juy-heres-who-can-get-it/jpf6gj4di">recent reclassification</a> of MDMA and psilocybin as medicines in Australia demonstrates.</p>
<p>Then there’s food. Food is not administered or regulated like a drug in a hospital, with the exception of total parenteral nutrition and similar substances.</p>
<p>But if doctors use food like a drug to contribute to patient wellbeing, then perhaps it should be subject to the same standards.</p>
<p>This may require radically rethinking the way meals are provided in a hospital. Perhaps meals should be administered, and regulated, with the same care as drugs. </p>
<p>Hospital lunches might never be the same. But that could be a good thing.</p><img src="https://counter.theconversation.com/content/216540/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sam Baron receives funding from the Australian Research Council.</span></em></p>Everybody thinks they know what drugs are, but a clear definition is surprisingly elusive.Sam Baron, Associate Professor, Philosophy of Science, Australian Catholic UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2128742023-11-08T19:10:33Z2023-11-08T19:10:33ZDo you think you have a penicillin allergy? You might be wrong<figure><img src="https://images.theconversation.com/files/555945/original/file-20231025-19-tbp1oy.jpg?ixlib=rb-1.1.0&rect=98%2C160%2C8144%2C5326&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/these-all-possible-causes-shot-young-2148946861">Shutterstock</a></span></figcaption></figure><p><em>Antimicrobial resistance is <a href="https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance">one of the biggest global threats</a> to health, food security and development. This month, The Conversation’s <a href="https://theconversation.com/au/topics/the-dangers-of-antibiotic-resistance-146983">experts explore how we got here and the potential solutions</a>.</em></p>
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<p>Penicillins are the most prescribed class of antibiotics in Australia. Originally derived from a fungus, penicillin antibiotics such as amoxicillin are used to treat common infections, including chest, sinus, ear, urinary tract and skin infections. </p>
<p>Penicillins are effective against a wide range of bacteria that cause common infections. But their activity is not so broad as to impact on good bacteria in our gut like other antibiotic classes do. They’re also cheap and readily accessible.</p>
<p>Up to <a href="https://www.sciencedirect.com/science/article/pii/S2772829322000376#bib1">20%</a> of Australians admitted in hospital say they have a penicillin allergy.</p>
<p>But not everyone who thinks they’re allergic to penicillin actually is. Research from <a href="https://www.sciencedirect.com/science/article/pii/S2772829322000376?via%3Dihub">our team</a> and others suggests that if we assess all these patients, up to 90% are not allergic to it.</p>
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Read more:
<a href="https://theconversation.com/weekly-dose-penicillin-the-mould-that-saves-millions-of-lives-63770">Weekly Dose: penicillin, the mould that saves millions of lives</a>
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<h2>Why does it matter?</h2>
<p>People who mistakenly think they’re allergic to penicillin may not get the most effective or safest antibiotics to treat their infection. </p>
<p>They are also at greater risk of developing <a href="https://www.sciencedirect.com/science/article/abs/pii/S009167491301467X">multidrug-resistant infections</a> or “superbugs”. This is because the antibiotic will kill off the bacteria that are susceptible to it, but the resistant bacteria are left behind to proliferate and cause further infection.</p>
<p>People who receive second-line antibiotics are more likely to have complications, such as <a href="https://www.sciencedirect.com/science/article/abs/pii/S009167491301467X">antibiotic-induced gut infections</a>. Second-line antibiotics tend to have a wider range of activity, killing both the bacteria causing infection, and the good bacteria required to keep our gut in balance. This allows bugs like <em>Clostridium difficile</em>, which normally lives in our gut but is controlled by other bacteria, to overgrow and cause inflammation. </p>
<p>For the health system, using second-line antibiotics means longer, more complicated hospital stays. Hospital stays for patients with penicillin allergies cost up to <a href="https://onlinelibrary.wiley.com/doi/abs/10.1046/j.1365-2222.2003.01638.x">63% more</a> more than those without. It also results in greater costs for medications and greater resources required to treat the patient. </p>
<h2>Why do people think they’re allergic?</h2>
<p>People incorrectly believe they are allergic to penicillin for a number of reasons. </p>
<p>They may have experienced side effects from penicillin, such as nausea or diarrhoea. But though unpleasant, this doesn’t mean an allergy.</p>
<p>Others had a rash as a child, but this could have been due to the illness itself or an interaction between the virus and the antibiotic. An Epstein-Barr viral infection treated with amoxicillin, for example, <a href="https://pubmed.ncbi.nlm.nih.gov/23589810/">causes</a> a fine, red rash. </p>
<figure class="align-center ">
<img alt="Woman sits it wheelchair in hospital" src="https://images.theconversation.com/files/555944/original/file-20231025-23-83c11.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/555944/original/file-20231025-23-83c11.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/555944/original/file-20231025-23-83c11.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/555944/original/file-20231025-23-83c11.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/555944/original/file-20231025-23-83c11.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/555944/original/file-20231025-23-83c11.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/555944/original/file-20231025-23-83c11.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">It’s important to know your true allergy status when you go to hospital.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/rear-view-senior-asian-woman-sitting-1605865573">Shutterstock</a></span>
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<p>Some believe a family history of reactions to penicillin means they cannot take them. But there is no evidence penicillin allergy is inherited. </p>
<p>If some time has passed between exposure, people can lose the allergic response. This is typically seen in adults who had a mild allergy as a child, but lose the response with time, so are said to have “grown out” of their allergy.</p>
<p>Then there are people who have had a genuine and serious reaction to penicillin. This includes anaphylaxis, with profound swelling, breathing difficulties and low blood pressure, and severe life-threatening reactions such as <a href="https://www.ncbi.nlm.nih.gov/books/NBK459323/#:%7E:text=Stevens%2DJohnson%20syndrome%2Ftoxic%20epidermal,in%20over%2080%25%20of%20cases.">Steven-Johnson’s syndrome</a>, which causes widespread blisters and wounds that resemble burns.</p>
<h2>Testing for penicillin</h2>
<p>When someone says they have a penicillin allergy, we first get them to explain what happened with the reaction, including to what antibiotic, in what context and how severe it was. </p>
<p>Then we perform skin tests to further assess the person’s risk of reaction. If skin tests are negative, we can then give the patient the penicillin in question under supervision (a “challenge”) to see if they react. </p>
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<img alt="Allergist performs skin test on patient's arm" src="https://images.theconversation.com/files/555946/original/file-20231025-27-q72zcu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/555946/original/file-20231025-27-q72zcu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/555946/original/file-20231025-27-q72zcu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/555946/original/file-20231025-27-q72zcu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/555946/original/file-20231025-27-q72zcu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/555946/original/file-20231025-27-q72zcu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/555946/original/file-20231025-27-q72zcu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Skin tests assess a patient’s reaction to the allergen.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/allergy-skin-prick-tests-184605983">Shutterstock</a></span>
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<p>Some people can skip the skin tests altogether and go straight to the challenge if the history tells us they are at low risk of reacting.</p>
<p><a href="https://www.sciencedirect.com/science/article/pii/S2772829322000376?via%3Dihub">Our study</a> followed 195 patients who reported a penicillin allergy across six Sydney hospitals. In the first phase, we assessed 85 people and found 82% weren’t allergic to penicillin. </p>
<p>In the second phase, we assessed 110 people, of whom 69% weren’t allergic.
This is slightly lower than research on the population as a whole, because we only looked at people who were referred for an allergy assessment. Many more patients carry an allergy label than those referred for testing.</p>
<p>In our study, eight weeks after their test, just 54% of participants in phase one correctly knew their penicillin allergy status. Some allergic people believed they were not allergic, and many non-allergic people believed they were allergic.</p>
<p>For phase two, we ensured people received a standardised letter outlining their results in addition to having a doctor or nurse explain them. This time, 92% were correct in their understanding when contacted eight weeks later. </p>
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<strong>
Read more:
<a href="https://theconversation.com/will-we-still-have-antibiotics-in-50-years-we-asked-7-global-experts-214950">Will we still have antibiotics in 50 years? We asked 7 global experts</a>
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<h2>Reducing long waits for allergy tests</h2>
<p>Ruling out allergies among people who think they can’t have penicillin is time- and labour-intensive. The wait time from someone first being referred to an allergy clinic to having testing can be <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10026071/">up to two years</a>. And it’s usually not available outside major metropolitan hospitals. </p>
<p>We need to improve access to testing and also look at <em>when</em> people can access allergy services. When a person is sick in hospital with a serious infection, it’s not the right time for testing.</p>
<p>We also need to ensure the results of allergy tests translate to the real world so people know their true allergy status. The fragmentation of our medical records are a barrier to clear and effective communication of a patient’s true allergy status, and urgently need to be improved.</p>
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<p><em>Read the other articles in The Conversation’s series on the dangers of antibiotic resistance <a href="https://theconversation.com/au/topics/the-dangers-of-antibiotic-resistance-146983">here</a>.</em></p><img src="https://counter.theconversation.com/content/212874/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Winnie Tong has received funding from Maridulu Budyari Gumal, the Sydney Partnership for Health, Education, Research and Enterprise (SPHERE), Triple I Clinical Academic Group seed grant 2017, and the Balnaves Foundation. The authors would like to acknowledge Professor Andrew Carr, their collaborators and participants on this project. </span></em></p><p class="fine-print"><em><span>Jacqueline Loprete does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Up to 20% of Australians admitted in hospital say they have a penicillin allergy. But not everyone who thinks they’re allergic to penicillin actually is.Winnie Tong, Clinical Immunologist & Allergist, Immunopathologist and Senior Lecturer, UNSW SydneyJacqueline Loprete, Postdoctoral fellow, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2155102023-11-02T09:59:22Z2023-11-02T09:59:22ZThe future of medicine: 50-year forecast offers hope for HIV and cancer patients and predicts climate change to increasingly set agenda<p>The Covid-19 pandemic has changed the way we think about health and revealed significant flaws within our health care systems. It has also raised questions about the role of technology, as well as ethical concerns about the distribution of wealth and its impact on global health. How will this collective awakening that we have experienced influence the coming years and decades? This was the subject of our <a href="https://www.sciencedirect.com/science/article/pii/S0016328723000010">research on the future of medicine</a>.</p>
<p>We utilised the Delphi method in a three-round study involving 22 experts from seven European countries. Participants included physicians, academics, and industry professionals. Despite a slight reduction in panel size in later rounds, study validity remained intact. Data were collected through audio or video responses and analysed using <a href="https://en.wikipedia.org/wiki/NVivo">NVivo</a> 12. The research focused on updating current medical trends, identifying key drivers for future development, and making health care foresights. Data were coded independently to minimise bias and formed the basis for questions in subsequent rounds.</p>
<h2>1 to 2 years: beta and data</h2>
<p>While we remain in “eternal beta” – a state in which products or drugs are tested through active use by a wide audience – sales of portable smart electronic devices will continue to grow thanks to advances in sensors, artificial intelligence (AI) and the proliferation of 5G technology. Data generated by personal devices will also increasingly be transferred to professional devices. This will enable doctors to treat their patients more holistically and better inform their prescriptions.</p>
<h2>2 to 5 years: the private sector strikes back, climate-related tensions</h2>
<p>Rising strains on public health care are likely to bolster the role of private entities. Innovations in this sector will likely hinge on smart sensors, the blockchain, and digital health records. Over the same period, climate change will exacerbate health issues such as malnutrition and water scarcity, especially in vulnerable regions, necessitating a broader health care response.</p>
<h2>5 to 10 years: innovations leading to inequalities</h2>
<p>Advancements in genomics are accelerating personalised medicine, enabling better prediction and treatment of genetic diseases. Technologies like drug-gene interaction studies allow for optimised drug dosing, while nanotechnology permits targeted micro-dosing, reducing complications. However, the high cost of these innovations will exacerbate health care disparities, potentially fuelling social conflict, especially as climate change imposes additional health burdens.</p>
<h2>10 to 30 years: climate change takes centre stage</h2>
<p>Global warming, which according to the World Health Organisation could claim the lives of around 250,000 people a year by 2030, risks exacerbating inequalities in access to health care. Various disasters (floods, heat waves, etc.) disproportionately affect disadvantaged populations who do not have the resources to cope. This could put a strain on existing health care infrastructures, leading to disparities in access to care.</p>
<p>In addition, global warming could lead to forced migrations, placing an additional burden on health care systems in regions receiving climate migrants and creating difficulties in accessing health care due to social, economic, and linguistic barriers.</p>
<p>Experts predict that, within 10 to 15 years, technological advances could be less effective in meeting the needs of racial- and ethnic-minority patient groups. Indeed, the lack of diversity in clinical trials, a widely debated topic in medical research today, could contribute to the reduced effectiveness of drugs on a broad population.</p>
<p>However, experts anticipate that this trend will gradually fade over the next 20 to 30 years. They believe that health care companies will gradually adapt their treatments for people from lower socio-economic backgrounds and minority ethnic groups.</p>
<h2>30 to 50: a quantum leap</h2>
<p>Finally, looking ahead half a century, experts predict the emergence of highly effective treatments and even cures for diseases such as HIV and hepatitis C. There is no doubt that considerable progress has been made in the prevention, diagnosis, and treatment of diseases, particularly cancer.</p>
<p>The experts in our study predict a significant leap forward in these areas. They do not necessarily envisage a complete cure for all types of cancer or the eradication of major diseases, but do foresee progress in diagnostic and therapeutic methods that will enable a higher percentage of patients to be successfully treated at an early stage.</p>
<p>Against this backdrop of progress, they nevertheless stress that antibiotic resistance remains a real challenge. It is true that the development of new antibiotic molecules is still relatively slow. Our experts draw our attention to certain initiatives that focus on modifying existing antibiotics to overcome resistance, while others are exploring the use of bacteriophages, or studying entirely new classes of antibiotics.</p>
<p>Technological advances and a faster pace of life will continue to take their toll on our mental health, perhaps even increasingly so, with mood disorders becoming widespread. We could also see an increase in depression and certain personality disorders. This would force patients and doctors to resort to preventive medication, or even a “magic pill”, to cure mental disorders.</p>
<p>In addition, the problem of chronic metabolic diseases such as cardiovascular disease, diabetes and obesity is set to worsen. Contributing factors include the increasing prevalence of sedentary lifestyles, unhealthy diets, and an ageing population.</p>
<p>The incidence of pancreatic cancer, for example, has risen sharply in recent years. Researchers attribute this not only to lifestyle factors such as smoking, obesity and poor diet, but also to long-term exposure to certain environmental pollutants. Understanding and addressing these links between health and the environment is therefore becoming crucial to the future of health care.</p>
<h2>The ageing challenge</h2>
<p>Finally, the ageing of the population represents another major challenge that will have a considerable impact on health care systems, and not just on Western systems. The prevalence of age-related diseases such as neurodegenerative disorders, osteoporosis and certain types of cancer is set to increase.</p>
<p>This trend will not only place a considerable burden on health services, but will also require major changes in the way health care is delivered. Emphasis will need to be placed on preventive measures, early detection and management of chronic diseases, as well as health care environments and services adapted to the elderly.</p>
<p>In short, as we move forward in time, we imagine progress in the use of technology. While some of us will be offered the means to extend our longevity and improve our quality of life, others may suffer significant health disadvantages, particularly as a result of climate change.</p>
<p>General practitioners will have a cross-sectional view of a patient’s overall state of health, while specialists will be able to provide more targeted treatments. Personal care will become an even hotter topic, as lifestyle choices will reflect a person’s financial resources and social status. This will allow a commercial industry to thrive on the challenges of modern life.</p><img src="https://counter.theconversation.com/content/215510/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Les auteurs ne travaillent pas, ne conseillent pas, ne possèdent pas de parts, ne reçoivent pas de fonds d'une organisation qui pourrait tirer profit de cet article, et n'ont déclaré aucune autre affiliation que leur organisme de recherche.</span></em></p>Climate change, inequality, the evolution of knowledge… Experts have been surveyed, and a consensus is emerging on what to expect from the effects of these factors in the medical field.René Rohrbeck, Professor of Strategy, Director EDHEC Chair for Foresight, Innovation and Transformation, EDHEC Business SchoolAhmed Khwaja, Professor of Marketing, Business & Public Enterprise, Head of the Marketing Subject Group, Cambridge Judge Business SchoolHeikki Karjaluoto, Professor of Marketing, University of JyväskyläIgnat Kulkov, Postdoctoral researcher, EDHEC Business SchoolJoel Mero, Associate professor of marketing, University of JyväskyläJulia Kulkova, Adjunct professor, University of TurkuShasha Lu, Associate Professor in Marketing, Cambridge Judge Business SchoolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2142642023-10-25T02:16:38Z2023-10-25T02:16:38ZDoctors are being sexually harassed at work. This needs to stop<figure><img src="https://images.theconversation.com/files/555689/original/file-20231024-17-7qggzi.jpg?ixlib=rb-1.1.0&rect=0%2C33%2C5615%2C3682&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-sad-female-caucasian-uk-us-1701457318">Shutterstock</a></span></figcaption></figure><p><a href="https://www.theguardian.com/australia-news/2023/sep/24/the-system-teaches-you-to-be-quiet-doctor-indecently-assaulted-by-senior-colleague-identifies-herself">Dominique Lee</a> was training in radiation oncology when she was invited to join her supervisor to discuss a training opportunity. Instead, she was drugged and sexually assaulted. </p>
<p>Lee reported the crime, and <a href="https://www.smh.com.au/national/nsw/oncologist-john-kearsley-jailed-after-drugging-and-indecently-assaulting-doctor-20160826-gr1q75.html">John Kearsley</a> was sentenced two years later. Kearsley has since been sentenced for another <a href="https://www.abc.net.au/news/2017-07-27/oncologist-john-kearsley-sentencing-hearing-for-indecent-assault/8748338">sexual assault</a> against the daughter of a patient. </p>
<p>For Lee, the impact of that assault has been profound. “It’s taken almost ten years to look at myself in the mirror and not feel shame and hate,” <a href="https://www.theguardian.com/australia-news/2023/sep/24/the-system-teaches-you-to-be-quiet-doctor-indecently-assaulted-by-senior-colleague-identifies-herself">she says</a>. “All I wanted to do was stop him from hurting other women, and that was my one agenda. I wasn’t set out to destroy his career. He did that on his own.”</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1705811088150008043"}"></div></p>
<p>Lee is not alone. It is always <a href="https://wordpress.com/post/ofdoctorsbydoctors.com/1119">difficult to measure</a> how often sexual harassment and assault occurs, but <a href="https://www.sap2.org.ar/i2/archivos/2224.pdf">global estimates</a> suggest around 33% of doctors in training have experienced sexual harassment in the workplace. Women are at higher risk and <a href="https://www.asmofnsw.org.au/images/ASMOFNSW/ASMOF%20submission%20to%20National%20Inquiry%20into%20Sexual%20Harassment%20in%20the%20Workplace%20.pdf">especially women in training</a>. </p>
<p>A <a href="https://www.bmj.com/content/382/bmj.p2090#:%7E:text=News-,Nearly%20a%20third%20of%20female%20surgeons%20have%20been,by%20a%20colleague%2C%20survey%20finds&text=Almost%20a%20third%20of%20female,a%20UK%20survey%20has%20found.">recent study</a> of <a href="https://journals.sagepub.com/doi/10.1177/00258172231194926">surgeons in the United Kingdom</a> found 63.3% of female surgeons and 23.7% of male surgeons had been sexually harassed by colleagues. </p>
<p>One of the study authors, Tamzin Cummings, told <a href="https://www.theguardian.com/society/2023/sep/12/female-surgeons-nhs-sexually-assaulted-metoo">The Guardian</a>:</p>
<blockquote>
<p>No one should need to call for a code of conduct that says, in essence, ‘please do not molest your work colleagues or students’, and yet this is one of the actions our report recommends.</p>
</blockquote>
<p>This week, I convened a meeting of medical leaders in Canberra to explore why doctors in Australia are vulnerable to sexual harassment. And we drafted a set of safety standards to prevent this in future. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/yes-sexism-is-rife-in-surgery-and-its-time-to-do-something-about-it-38715">Yes, sexism is rife in surgery – and it's time to do something about it</a>
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<h2>What is it about the culture of medicine?</h2>
<p>Doctors work in a rigid hierarchy, and train for more than 12 years to obtain their specialist qualifications. They have <a href="https://www.theguardian.com/commentisfree/2019/sep/10/hospital-hierarchies-are-fostering-sexual-harassment-against-young-doctors">a lot to lose</a> from disclosing assault and harassment. </p>
<p>In Lee’s victim impact statement, she acknowledged how differences in power made junior doctors vulnerable:</p>
<blockquote>
<p>Before pleading guilty to these assault charges, the perpetrator used to hold a high position in a well-known cancer centre and he was a respected member of the community. I, on the other hand, was still a trainee. </p>
</blockquote>
<p>Medicine can be a brutal profession. The work is long, arduous and high stakes. The suicide rate is <a href="https://www.mja.com.au/journal/2018/reducing-risk-suicide-medical-profession">high</a>, <a href="https://bjgp.org/content/68/669/168">particularly in women</a>, and <a href="https://insightplus.mja.com.au/2023/19/every-doctor-has-a-right-to-a-safe-workplace/">violence</a> at work <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7531183/#:%7E:text=Violent%20events%20ranged%20from%2015.0,spread%20SARS%2DCoV%2D2.">is increasing</a>. </p>
<p>Doctors often work and live in environments that make them vulnerable. It is common for doctors to live in hospitals when on call, or when <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10086783/">placed in rural communities</a> where they lack their usual social supports. </p>
<p>It is normal to discuss sex and human bodies during training, so survivors often feel it took them too long to pick up early signs of escalating abuse, like intrusive sexual comments. </p>
<p>Doctors work in close physical proximity, particularly in surgery, so it can also be easy to excuse inappropriate touching which can feel like an “accident”. Exposure to discrimination and harassment is so common, they become “<a href="https://pubmed.ncbi.nlm.nih.gov/22341202/">too used to it</a>”. </p>
<figure class="align-center ">
<img alt="Surgeons work in an operating theatre" src="https://images.theconversation.com/files/555690/original/file-20231024-29-t1kmh1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/555690/original/file-20231024-29-t1kmh1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/555690/original/file-20231024-29-t1kmh1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/555690/original/file-20231024-29-t1kmh1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/555690/original/file-20231024-29-t1kmh1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/555690/original/file-20231024-29-t1kmh1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/555690/original/file-20231024-29-t1kmh1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Doctors work in close physical proximity, where inappropriate touching might be brushed off as an ‘accident’.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/surgical-team-performing-surgery-modern-operation-1932229913">Shutterstock</a></span>
</figcaption>
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<p>Several of the doctors in our 2019 <a href="https://ofdoctorsbydoctors.files.wordpress.com/2023/10/sexual-assault-and-harassment-of-doctors-by-doctors-medical-education.pdf">study</a> on sexual harassment commented that women doctors walk a fine line, trying to be strong, competent and capable, while also being “a good girl, being approachable and being nice to the nursing staff”. Female doctors do not want to be seen as “troublemakers”, because it impacts their careers. </p>
<p><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8712706/">Doctors report</a> the culture of self-sacrifice in medicine can <a href="https://www.nejm.org/doi/full/10.1056/NEJMpv2303217">normalise abuse</a>, and can mean young doctors accept harassment as “part of the job”. </p>
<p>Wellness programs can be a way of side-stepping workplace obligations, emphasising individual resilience without addressing the harassment problem. We call this “<a href="https://thiswildmind.com/2021/09/10/we-are-weaponizing-self-care-especially-in-workplaces/">weaponising wellness</a>”. </p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/depression-burnout-insomnia-headaches-how-a-toxic-and-sexist-workplace-culture-can-affect-your-health-158062">Depression, burnout, insomnia, headaches: how a toxic and sexist workplace culture can affect your health</a>
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<p>Medical workplaces are highly diverse, which makes regulation challenging. Doctors work in hospitals, aged care facilities, solo doctor rural practices, large corporate community health centres, research institutes, universities and even people’s homes. Many are contractors or small business owners, which means they do not have the same structural protections of employees. </p>
<p>Even if they want to report, it’s hard to work out where to do so. Lee reported to the police, and her case was heard by a criminal court. However, she could have reported to her professional college, hospital, medical defence organisation, medical board, Human Rights Commission, union or any number of other avenues. No wonder survivors are confused. </p>
<p>As Lee <a href="https://www.theguardian.com/australia-news/2023/sep/24/the-system-teaches-you-to-be-quiet-doctor-indecently-assaulted-by-senior-colleague-identifies-herself">told The Guardian</a>, “the system teaches you to be quiet”. </p>
<h2>We’re setting a new standard</h2>
<p>This week, my colleagues and I brought together 140 experts at Old Parliament House to tackle this difficult problem. </p>
<p>We had international leaders from law, medical education, health-care management, psychiatry and psychology, Medical Boards, doctors’ health advisory services and various medical workplaces. We had representatives from Australia, New Zealand the UK and Pakistan. One of our participants was from an Antarctic research station. Some were students or doctors in training. Most had decades of experience. </p>
<p>The purpose of the summit was simple: to identify and address the features of medical workplaces that make doctors particularly vulnerable, and address them. </p>
<p>We recognise that many features of medicine are common to all workplaces. We wanted to build on existing frameworks and legislative requirements like <a href="https://www.respectatwork.gov.au/">Respect at Work</a>, not replace them. </p>
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<img alt="Exhausted doctor leans up against a wall" src="https://images.theconversation.com/files/555694/original/file-20231024-27-u6x8pp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/555694/original/file-20231024-27-u6x8pp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/555694/original/file-20231024-27-u6x8pp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/555694/original/file-20231024-27-u6x8pp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/555694/original/file-20231024-27-u6x8pp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/555694/original/file-20231024-27-u6x8pp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/555694/original/file-20231024-27-u6x8pp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">The summit addressed why doctors are vulnerable and how this can be addressed.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/sad-surgeon-leaning-against-glass-door-584308879">Shutterstock</a></span>
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<p>We drafted a set of sexual safety standards, that can apply to all medical workplaces and add to the legislative requirements we are already required to meet. </p>
<p>These standards include preventing sexual harassment and identifying, supporting and managing high-risk targets, perpetrators and environments in medical workplaces. They also encompass reducing the trauma of the reporting process, and the compassionate rehabilitation of survivors. </p>
<p>We mapped the options for reporting, developing a resource for survivors to choose and navigate the complex systems available to them. </p>
<p>Importantly, we established a community of diverse, passionate, expert global leaders across medicine who are determined to use their skills in managing complexity to reduce sexual harm in the profession. </p>
<p>Medicine has unique challenges, but we are not the only profession tackling this difficult problem. We manage physical and psychological trauma every day, and we are experts in navigating complexity. It’s time we used our skills to heal our own profession. </p>
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<strong>
Read more:
<a href="https://theconversation.com/sexual-harassment-at-work-isnt-just-discrimination-it-needs-to-be-treated-as-a-health-and-safety-issue-144940">Sexual harassment at work isn't just discrimination. It needs to be treated as a health and safety issue</a>
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<img src="https://counter.theconversation.com/content/214264/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>I am the lead editor of an international book on sexual harassment in medicine, to be published by Cambridge University Press in 2024. </span></em></p>This week medical leaders met in Canberra to explore why women doctors in Australia are vulnerable to sexual harassment – and to draft a set of safety standards to prevent this in future.Louise Stone, General practitioner; Associate Professor, ANU Medical School, Australian National UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2146222023-10-12T12:31:00Z2023-10-12T12:31:00ZHorseshoe crab blood is vital for testing intravenous drugs, but new synthetic alternatives could mean pharma won’t bleed this unique species dry<figure><img src="https://images.theconversation.com/files/552874/original/file-20231010-19-onfdw4.jpg?ixlib=rb-1.1.0&rect=33%2C8%2C5579%2C3728&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Horseshoe crabs in spawning season at Reeds Beach, N.J., on June 13, 2023.</span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/HorseshoeCrabHarvest/053d4f924f9c453f808a4d3724a87e73/photo">AP Photo/Matt Rourke</a></span></figcaption></figure><p>If you have ever gotten a vaccine or received an intravenous drug and did not come down with a potentially life-threatening fever, you can thank a horseshoe crab (<em>Limulus polyphemus</em>).</p>
<p>How can animals that are <a href="https://www.britannica.com/animal/horseshoe-crab">often called living fossils</a>, because they have barely changed over millions of years, be so important in modern medicine? Horseshoe crab blood is used to produce a substance called limulus amebocyte lysate, or LAL, which scientists use to test for <a href="https://www.britannica.com/science/endotoxin">toxic substances called endotoxins</a> in intravenous drugs. </p>
<p>These toxins, produced by bacteria, are ubiquitous in the environment and can’t be removed simply through sterilization. They can cause a reaction historically referred to as “<a href="https://www.fda.gov/inspections-compliance-enforcement-and-criminal-investigations/inspection-technical-guides/pyrogens-still-danger">injection fever</a>.” A strong concentration can lead to shock and even death. </p>
<p>Identifying LAL as a highly sensitive detector of endotoxins was a 20th-century medical safety breakthrough. Now, however, critics are raising questions about environmental impacts and the process for reviewing and approving synthetic alternatives to horseshoe crab blood.</p>
<p>We study <a href="https://scholar.google.com/citations?user=Dd_T980AAAAJ&hl=en&authuser=1&oi=ao">science, technology</a> and <a href="https://www.linkedin.com/in/jolie-crunelle/%20student">public policy</a>, and recently published a <a href="https://osf.io/3tm9g/">white paper</a> examining social, political and economic issues associated with using horseshoe crabs to produce LAL. We see this issue as a test case for complicated problems that cut across multiple agencies and require attention to both nature and human health.</p>
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<figcaption><span class="caption">Protecting horseshoe crabs will require persuading the heavily regulated pharmaceutical industry to embrace change.</span></figcaption>
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<h2>An ocean solution</h2>
<p>Doctors began injecting patients with various solutions <a href="https://doi.org/10.1016/j.socscimed.2004.06.044">in the mid-1800s</a>, but it was not until the 1920s that biochemist <a href="https://lemelson.mit.edu/resources/florence-seibert">Florence Seibert</a> discovered that febrile reactions were due to contaminated water in these solutions. She created a method for detecting and removing the substances that caused this reaction, and it became the medical standard in the 1940s.</p>
<p>Known as the <a href="https://www.matresearch.com/pyrogen-testing/">rabbit pyrogen test</a>, it required scientists to inject intravenous drugs into rabbits, then monitor the animals. A feverish rabbit meant that a batch of drugs was contaminated.</p>
<p>The LAL method was discovered by accident. Working with horseshoe crabs at the <a href="https://www.mbl.edu/">Marine Biological Laboratory</a> at Woods Hole, Massachusetts, in the 1950s and ’60s, <a href="https://www.goldengooseaward.org/01awardees/horseshoe-crab-blood">pathobiologist Frederik Bang and medical researcher Jack Levin</a> noticed that the animals’ <a href="https://hub.jhu.edu/magazine/2021/summer/horseshoe-crabs-covid19-medical-uses/">blue blood</a> coagulated in a curious manner. Through a series of experiments, they isolated endotoxin as the coagulant and devised a method for extracting LAL from the blood. This compound would gel or clot nearly instantaneously in the presence of fever-inducing toxins.</p>
<p>Academic researchers, biomedical companies and the U.S. Food and Drug Administration refined LAL production and measured it against the rabbit test. By the 1990s, LAL was the <a href="https://www.fda.gov/inspections-compliance-enforcement-and-criminal-investigations/inspection-technical-guides/bacterial-endotoxinspyrogens">FDA-approved method</a> for testing medicines for endotoxin, largely replacing rabbits.</p>
<p>Producing LAL requires harvesting horseshoe crabs from oceans and beaches, <a href="https://www.theatlantic.com/technology/archive/2014/02/the-blood-harvest/284078/">draining up to 30% of their blood</a> in a laboratory and returning the live crabs to the ocean. There’s dispute about <a href="https://www.scientificamerican.com/article/medical-labs-may-be-killing-horseshoe-crabs/">how many crabs die in the process</a> – estimates range from a few percent to 30% or more – and about possible harmful effects on survivors. </p>
<p>Today there are five FDA-licensed <a href="https://asmfc.org/uploads/file/645bf065HSC_Biomedical_BMPs_2023.pdf">LAL producers</a> along the U.S. East Coast. The amount of LAL they produce, and its sales value, are proprietary. </p>
<h2>Bait versus biotech</h2>
<p>As biomedical LAL production ramped up in the 1990s, so did harvesting horseshoe crabs to use as bait for other species, particularly eel and whelk for foreign seafood markets. Over the past 25 years, hundreds of thousands – and in the early years, millions – of horseshoe crabs have been harvested each year for these purposes. Combined, the two fisheries kill <a href="https://asmfc.org/species/horseshoe-crab">over half a million</a> horseshoe crabs every year.</p>
<p>There’s no agreed total population estimate for <em>Limulus</em>, but the most recent <a href="https://asmfc.org/uploads/file/63d2ed62HSCAssessment_PeerReviewReport_May2019.pdf">federal assessment of horseshoe crab fisheries</a> found the population was neither strongly growing nor declining.</p>
<p>Conservationists are worried, and not just about the crabs. Millions of shorebirds <a href="https://atlanticflywayshorebirds.org/">migrate along the Atlantic coast</a>, and many stop in spring, when horseshoe crabs spawn on mid-Atlantic beaches, to feed on the crabs’ eggs. Particularly for <a href="https://www.allaboutbirds.org/guide/Red_Knot/overview">red knots</a> – a species that can migrate up to 9,000 miles between the tip of South America and the Canadian Arctic – gorging on horseshoe crab eggs provides a critical energy-rich boost on their grueling journey.</p>
<p>Red knots were <a href="https://www.federalregister.gov/documents/2014/12/11/2014-28338/endangered-and-threatened-wildlife-and-plants-threatened-species-status-for-the-rufa-red-knot">listed as threatened</a> under the Endangered Species Act in 2015, largely because horseshoe crab fishing threatened this key food source. As biomedical crab harvests came to equal or <a href="https://asmfc.org/species/horseshoe-crab">surpass bait harvests</a>, conservation groups began calling on the LAL industry to find new sources.</p>
<p><div data-react-class="InstagramEmbed" data-react-props="{"url":"https://www.instagram.com/p/Ct2Aji4xcPJ/?utm_source=ig_web_copy_link\u0026igshid=MzRlODBiNWFlZA==","accessToken":"127105130696839|b4b75090c9688d81dfd245afe6052f20"}"></div></p>
<h2>Biomedical alternatives</h2>
<p>Many important medicines are derived from living organisms. Penicillin, the first important antibiotic, was <a href="https://www.sciencemuseum.org.uk/objects-and-stories/how-was-penicillin-developed">originally produced from molds</a>. Other medicines currently in use come from sources including <a href="https://www.goodrx.com/well-being/diet-nutrition/medications-that-contain-animal-byproducts">cows, pigs, chickens and fish</a>. The ocean is a <a href="https://oceanexplorer.noaa.gov/facts/medicinesfromsea.html">promising source</a> for such products.</p>
<p>When possible, synthesizing these substances in laboratories – especially widely used medications like <a href="https://www.cityofhope.org/breakthroughs/art-riggs-tribute">insulin</a> – offers many benefits. It’s typically cheaper and more efficient, and it avoids putting species at risk, as well as addressing <a href="https://www.uspharmacist.com/article/animal-derived-medications-can-be-problematic-for-some-patients">concerns some patients have</a> about using animal-derived medical products.</p>
<p>In the 1990s, researchers at the National University of Singapore <a href="https://patents.google.com/patent/WO1999015676A1/en?inventor=Jeak+Ling+Ding">invented and patented</a> the first process for creating a synthetic, endotoxin-detecting compound using horseshoe crab DNA and <a href="https://www.genome.gov/genetics-glossary/Recombinant-DNA-Technology">recombinant DNA technology</a>. The result, dubbed recombinant Factor C (rFC), mimicked the first step in the three-part cascade reaction that occurs when LAL is exposed to endotoxin. </p>
<p>Later, several biomedical firms <a href="https://www.americanpharmaceuticalreview.com/Featured-Articles/569887-Historical-Milestones-and-Industry-Drivers-in-the-Development-of-Recombinant-Lysate-for-Bacterial-Endotoxin-Testing/">produced their own versions</a> of rFC and compounds called recombinant cascade reagents (rCRs), which reproduce the entire LAL reaction without using horseshoe crab blood. Yet, today, LAL remains the dominant technology for detecting endotoxins in medicine. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/552876/original/file-20231010-22-ilv12l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A vial partly filled with pale blue fluid" src="https://images.theconversation.com/files/552876/original/file-20231010-22-ilv12l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/552876/original/file-20231010-22-ilv12l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/552876/original/file-20231010-22-ilv12l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/552876/original/file-20231010-22-ilv12l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/552876/original/file-20231010-22-ilv12l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/552876/original/file-20231010-22-ilv12l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/552876/original/file-20231010-22-ilv12l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A sample of horseshoe crab blood.</span>
<span class="attribution"><a class="source" href="https://flic.kr/p/riAZsU">Florida Fish and Wildlife Commission</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
</figcaption>
</figure>
<p>The main reason is that the <a href="https://www.usp.org/">U.S. Pharmacopeia</a>, a quasi-regulatory organization that sets safety standards for medical products, considers rFC and rCR as “alternative” methods for detecting endotoxins, so they require case-by-case validation for use – a potentially lengthy and expensive process. The FDA generally defers to the U.S. Pharmacopeia.</p>
<p>A few large pharmaceutical companies with deep pockets have committed to <a href="https://www.esg.lilly.com/environmental/biodiversity?redirect-referrer=https%3A%2F%2Fwww.google.com%2F#case-studies">switching from LAL to rFC</a>. But most drug producers are sticking with the tried-and-true method. </p>
<p>Conservation groups want the U.S. Pharmacopeia to <a href="https://www.audubon.org/magazine/summer-2018/inside-biomedical-revolution-save-horseshoe-crabs">fully certify rFC</a> for use in industry with no extra testing or validation. In their view, LAL producers are stalling rFC and rCR approval to protect their <a href="https://www.npr.org/2023/06/10/1180761446/coastal-biomedical-labs-are-bleeding-more-horseshoe-crabs-with-little-accountabi">market in endotoxin detection</a>. The U.S. Pharmacopeia and LAL producers counter that they are doing due diligence to <a href="https://hsc.criver.com/#lal-endo">protect public health</a>.</p>
<h2>Change in the offing</h2>
<p>Change may be coming. All major LAL producers now have their own recombinant products – a tacit acknowledgment that markets and regulations are moving toward <em>Limulus</em>-free ways to test for endotoxins. </p>
<p>Atlantic fisheries regulators are currently considering <a href="https://www.asmfc.org/home/2023-annual-meeting">new harvest limits for horseshoe crabs</a>, and the U.S. Pharmacopeia is <a href="https://www.uspnf.com/notices/86-bet-using-recombinant-tests-gen-annc-20230822">weighing guidance</a> on recombinant alternatives to LAL. Public comments will be solicited over the winter of 2024, followed by U.S. Pharmacopeia and FDA review. </p>
<p>Even if rFC and rCR don’t win immediate approval, we believe that collecting more complete data on horseshoe crab populations and requiring more transparency from the LAL industry on <a href="https://asmfc.org/uploads/file/645bf065HSC_Biomedical_BMPs_2023.pdf">how it handles the crabs</a> would represent progress. So would directing medical companies to use recombinant products for testing during the manufacturing process, while saving LAL solely for final product testing. </p>
<p>Making policy on complex scientific issues across diverse agencies is never easy. But in our view, incremental actions that protect both human health and the environment could be important steps forward.</p><img src="https://counter.theconversation.com/content/214622/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>This material is based upon work supported by the National Science Foundation under Award No. 2121146, as well as the Leverhulme Trust through a Leverhulme Trust Research Project Grant. Any opinions, findings, and conclusions or recommendations expressed in this material are those of the author(s) and do not necessarily reflect the views of the National Science Foundation or the Leverhulme Trust.</span></em></p><p class="fine-print"><em><span>Jolie Crunelle receives funding from the Aberg Family Fellowship at Rochester Institute of Technology. </span></em></p>Horseshoe crabs play a unique role in medicine, but they’re also ecologically important in their home waters along the Atlantic coast. Can regulators balance the needs of humans and nature?Kristoffer Whitney, Associate Professor of Science, Technology and Society, Rochester Institute of TechnologyJolie Crunelle, Master's Degree Student in Science, Technology, and Public Policy, Rochester Institute of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2147892023-10-10T14:53:07Z2023-10-10T14:53:07ZMauritius sea sponge produces chemicals that can kill liver cancer cells – findings are a positive first step<p>For thousands of years, medicines have been developed from natural sources – mostly from plants. In recent decades, though, drug hunters have been looking at the immense diversity of marine organisms as potential sources of new medicines. </p>
<p>Marine sponges have garnered particular <a href="https://www.mdpi.com/1420-3049/27/5/1539">attention</a>. They are considered champion producers of molecules (known as “natural products”). They produce these because they use toxic compounds to deter predators, communicate with their neighbours, or prevent algae and bacteria from growing on them.</p>
<p>Marine sponges are a remarkably diverse group of animals, with <a href="http://www.marinespecies.org/porifera">over 9,000 species</a>. They come in a wide array of shapes, sizes and colours, ranging from small, inconspicuous forms to large and vibrant reef-building varieties. They look like a sedentary blob of porous tissue on the seafloor, which gives them their name. </p>
<p>As some of the most primitive animals on the planet, they lack complex organs and tissues. Without physical and mechanical features to flee (fins, legs), attack (spines), and protect themselves (shells), they have evolved to survive by producing chemical compounds. Some of these compounds have been found to possess valuable properties against <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5666418/">cancer</a> and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10143917/">microbial infections</a>. </p>
<p>Interest in these properties started in the early 1950s after the discovery of two new natural products from the Caribbean sponge species <em>Tectitethya crypta</em>. The products were later approved for use as drugs against <a href="https://www.nhm.ac.uk/discover/can-sponges-cure-cancer.html">leukemia</a> and <a href="https://ocean.si.edu/ocean-life/invertebrates/sea-sponge-hiv-medicine">HIV</a>. </p>
<p>Discoveries like this have raised substantial interest in therapeutic applications of sponge-derived chemicals. </p>
<p>This is where my home country, Mauritius, has huge potential. <a href="https://www.mdgdb.com/index.html">Mauritius</a> has an <a href="https://scholar.sun.ac.za/items/0f93750f-8150-4d13-ab42-099f8605d7d5">array of sponge species</a>, offering the opportunity to discover bioactive agents. </p>
<p>I obtained my PhD in the field of applied marine biochemistry at the University of Mauritius. As part of my studies I worked with my research supervisors Ranjeet Bhagooli, Theeshan Bahorun, Vidushi Neergheen and late Alexander Kagansky to study the anticancer potential of the sponge <em><a href="https://www.marinespecies.org/aphia.php?p=taxdetails&id=166805">Neopetrosia exigua</a></em> from Mauritius waters. </p>
<p>We have <a href="https://sajs.co.za/article/view/13745">just published a paper</a> which shows, for the first time, that chemicals produced by <em>N. exigua</em> have the capacity to selectively kill liver cancer cells, with minimal harm to normal cells. Based on our findings about its pharmacological properties we suggest that the Mauritian sponge <em>N. exigua</em> has potential to be developed into a less toxic therapeutic candidate against liver cancer. </p>
<p>Our study is the first stage of the biodiscovery process. There are numerous steps which can take around 15 to 20 years from discovery of active compounds to use as medicines in humans.</p>
<h2>Studying how a sponge kills cancer cells</h2>
<p>Before our study, <em>Neopetrosia</em> species were already known to be a rich source of bioactive novel compounds, yet studies showing how they killed cancer cells were limited.</p>
<p>For our study, the first step was to collect a sample of <em>N. exigua</em> sponge from the Mauritian coral reefs by snorkelling and scuba diving. What could be better for a passionate lover of the sea than to have one of the world’s most pristine marine ecosystems as her working environment?</p>
<p>Once we had our sample, the sponge was carefully processed in the laboratory to obtain different extracts containing distinct natural products. These extracts were tested at the University of Edinburgh for their toxic effects against a panel of human cancer cell lines. Cell lines are groups of cells derived from living organisms that can keep growing and dividing in the lab. Scientists use them to learn about how cells work, test new medicines, and figure out how diseases function. </p>
<p>We also assessed the effects of the sponge extracts on non-cancerous cells to see how toxic they were to normal cells. This is particularly interesting since some anticancer treatments induce DNA damage indiscriminately, killing both normal and cancer cells. Cancer patients on those treatments may suffer from adverse side effects including nausea, anaemia, fatigue, hair loss and infections. </p>
<p>We found that one particular extract had the ability to selectively kill liver cancer cells at very low doses while displaying very low toxicity towards normal cells. </p>
<p>We also observed how the extract did this: <em>N. exigua</em> constituents activated various proteins that led to the breakdown of the liver cancer cells through a programmed cell death process called <a href="https://www.genome.gov/genetics-glossary/apoptosis">apoptosis</a>. This process helps maintain the overall health and balance of an organism by getting rid of unwanted or potentially harmful cells. When apoptosis malfunctions, these harmful cells can continue to grow and divide, potentially forming a tumour.</p>
<h2>Biodiscovery process</h2>
<p>To validate the extract’s potential use, the next step will be to isolate and identify the natural products accountable for its anticancer activity using advanced analytical techniques such as <a href="https://www.britannica.com/science/chromatography">chromatography</a> and mass <a href="https://www.atascientific.com.au/spectrometry/">spectrometry</a>.</p>
<p>This will set the stage for future evaluations in suitable experimental animal models to probe its efficacy and toxicity. If this step is successful, the tests proceed with humans in clinical trials. </p>
<p>Scientific data about the pharmacological properties of Mauritian marine organisms could create opportunities to promote marine biodiscovery research and sustainable use of the ocean resources in Mauritius. It will also add another reason to conserve the country’s marine biodiversity. </p>
<p>The marine sponge <em>Neopetrosia exigua</em> is highly distributed in the Indian Ocean, Atlantic Ocean (Caribbean Sea) and Pacific Ocean. However, its population density has significantly declined over the last few years in Mauritius due to a continued rise in ocean temperatures.</p><img src="https://counter.theconversation.com/content/214789/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rima Beesoo received funding from the Mauritius Research and Innovation Council, L'Oréal-UNESCO Foundation and Merck Foundation.
Previous Affiliation during the course of this research study: University of Mauritius</span></em></p>A marine sponge from Mauritius has shown potential as the source of compounds that kill liver cancer cells.Rima Beesoo, Postdoctoral Research Fellow, Leibniz Centre for Tropical Marine Research (ZMT)Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2125022023-09-06T12:27:15Z2023-09-06T12:27:15ZTraditional medicine provides health care to many around the globe – the WHO is trying to make it safer and more standardized<figure><img src="https://images.theconversation.com/files/546464/original/file-20230905-503-nlkg3v.jpg?ixlib=rb-1.1.0&rect=3%2C9%2C2114%2C1400&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Ayurveda is one form of traditional medicine that can integrate aromatherapy. It's popular in South Asia. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/ayurveda-aromatherapy-with-essential-oil-diffuser-royalty-free-image/1333713382?phrase=ayurveda&adppopup=true">Microgen Images/Science Photo Library</a></span></figcaption></figure><p>For approximately <a href="https://www.who.int/news/item/25-03-2022-who-establishes-the-global-centre-for-traditional-medicine-in-india">80% of the world’s population</a>, the first stop after catching a cold or breaking a bone isn’t the hospital — maybe because there isn’t one nearby, or they can’t afford it. Instead, the first step is consulting traditional medicine, which cultures around the world have been using for thousands of years.</p>
<p><a href="https://www.who.int/health-topics/traditional-complementary-and-integrative-medicine#tab=tab_1">Traditional medicine</a> encompasses the healing knowledge, skills and practices used by a variety of cultures and groups. </p>
<p>Examples of traditional medicine include <a href="https://www.hopkinsmedicine.org/health/wellness-and-prevention/herbal-medicine">herbal medicine</a>; <a href="https://www.mayoclinic.org/tests-procedures/acupuncture/about/pac-20392763">acupuncture</a>; <a href="https://www.sciencedirect.com/topics/medicine-and-dentistry/tui-na">Tui Na</a> – which is a type of massage originating in China; <a href="https://www.nccih.nih.gov/health/ayurvedic-medicine-in-depth">Ayurveda</a> – which is an ancient system of promoting health through diet, exercise and lifestyle from India; <a href="https://www.britannica.com/science/Unani-medicine">and Unani</a> – which is another ancient system of health from South Asia, balancing key aspects of the mind, body and spirit. </p>
<p>In recognizing that traditional medicine and other alternative forms of healing are critical sources of health care for many people worldwide, the World Health Organization and the government of India co-hosted their first-ever <a href="https://www.who.int/news-room/events/detail/2023/08/17/default-calendar/the-first-who-traditional-medicine-global-summit">Traditional Medicine Summit</a>. The summit took place in August 2023 in Gandhinagar, Gujarat, India. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/jW-B8BpLQJE?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">August 2023 marked the WHO’s first global summit on traditional medicine.</span></figcaption>
</figure>
<p>The summit brought together health care policymakers, traditional medicine workers and users, international organizations, academics and private sector stakeholders from 88 <a href="https://www.who.int/countries">WHO member states</a>. Leaders at the summit aimed to share best practices and scientific evidence and data around traditional medicine. </p>
<p>As researchers interested in how to provide patients both in the U.S. and around the globe with the best <a href="http://gsm.utmck.edu/internalmed/faculty/terry.cfm">possible medical care</a>, <a href="https://scholar.google.com/citations?user=Wng1Wh0AAAAJ&hl=en">we were interested</a> in the summit’s findings. Understanding traditional medicine can help health care professionals create sustainable, personalized and culturally respectful practices.</p>
<h2>Critical health care for many</h2>
<p>In many countries, traditional medicine costs less and is <a href="https://doi.org/10.1093%2Fheapol%2Fczw022">more accessible</a> than conventional health care. And many conventional medicines come from the same source as compounds used in traditional medicine – <a href="https://doi.org/10.1021/acs.jnatprod.9b01285">up to 50% of drugs</a> have a <a href="https://theconversation.com/nature-is-the-worlds-original-pharmacy-returning-to-medicines-roots-could-help-fill-drug-discovery-gaps-176963">natural product root</a>, <a href="https://doi.org/10.1016/j.vph.2018.10.008">like aspirin</a>. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/546451/original/file-20230905-17-3flfzw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="An elderly man wearing a gray button-down shirt sorts bundles of dried herbs into eight piles, behind him is a wall of wooden drawers." src="https://images.theconversation.com/files/546451/original/file-20230905-17-3flfzw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/546451/original/file-20230905-17-3flfzw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/546451/original/file-20230905-17-3flfzw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/546451/original/file-20230905-17-3flfzw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/546451/original/file-20230905-17-3flfzw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/546451/original/file-20230905-17-3flfzw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/546451/original/file-20230905-17-3flfzw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">An herbalist sorts herbs at the Great China Herb Company in Chinatown in San Francisco. Herbal medicine is one form of traditional medicine.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/TravelTripSanFranciscoChinatown/c09c3fae7725457ca4e548ceda2a2f34/photo?Query=traditional%20medicine&mediaType=photo&sortBy=&dateRange=Anytime&totalCount=377&currentItemNo=1&vs=true">AP Photo/Eric Risberg</a></span>
</figcaption>
</figure>
<p><a href="https://doi.org/10.2147/PPA.S398644">Many factors</a> may influence whether someone chooses traditional medicine, such as age and gender, religion, education and income level, and <a href="https://doi.org/10.1155/2021/9962892">distance to travel for treatment</a>. Cultural factors may also influence people’s use of traditional medicine. </p>
<p>In China, for example, as more people have embraced Western culture, fewer have <a href="https://doi.org/10.2105/AJPH.93.7.1082">chosen traditional medicine</a>. In contrast, many African migrants to Australia continue to use traditional medicine to express their cultural identity and maintain <a href="https://doi.org/10.1186/s12906-021-03424-w">a cohesive ethnic community</a>. A patient’s preference for traditional medicine often has significant personal, environmental and cultural relevance.</p>
<h2>A framework for traditional medicine</h2>
<p>Countries have been pushing the WHO to study and track data on traditional medicine for years. In the past, WHO has developed a “<a href="https://www.who.int/publications/i/item/9789241506096">traditional medicine strategy</a>” to help member states research, integrate and regulate traditional medicine in their national health systems. </p>
<p>The WHO also <a href="https://www.who.int/teams/integrated-health-services/traditional-complementary-and-integrative-medicine">created international terminology standards</a> for practicing various forms of traditional medicine.</p>
<p>The practice of traditional medicine varies greatly between countries, depending on how accessible it is and <a href="https://www.who.int/publications/i/item/978924151536">how culturally important it is</a> in each country. To make traditional medicine safer and more accessible on a broader scale, it’s important for policymakers and public health experts to develop standards and share best practices. The WHO summit was one step toward that goal.</p>
<p>The WHO also aims to collect data that could inform these standards and best practices. It is conducting the <a href="https://www.who.int/news-room/events/detail/2023/08/17/default-calendar/the-first-who-traditional-medicine-global-summit">Global Survey on Traditional Medicine</a> in 2023. As of August, approximately 55 member states out of the total 194 have completed and submitted their data.</p>
<h2>Acupuncture – a case study in safety and efficacy</h2>
<p>Some traditional medicine practices <a href="https://doi.org/10.7453/gahmj.2014.042">such as acupuncture</a> have shown consistent and credible benefits, and have even started to make it <a href="https://time.com/6171247/acupuncture-health-benefits-research/">into mainstream medicine</a> in the U.S. But leaders at the summit emphasized a need for more research on the efficacy and safety of traditional medicine. </p>
<p>Although traditional medicine can <a href="https://www.who.int/news-room/feature-stories/detail/traditional-medicine-has-a-long-history-of-contributing-to-conventional-medicine-and-continues-to-hold-promise">have a range of benefits</a>, some treatments come with health risks. </p>
<p>For example, acupuncture is <a href="https://www.nccih.nih.gov/health/acupuncture-what-you-need-to-know#">a traditional healing practice</a> that entails inserting needles at specific points on the body to relieve pain. But acupuncture can <a href="https://www.nccih.nih.gov/health/acupuncture-what-you-need-to-know">cause infections and injuries</a> if the practitioner doesn’t use sterile needles or if needles are inserted incorrectly.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/546455/original/file-20230905-17-dzwxii.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Two hands insert a needle into a patient's back, which is partially covered with a towel and which already has seven needles stuck in two lines." src="https://images.theconversation.com/files/546455/original/file-20230905-17-dzwxii.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/546455/original/file-20230905-17-dzwxii.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=372&fit=crop&dpr=1 600w, https://images.theconversation.com/files/546455/original/file-20230905-17-dzwxii.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=372&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/546455/original/file-20230905-17-dzwxii.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=372&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/546455/original/file-20230905-17-dzwxii.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=467&fit=crop&dpr=1 754w, https://images.theconversation.com/files/546455/original/file-20230905-17-dzwxii.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=467&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/546455/original/file-20230905-17-dzwxii.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=467&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Acupuncture is an example of a form of traditional healing that’s been implemented on a wide scale in the U.S. It has a variety of benefits, including no risk of addiction.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/AcupuncturePainRelief/0b79ca38552c4b86a845bf4645755106/photo?Query=acupuncture&mediaType=photo&sortBy=&dateRange=Anytime&totalCount=246&currentItemNo=1&vs=true">AP Photo/M. Spencer Green</a></span>
</figcaption>
</figure>
<p>Still, acupuncture is the most commonly used traditional medicine practice across countries, with <a href="https://www.who.int/publications/i/item/978-92-4-001688-0">113 WHO member states</a> acknowledging their citizens practiced acupuncture in 2019.</p>
<p>Interestingly, <a href="https://news.va.gov/94087/battlefield-acupuncture-an-emerging-and-promising-alternative-to-risky-pain-medications/">battlefield acupuncture</a> has successfully treated many U.S. military members, for example, for pain reduction. It is simple to use, transportable and has no risk of addiction.</p>
<p>There’s also some evidence supporting the use of traditional medicine, including <a href="https://www.va.gov/WHOLEHEALTH/professional-resources/Acupuncture.asp">acupuncture</a>, <a href="https://www.va.gov/WHOLEHEALTH/professional-resources/Meditation.asp">meditation</a> and <a href="https://www.va.gov/WHOLEHEALTH/professional-resources/Yoga.asp">yoga</a> to treat post-traumatic stress disorder. </p>
<p>However, acupuncture practitioners aren’t trained in a uniform way across countries. To provide guidelines for best practice, the WHO developed standardized <a href="https://www.who.int/publications/i/item/978-92-4-001688-0">benchmarks for practicing acupuncture</a> in 2021. The WHO aims to develop similar standards for other forms of traditional medicine as well. </p>
<p>Interest in traditional medicine is growing among those who have mainly used conventional medicine in the past. More research and collaborative efforts to develop safety standards can make traditional medicine accessible to all who seek it.</p><img src="https://counter.theconversation.com/content/212502/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr. Ling Zhao received her medical training in China and PhD in the US. Her research focuses on novel interventions for chronic diseases. She has received research funding from NIH, including NCCIH. </span></em></p><p class="fine-print"><em><span>Paul D. Terry does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>More people are seeking out traditional forms of medicine, from acupuncture to herbal medicines. The WHO is working to develop standards to make these healing practices implementable on a wide scale.Ling Zhao, Professor of Nutrition, University of TennesseePaul D. Terry, Professor of Epidemiology, University of TennesseeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2114122023-08-31T21:39:50Z2023-08-31T21:39:50ZHere’s what new 60-day prescriptions mean for you and your hip pocket<figure><img src="https://images.theconversation.com/files/545417/original/file-20230829-19-mvx2g4.jpg?ixlib=rb-1.1.0&rect=1%2C0%2C997%2C666&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/customer-paying-bill-by-cell-phone-623126426">Shutterstock</a></span></figcaption></figure><p>From today, there are significant <a href="https://www.health.gov.au/our-work/60-day-prescriptions">changes</a> to how some common medicines are prescribed and dispensed in Australia. This means you could walk away from the pharmacy with 60-days’ worth of your usual medicine from a single prescription.</p>
<p>Until now, most long-term medicines were only available for 30 days at a time. So the price of these medicines for some patients may effectively halve. </p>
<p>You would also need fewer trips to the GP for a prescription and fewer visits to the pharmacy to have your medicine dispensed.</p>
<p>But not all medicines are yet eligible for 60-day scripts and not everyone is prescribed 60-days’ worth of medicine at a time. Here’s what the changes mean for you.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/last-year-half-a-million-australians-couldnt-afford-to-fill-a-script-heres-how-to-rein-in-rising-health-costs-178301">Last year, half a million Australians couldn't afford to fill a script. Here's how to rein in rising health costs</a>
</strong>
</em>
</p>
<hr>
<h2>Can I get a 60-day script today?</h2>
<p>If you have a current prescription, you need to use this prescription first before you get a new one. To be eligible for a prescription that provides medicine for 60 days your medication needs to be on the <a href="https://www.pbs.gov.au/industry/listing/elements/pbac-meetings/pbac-outcomes/2022-12/Increased-Dispensing-Quantities-List-of-Medicines.pdf">approved list</a>.</p>
<p>Your doctor also needs to assess if you are stable on it. This is to avoid wastage. We know new treatments can result in frequent changes to medication regimens, which would result in wasted medicines if they don’t end up being used.</p>
<p>Your doctor may also give you “repeat” prescriptions for 60-days’ worth of medicines at a time. Under the new rules, this could mean up to <a href="https://www.health.gov.au/resources/publications/60-day-prescriptions-information-kit-for-prescribers?language=ha">12 months’ supply</a> of medicine (the initial script plus five “repeats”). You would have to pay for each of these repeat scripts when your medicine is dispensed every 60 days.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/what-time-of-day-should-i-take-my-medicine-125809">What time of day should I take my medicine?</a>
</strong>
</em>
</p>
<hr>
<h2>Is my medicine on the list?</h2>
<p>The roll-out of 60-day scripts will be in three stages. The first stage, which begins today, <a href="https://www.health.gov.au/our-work/60-day-dispensing/pbs-medicines-current-item-codes">includes</a> medicines for cardiovascular disease (such as heart disease and stroke), heart failure, high cholesterol, gout, osteoporosis, and the gut conditions Crohn’s disease and ulcerative colitis.</p>
<p>This includes some of the most common medicines prescribed in Australia, such as atorvastatin for lowering cholesterol, and perindopril for lowering blood pressure.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/545419/original/file-20230829-21-3sh11g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Person adding medications to pill organizer" src="https://images.theconversation.com/files/545419/original/file-20230829-21-3sh11g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/545419/original/file-20230829-21-3sh11g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/545419/original/file-20230829-21-3sh11g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/545419/original/file-20230829-21-3sh11g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/545419/original/file-20230829-21-3sh11g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/545419/original/file-20230829-21-3sh11g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/545419/original/file-20230829-21-3sh11g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Not all your medicines may be affected by the changes.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/1TL8AoEDj_c">Laurynas Mereckas/Unsplash</a></span>
</figcaption>
</figure>
<p>The following stages, set to be rolled out over the coming 12 months, include medicines for diabetes, epilepsy, glaucoma, asthma and Parkinson’s disease. </p>
<p>When fully implemented, these changes will affect more than 300 prescription medicines available on the Pharmaceutical Benefits Scheme (PBS).</p>
<p>These medicines have been chosen because they are appropriate treatments for people living with stable, chronic health conditions, they meet clinical safety criteria, and are considered cost-effective.</p>
<p>Medicines not available for 60-day dispensing are those only for short-term use and medicines known to be at risk of overuse. These <a href="https://www.nps.org.au/australian-prescriber/articles/pharmaceutical-drug-misuse-in-australia#information-sources-for-prescribers">include</a> pain medicines and some medicines for mental health conditions.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/heres-why-pharmacists-are-angry-at-script-changes-and-why-the-government-is-making-them-anyway-204028">Here's why pharmacists are angry at script changes – and why the government is making them anyway</a>
</strong>
</em>
</p>
<hr>
<h2>Will I save money?</h2>
<p>The government has brought in these changes mainly to try to make medicines more affordable. We know people do not seek medical care or fill prescriptions <a href="https://www.abs.gov.au/statistics/health/health-services/patient-experiences/latest-release">due to cost</a>. </p>
<p>The <a href="https://www.pbs.gov.au/info/healthpro/explanatory-notes/front/fee">maximum price you pay</a> at the pharmacy for a PBS script (known as the co-payment) is not changing. <a href="https://www.pbs.gov.au/info/about-the-pbs">It’s still</a> A$7.30 for concession card holders and $30 for non-concession card holders. But by having 60-day dispensing, you’ll only be charged this every two months instead of every month.</p>
<p>But not everyone will save money from a 60-day prescription because in some cases your pharmacy may already be discounting your medicine. If the price for 60-days’ supply would not take the price over $30, you may not be getting two scripts for the price of one. </p>
<p>For example, a commonly discounted medicine is atorvastatin. In Australia, a non-concession patient generally pays between $8 and $22 for 30-days’ supply. But it’s likely that a 60-day supply would cost between $15 and $30.</p>
<p>The amount you or your family need to pay to reach the <a href="https://www.pbs.gov.au/info/general/faq#WhatisthePBSSafetyNet">PBS safety net</a> is also not changing. This is the threshold you need to reach before medicines become free (for concession card holders) or discounted (non-concession card holders) for the rest of the calendar year. In some instances, 60-day dispensing may result in you or your family reaching the safety net threshold later, or not at all.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/545421/original/file-20230829-15-pcnddr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Older woman looking into purse, holding coin" src="https://images.theconversation.com/files/545421/original/file-20230829-15-pcnddr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/545421/original/file-20230829-15-pcnddr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/545421/original/file-20230829-15-pcnddr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/545421/original/file-20230829-15-pcnddr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/545421/original/file-20230829-15-pcnddr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/545421/original/file-20230829-15-pcnddr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/545421/original/file-20230829-15-pcnddr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The changes are meant to make medicines more affordable.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/hands-old-person-senior-hold-wallet-1844510152">Shutterstock</a></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/what-is-the-pbs-safety-net-and-is-it-really-the-best-way-to-cut-the-cost-of-medicines-180315">What is the PBS safety net and is it really the best way to cut the cost of medicines?</a>
</strong>
</em>
</p>
<hr>
<h2>How should I store my medicine?</h2>
<p>If you don’t store your medicines correctly at home they can become degraded and not work so well. With a 60-day supply, correct storage is even more important. </p>
<p>As a general rule of thumb, never store your medicines in hot rooms or your car (even in winter) and don’t store them in direct sunlight. If your medicine needs to be stored in the fridge, your pharmacist will let you know.</p>
<p>One example is <a href="https://media.healthdirect.org.au/medicines/GuildLink_Information/58775/CMI/ujcxalae10320.pdf">latanoprost</a>, which are drops for the eye condition glaucoma. You can keep the bottle you are using in the cupboard but you need to store the unopened, second bottle in the fridge.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/health-check-what-should-you-do-with-your-unused-medicine-81406">Health Check: what should you do with your unused medicine?</a>
</strong>
</em>
</p>
<hr>
<h2>In a nutshell</h2>
<p>Remember, 60-day dispensing is only available for new prescriptions. When you next see your doctor, if your condition is stable and your medicine is suitable, you will be provided a 60-day script. Your pharmacist will then dispense a 60-day supply.</p>
<hr>
<p><em>If you have any questions about the new rules, ask your local pharmacist. Information is also available from the <a href="https://www.health.gov.au/our-work/60-day-prescriptions">Commonwealth health department</a> and the <a href="https://www.60dayscripts.com.au/">Consumers Health Forum</a>.</em></p><img src="https://counter.theconversation.com/content/211412/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew Bartlett is a member of the Pharmaceutical Society of Australia, a previous director of Blooms the Chemist management services and remains a shareholder.</span></em></p><p class="fine-print"><em><span>Associate Professor Nial Wheate in the past has received funding from the ACT Cancer Council, Tenovus Scotland, Medical Research Scotland, Scottish Crucible, and the Scottish Universities Life Sciences Alliance. He is a Fellow of the Royal Australian Chemical Institute, a member of the Australasian Pharmaceutical Science Association, and a member of the Australian Institute of Company Directors. Nial is the chief scientific officer of Vaihea Skincare LLC, a director of SetDose Pty Ltd a medical device company, and a Standards Australia panel member for sunscreen agents. Nial regularly consults to industry on issues to do with medicine risk assessments, manufacturing, design, and testing.</span></em></p>The price you pay at the pharmacy for your long-term medicines may effectively halve. But not all medicines or patients qualify.Andrew Bartlett, Associate Lecturer Pharmacy Practice, University of SydneyNial Wheate, Associate Professor of the Sydney Pharmacy School, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2077532023-08-22T14:52:07Z2023-08-22T14:52:07ZSix pregnancy terms you probably won’t hear again, including ‘high risk’ and ‘failed’<figure><img src="https://images.theconversation.com/files/542983/original/file-20230816-17-towf59.jpg?ixlib=rb-1.1.0&rect=7%2C7%2C5152%2C3435&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The language midwives use is an important part of the care they provide.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/happy-pregnant-woman-visit-gynecologist-doctor-1404770729">Blue Planet Studio/Shutterstock</a></span></figcaption></figure><p>Medical terminology evolves alongside our understanding of medicine. As time goes by, new terms are adopted while others are abandoned. In midwifery, there should always be a strong emphasis on the language we use, particularly in pregnancy.</p>
<p>In 2020, the Royal College of Midwives launched an initiative to discover the impact language has on women. The aim of the <a href="https://www.rcm.org.uk/rebirth-hub/">Re:Birth</a> project was to find language around pregnancy that could be understood both by people delivering maternity care and those receiving it. </p>
<p>It was the first project of its kind to consult the maternity community (including new mothers and healthcare professionals) directly on their preferred language to describe labour and birth. The findings of the project supported the fact that many women were less concerned about the way their baby was born but with whether they had a positive experience and felt safe and listened to.</p>
<p>Last year, the Royal College of Midwives published a <a href="https://www.rcm.org.uk/media/6234/re_birth_summary_.pdf">report</a> outlining their findings and a new pocket guide is being issued to midwives this year. </p>
<hr>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption"></span>
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<p><em>This article is part of <a href="https://theconversation.com/uk/topics/womens-health-matters-143335">Women’s Health Matters</a>, a series about the health and wellbeing of women and girls around the world. From menopause to miscarriage, pleasure to pain the articles in this series will delve into the full spectrum of women’s health issues to provide valuable information, insights and resources for women of all ages.</em></p>
<p><em>You may be interested in:</em></p>
<p><em><a href="https://theconversation.com/spain-is-the-egg-donation-capital-of-europe-heres-what-its-like-to-be-a-donor-205780">Spain is the egg donation capital of Europe – here’s what it’s like to be a donor</a></em></p>
<p><em><a href="https://theconversation.com/dirty-red-how-periods-have-been-stigmatised-through-history-to-the-modern-day-206967">‘Dirty red’: how periods have been stigmatised through history to the modern day</a></em></p>
<p><em><a href="https://theconversation.com/the-orgasm-gap-and-why-women-climax-less-than-men-208614">The orgasm gap and why women climax less than men</a></em></p>
<hr>
<p>Here are six maternity terms you are now unlikely to hear:</p>
<h2>1. Delivery</h2>
<p>The term “birth” has now been accepted, rather than the term “delivery”, which has commonly been used in the past. Women and health professionals also wanted accurate, specific descriptions as far as possible to describe what had happened in the labour and birth. For example, “birth with forceps” or “birth with ventouse”. This also includes “caesarean birth”.</p>
<h2>2. Low risk / high risk</h2>
<p>“Universal care needs” is being used rather than “low risk”. While “additional care needs” is now the preferred term for “high risk”. The word “risk” is associated with uncertainty and it is vital that women feel comfortable and confident during their pregnancy.</p>
<h2>3. Normal</h2>
<p>“Normal birth” is a term that has long been used by midwives and other healthcare professionals to describe a spontaneous, physiological vaginal delivery. But what counts as “normal”? Does this label someone as “abnormal” if they did not experience what we classify as “normal” birth?</p>
<p>The new preferred term, “spontaneous vaginal birth”, covers spontaneous labour without significant medical interventions such as induction and oxytocin. It also covers spontaneous vaginal birth without the need for instruments, such as forceps. </p>
<h2>4. Emergency caesarean</h2>
<p>The new overarching term for an operative caesarean section is “caesarean birth”. This replaces the word “emergency”, which is a term that may cause alarm. The term “unplanned caesarean birth” is now preferred over “emergency caesarean”. </p>
<h2>5. Incompetent cervix</h2>
<p>“Incompetent cervix” has connotations of personal failure. So, the preferred term is now “cervical insufficiency”. </p>
<h2>6. Failure / failed</h2>
<p>During the Re:Birth project, women were keen to share how terms such as “failure to progress” can contribute to feelings of failure and trauma. “Delayed progress in labour” or “slow labour” are now preferred terms.</p>
<p>We can apply the same logic to terms such as “failed induction” or “failed homebirth”. “Induction of labour, with delay and followed by operative birth” and “transfer in during planned homebirth” are favoured, respectively. </p>
<figure class="align-center ">
<img alt="A pregnant woman wearing a yellow top clutches her belly." src="https://images.theconversation.com/files/543009/original/file-20230816-17-ku8n22.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/543009/original/file-20230816-17-ku8n22.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/543009/original/file-20230816-17-ku8n22.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/543009/original/file-20230816-17-ku8n22.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/543009/original/file-20230816-17-ku8n22.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/543009/original/file-20230816-17-ku8n22.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/543009/original/file-20230816-17-ku8n22.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Language matters.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/pregnant-african-american-woman-doing-morning-1842709132">Prostock-studio/Shutterstock</a></span>
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</figure>
<p>Language which infantalises pregnant women, such as “good girl” or “you are allowed/not allowed to” should also be avoided, as should language which has connotations of blame. Examples of this include “poor maternal effort” and “refused”. </p>
<p>During pregnancy and birth, which is a vulnerable time for many, the role of the midwife is to empower women and to value their autonomy over their care decisions. </p>
<p>The Nursing and Midwifery Council’s <a href="https://www.nmc.org.uk/globalassets/sitedocuments/standards/standards-of-proficiency-for-midwives.pdf">standards of proficiency for midwives</a> document states that midwives provide universal care for all women and new-born infants. Midwives support physical, psychological, social, cultural and spiritual safety. The emphasis on psychological care is clear, therefore, with language having a profound impact on wellbeing.</p>
<p>Healthcare professionals must acknowledge that the language we use is an important part of the care we provide. Improved psychological safety and wellbeing is closely linked to improved safety, positive outcomes and future experiences. Language matters.</p><img src="https://counter.theconversation.com/content/207753/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sarah Aubrey does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Several familiar maternity terms have been abandoned after a consultation with pregnant women and healthcare professionals.Sarah Aubrey, Lead Midwife for Education, University of South WalesLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2114802023-08-17T00:03:10Z2023-08-17T00:03:10ZMaking the most out of boreal plant resources<figure><img src="https://images.theconversation.com/files/542409/original/file-20230809-27838-bwvns3.jpg?ixlib=rb-1.1.0&rect=1%2C3%2C1010%2C679&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Narrow-leaved kalmia is an invasive plant typical of boreal ecosystems. Its proliferation can hinder the reforestation of areas subject to disturbances.</span> <span class="attribution"><a class="source" href="https://www.inaturalist.org/observations/28905420">(Jacques Ibarzabal/iNaturalist)</a></span></figcaption></figure><p>Plants produce molecules to interact with their environment and protect themselves against external threats. These molecules can also have antioxidant, anti-inflammatory and antibacterial properties, some of which are beneficial to human health. These properties are valued by traditional medicines and inspire the development of medicinal products by contemporary chemists. </p>
<p>The majority of medications on the market are <a href="https://www.nature.com/articles/nchem.2479">or are derived from natural products</a>. Among others, several classes of antibiotics used to combat bacterial infections are based on the chemical structure of natural products.</p>
<p>For example, erythromycin A is a natural antibiotic produced by a micro-organism. It is used to combat various bacterial infections. Another antibiotic, clarithromycin, is made by changing the structure of erythromycin A. </p>
<p>Derived from living organisms, biobased products also have applications in a wide range of fields, including <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/ics.12564">cosmetics</a>, food supplements, crop protection products and <a href="https://pubs.acs.org/doi/full/10.1021/acs.jafc.2c06938">animal feed</a>. </p>
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<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/524152/original/file-20230503-20-rp105s.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/524152/original/file-20230503-20-rp105s.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/524152/original/file-20230503-20-rp105s.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/524152/original/file-20230503-20-rp105s.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/524152/original/file-20230503-20-rp105s.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/524152/original/file-20230503-20-rp105s.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/524152/original/file-20230503-20-rp105s.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<p><strong>This article is part of <em>La Conversation Canada’s</em> series <a href="https://theconversation.com/ca-fr/topics/foret-boreale-138017">The boreal forest: A thousand secrets, a thousand dangers</a></strong></p>
<p><br><em>La Conversation Canada invites you to take a virtual walk in the heart of the boreal forest. In this series, our experts focus on management and sustainable development issues, natural disturbances, the ecology of terrestrial wildlife and aquatic ecosystems, northern agriculture and the cultural and economic importance of the boreal forest for Indigenous peoples. We hope you have a pleasant — and informative — walk through the forest!</em></p>
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<p>Our research group at the LASEVE laboratory at the Université du Québec à Chicoutimi is interested in the use of natural products derived from elements in the boreal forest. The choice of species studied is based in part on the traditional uses of plants by Indigenous communities. </p>
<h2>Discovering fascinating molecules</h2>
<p>Molecules of interest are often extracted by macerating plants in various solvents (water, ethanol, glycerine). Biological tests are used to quickly assess the benefits of the extracts. An example would be to measure the antibiotic power of natural products by treating bacteria grown in the laboratory. </p>
<p>Biological tests also make it easier to select and isolate the molecules with the most interesting properties; this is known as “bioguided fractionation.”</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/542407/original/file-20230811-15-wiokuj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="schéma" src="https://images.theconversation.com/files/542407/original/file-20230811-15-wiokuj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/542407/original/file-20230811-15-wiokuj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=169&fit=crop&dpr=1 600w, https://images.theconversation.com/files/542407/original/file-20230811-15-wiokuj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=169&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/542407/original/file-20230811-15-wiokuj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=169&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/542407/original/file-20230811-15-wiokuj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=212&fit=crop&dpr=1 754w, https://images.theconversation.com/files/542407/original/file-20230811-15-wiokuj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=212&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/542407/original/file-20230811-15-wiokuj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=212&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Schematic diagram of the approach to discovering new bioactive substances from forest biomass.</span>
<span class="attribution"><span class="source">(Jérôme Alsarraf)</span>, <span class="license">Fourni par l'auteur</span></span>
</figcaption>
</figure>
<h2>Balsam poplar as an antibacterial agent</h2>
<p>Methicillin-resistant Staphylococcus Aureus (MRSA) is one of the six bacteria causing the majority of antibiotic resistance-related deaths worldwide. Bacterial resistance to antibiotics <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)02724-0/fulltext">compromises our ability to fight bacterial infections</a>. In this context, the discovery of new classes of antibacterial agents is becoming a public health issue. </p>
<p>More specifically, we identified a family of antibacterial molecules extracted from <a href="https://www.sciencedirect.com/science/article/pii/S0040403912021338">balsam poplar (<em>Populus balsamifera</em>) buds</a>. These original compounds, known as balsacones, are active against MRSA. What’s more, unlike <a href="https://www.frontiersin.org/articles/10.3389/fmicb.2019.02341/full">other antibiotics</a>, their use does not appear to induce resistance in the bacteria treated. </p>
<p>However, the yields from isolating balsacones from balsam poplar buds are low. In other words, for one kilogram of plant, we only manage to obtain around ten milligrams of molecules — quantities that are far too small to study the properties of these molecules in detail. </p>
<p>Nevertheless, balsacones remain promising products in the fight against bacterial resistance.</p>
<h2>A greener production</h2>
<p>Molecules of interest are usually obtained by synthesis. In other words, they are derived from the successive assembly of different ‘building blocks’ to produce the desired molecule. Conventional approaches use simple building blocks from the petroleum industry. These methods are tedious and require several stages of synthesis, all of which are based on the use of harmful and non-renewable raw materials. </p>
<p>The coming scarcity of fossil fuels, combined with the environmental issues surrounding petrochemicals, call for the <a href="https://pubs.rsc.org/en/content/articlelanding/2006/gc/b604483m">development of more sustainable alternatives</a>. One strategy for overcoming these limitations is to use natural products as ‘building blocks’ for the synthesis of high value-added molecules. These building blocks are an ideal replacement for petroleum-based products. </p>
<p>This approach, known as xylochemistry when the ‘building blocks’ <a href="https://pubs.rsc.org/en/content/articlelanding/2020/gc/d0gc01484b">come from wood</a>, avoids the use of non-renewable raw materials. The idea behind this method is to simplify the synthesis sequence by using biosourced molecules. What’s more, the variety of natural precursors available means that the products available can be diversified and new derivatives discovered. </p>
<p>Based on this principle, we have synthesized several balsacones in a single synthesis step, <a href="https://pubs.acs.org/doi/abs/10.1021/acssuschemeng.0c01545">by combining two biosourced molecules</a>. </p>
<p>The procedure is based on several principles of <a href="https://pubs.rsc.org/en/content/articlelanding/2010/CS/B918763B">so-called “green chemistry.”</a> It has also made it possible to produce novel molecules related to balsacones in order to gain a better understanding of the structural parameters that give balsacones their <a href="https://www.mdpi.com/2079-6382/10/6/620">antibacterial properties</a>. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/542404/original/file-20230811-4652-8jnelf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="schema" src="https://images.theconversation.com/files/542404/original/file-20230811-4652-8jnelf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/542404/original/file-20230811-4652-8jnelf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=169&fit=crop&dpr=1 600w, https://images.theconversation.com/files/542404/original/file-20230811-4652-8jnelf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=169&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/542404/original/file-20230811-4652-8jnelf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=169&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/542404/original/file-20230811-4652-8jnelf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=212&fit=crop&dpr=1 754w, https://images.theconversation.com/files/542404/original/file-20230811-4652-8jnelf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=212&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/542404/original/file-20230811-4652-8jnelf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=212&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Principle of the xylochemical synthesis approach (right) compared with the classical synthesis approach (left).</span>
<span class="attribution"><span class="source">(Jérôme Alsarraf)</span>, <span class="license">Fourni par l'auteur</span></span>
</figcaption>
</figure>
<h2>Valuing the treasures of the boreal forest</h2>
<p>Every year, the Québec forest industry produces more than 1.7 million tons of bark. </p>
<p>Little use is made of these residues, despite their high content of molecules with interesting properties. </p>
<p>Our laboratory is working to develop methods to add value to these by-products of forestry by identifying the molecules they contain and characterizing their biological properties. </p>
<p>We are also interested in other plant species that originate in the boreal forest and are indirectly involved in its management. For example, narrow-leaved kalmia (<em>Kalmia angustifolia</em>) is an invasive plant typical of boreal ecosystems. Its proliferation can hinder the reforestation of areas subject to disturbances such as insect pest epidemics or fires, the frequency and severity of which are <a href="https://cdnsciencepub.com/doi/10.1139/cjfr-2019-0094">likely to increase in the current context of climate change</a>. </p>
<p>Our team’s research has shown that this species contains a molecule that can be used to produce balsacone A, a compound with antibacterial properties. </p>
<p>By harvesting narrow-leaved kalmia, our approaches to extracting and processing biomolecules could increase the added value of this biomass, as part of a circular economy approach. </p>
<p>For example, plant extracts from the boreal forest can lead to the discovery of new substances that can help address global public health issues. </p>
<p>Using natural molecules as building blocks to prepare more complex derivatives also makes it possible to generate high added-value products in a more environmentally-friendly way. </p>
<p>In this context, the study of natural products will make a major contribution to sustainable development and forest productivity.</p><img src="https://counter.theconversation.com/content/211480/count.gif" alt="La Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jérôme Alsarraf is a member of the Centre de recherche sur la boréalie (CREB), has received funding from the Natural Sciences and Engineering Research Council of Canada (NSERC) and the Mathematics of Information Technology and Complex Systems (MITACS).</span></em></p><p class="fine-print"><em><span>André Pichette is a member of the Ordre des chimistes du Québec (OCQ), has received funding from Fonds de recherche du Québec – Santé (FRQS), Natural Sciences and Engineering Research Council of Canada (NSERC) – Alliance, Mathematics of Information Technology and Complex Systems (MITACS) and the Canadian Institutes of Health Research (CIHR).</span></em></p><p class="fine-print"><em><span>Jean Legault is a member of the Order of Chemists of Quebec. He has received funding from FQRNT, FRQS, NSERC and MITACS.</span></em></p>Boreal plants produce molecules that are valued by traditional medicines and inspire the development of medicinal products by contemporary chemists.Jérôme Alsarraf, Professeur de Chimie, Université du Québec à Chicoutimi (UQAC)Andre Pichette, Professeur en chimie des produits naturels, Université du Québec à Chicoutimi (UQAC)Jean Legault, Professeur-chercheur en biochimie et pharmacologie, Université du Québec à Chicoutimi (UQAC)Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2114552023-08-16T14:52:16Z2023-08-16T14:52:16ZMore than half of life on Earth is found in soil – here’s why that’s important<figure><img src="https://images.theconversation.com/files/542806/original/file-20230815-17-8wyoa2.jpeg?ixlib=rb-1.1.0&rect=93%2C67%2C1501%2C831&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Springtails (Fasciosminthurus quinquefasciatus) are found in any damp soil.</span> <span class="attribution"><a class="source" href="https://www.chaosofdelight.org/gallery/5kispkk47gfjazdxskbw7m04mgvga3">Andy Murray/chaosofdelight.org</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span></figcaption></figure><p>A <a href="https://www.pnas.org/doi/abs/10.1073/pnas.2304663120">recent study</a> has found that soil is home to 59% of all life on Earth, from an insect feeding on the soil surface to a tiny microbe nestled in a soil pore. This discovery crowns soil as the most biodiverse habitat on the planet.</p>
<p>The paper estimates that around 2 million species of <a href="https://www.britannica.com/animal/arthropod">arthropod</a> (think insects and spiders) inhabit the soil – some 30% of all known arthropod species. There are far fewer species of soil specialists such as <a href="https://www.sciencedirect.com/topics/agricultural-and-biological-sciences/enchytraeidae"><em>enchytraeidae</em></a> (resembling mini earthworms) and <a href="https://www.britannica.com/animal/oligochaete"><em>oligochaeta</em></a> (worms), with only 770 and 6,000 species respectively. That might not seem like a lot, but it still represents around 98% and 63% of these animal groups.</p>
<p>The variety of mammals living in soil is, by comparison, quite limited. Only 3.8% of mammal species are associated with this habitat. On the other hand, 85% of plants have their roots buried in the soil and around 43% of <a href="https://www.britannica.com/animal/nematode"><em>nematode</em></a> (tiny worms) species call soil their home, or reside within the plants and animals that inhabit it.</p>
<p>However, the number of animal and plant species that live in soil are dwarfed by microscopic organisms. The researchers estimate that a mind-blowing 430 million species (or more than 50%) of bacteria and 5.6 million species (or 90%) of fungi have made soil their home.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/the-melting-arctic-is-a-crime-scene-the-microbes-i-study-have-long-warned-us-of-this-catastrophe-but-they-are-also-driving-it-207785">The melting Arctic is a crime scene. The microbes I study have long warned us of this catastrophe – but they are also driving it</a>
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<p>But perhaps more important than the raw numbers are the functions that this biodiversity performs. The life within the soil not only helps to produce the food we eat, it also plays a crucial role in holding the soil together and even gives us potential sources for new antibiotics and medicines.</p>
<h2>Helping plants grow</h2>
<p>Small animals, including <a href="https://www.britannica.com/animal/earthworm">earthworms</a> and <a href="https://www.britannica.com/animal/springtail">springtails</a>, break down plant material and other forms of organic matter, such as dead insects, and incorporate them into the soil. This process releases the nutrients that most plants rely on to grow. But it’s not the only way that soil organisms <a href="https://theconversation.com/tapping-the-plant-microbiome-to-improve-farming-and-plant-health-36288">help plants gain more nutrition</a>. </p>
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<figcaption><span class="caption">How soil organisms break down plant remains and create soil pores.</span></figcaption>
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<p><a href="https://www.rhs.org.uk/biodiversity/mycorrhizal-fungi"><em>Mycorrhizal</em> fungi</a> (a species of fungi that grow in association with plant roots), for instance, embed themselves in the roots of plants where they extract energy-rich compounds. In return, the fungi help plants expand their reach in the soil, allowing them to access a greater amount of nutrients.</p>
<p>Other species that are vital for food production include <a href="https://www.britannica.com/science/nitrogen-fixing-bacteria">nitrogen-fixing bacteria</a>. They are commonly associated with legumes such as beans and clover. These bacteria convert nitrogen gas from the atmosphere into compounds that the plants can use – an undertaking that can otherwise only be done synthetically, using vast amounts of energy.</p>
<h2>Holding soil together</h2>
<p>As organisms penetrate the soil, whether by burrowing, creating nests or as a means of anchoring themselves, they engineer pathways through the soil and contribute to its structure. Notable examples include <a href="https://www.britannica.com/animal/termite">termites</a> rearranging the soil to create channels for air and water to filter through, as well as <a href="https://doi.org/10.1093/aob/mcab029">roots and root hairs enmeshing soil</a>.</p>
<p>The incorporation of decomposed plant material into the soil serves a similarly crucial purpose. It helps to hold the soil together and creates pores that protect the soil from erosion and increase its capacity to store water.</p>
<p>Some of this organic material is also locked away with soil minerals, leading to the <a href="https://theconversation.com/france-has-a-great-plan-for-its-soil-and-its-not-just-about-wine-47335">storage of carbon</a>. In fact, <a href="https://www.ipcc.ch/site/assets/uploads/2018/03/WGI_TAR_full_report.pdf">soils hold</a> three times as much carbon as vegetation and twice as much as the atmosphere. </p>
<figure class="align-center ">
<img alt="A termite mound on the Savanna." src="https://images.theconversation.com/files/542774/original/file-20230815-19-a37hww.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/542774/original/file-20230815-19-a37hww.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=434&fit=crop&dpr=1 600w, https://images.theconversation.com/files/542774/original/file-20230815-19-a37hww.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=434&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/542774/original/file-20230815-19-a37hww.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=434&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/542774/original/file-20230815-19-a37hww.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=546&fit=crop&dpr=1 754w, https://images.theconversation.com/files/542774/original/file-20230815-19-a37hww.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=546&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/542774/original/file-20230815-19-a37hww.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=546&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Termites create structures above and below ground for air and water to move through.</span>
<span class="attribution"><span class="source">John Quinton</span>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
</figcaption>
</figure>
<h2>Biodiversity increases resilience</h2>
<p>In many cases, these functions involve a variety of species. Having multiple species perform the same function offers a safety net if conditions change, such as during a drought or a flood. </p>
<p>Some species are more resilient to these events than others. When conditions change, unaffected organisms within the soil can step in to fulfil the same functions as those that might have suffered – a process ecologists call “functional redundancy”. This improves the ability of an ecosystem, such as soil, to withstand and recover from environmental shocks. </p>
<p>Soil biodiversity is also a key reservoir for new drugs. Soil bacteria have produced <a href="https://doi.org/10.1016/j.cub.2009.04.001">most of our antibiotics</a>, including streptomycin, chloramphenicol and tetracycline. Unfortunately, the rise of antibiotic resistance has rendered many early antibiotics ineffective. However, searching through different soils is <a href="https://www.nature.com/articles/d41586-018-01931-4">yielding promising new antibiotics</a> with the potential to kill “superbugs” that are resistant to existing drugs.</p>
<figure class="align-center ">
<img alt="A soil animal eating mould." src="https://images.theconversation.com/files/542612/original/file-20230814-25671-a5b8tl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/542612/original/file-20230814-25671-a5b8tl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/542612/original/file-20230814-25671-a5b8tl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/542612/original/file-20230814-25671-a5b8tl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/542612/original/file-20230814-25671-a5b8tl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/542612/original/file-20230814-25671-a5b8tl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/542612/original/file-20230814-25671-a5b8tl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A peeudachorutes species eating a slime mould.</span>
<span class="attribution"><a class="source" href="https://www.chaosofdelight.org/gallery/m5bftdf81d97p7ib5tgiais5dymfb8">Andy Murray/ChaosofDelight.org</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
</figcaption>
</figure>
<p>Soil biodiversity plays an important role in producing the food we eat, sustaining soil health and helping to deliver a range of other services, from sourcing medicines to reducing the impact of floods and droughts. The importance of protecting our soils for future generations becomes ever clearer.</p>
<hr>
<figure class="align-right ">
<img alt="Imagine weekly climate newsletter" src="https://images.theconversation.com/files/434988/original/file-20211201-21-13avx6y.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/434988/original/file-20211201-21-13avx6y.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/434988/original/file-20211201-21-13avx6y.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/434988/original/file-20211201-21-13avx6y.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/434988/original/file-20211201-21-13avx6y.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/434988/original/file-20211201-21-13avx6y.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/434988/original/file-20211201-21-13avx6y.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
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<p class="fine-print"><em><span>John Quinton receives research funding from the Natural Environment Research Council, The Engineering and Physical Sciences Research Council and the European Commission</span></em></p>With more than one species for every person on the planet, soils are the most diverse habitat on Earth.John Quinton, Professor of Soil Science, Lancaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2101452023-08-13T09:13:13Z2023-08-13T09:13:13ZGhana’s national health insurance users often end up paying as much as those who don’t belong. So why join?<figure><img src="https://images.theconversation.com/files/540973/original/file-20230803-21-w7isdv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Ghana's national healthcare system is designed for all. But there are pitfalls. </span> <span class="attribution"><span class="source">Getty Images </span></span></figcaption></figure><p>Health financing is a challenge any country has to deal with to provide good healthcare services. It’s especially important for developing countries such as Ghana, where ability to pay is a hindrance to accessing all the healthcare services that people might need. </p>
<p>The “cash and carry” system, where sick people have to pay out of pocket to obtain care, has obvious adverse implications. People who can’t pay won’t be attended to. This could lead to irreversible consequences – even death. </p>
<p>Health insurance has come up as a means to provide subscribers with at least basic healthcare even if they are unable to pay. </p>
<p>Ghana’s public health insurance programme, the <a href="https://www.nhis.gov.gh/">National Health Insurance Scheme</a>, was introduced in 2004. In principle it is mandatory, but in practice it is voluntary. </p>
<p>The active enrolment rate of the public health insurance scheme – the proportion of the population covered – rose to its highest in 2015, when it was 41%. At the end of <a href="https://www.nhis.gov.gh/files/2018%20Annual%20Report.pdf">2018 </a> it stood at 36%. </p>
<p>(The National Health Insurance Scheme estimated the enrolment rate at end of year <a href="https://www.nhis.gov.gh/News/nhia-clarifies-issues-raised-by-the-ranking-member-on-the-parliamentary-select-committee-on-health-5391">2021 </a>at approximately 54%.) </p>
<p>Clearly, many people are not covered under the National Health Insurance Scheme. The low uptake is an impediment to achieving universal health coverage. But the question is why a social protection programme of this nature has relatively low coverage rates.</p>
<p>The scheme is designed to offer poor households exemptions from annual premium payments. Therefore, the ability to pay insurance premiums shouldn’t be a contributing factor to the low coverage rates. </p>
<p>Private health insurance programmes are not widespread in Ghana either. The <a href="https://www.statsghana.gov.gh/gssmain/fileUpload/pressrelease/GLSS7%20MAIN%20REPORT_FINAL.pdf">Ghana Living Standards Survey 7</a> conducted by the <a href="https://statsghana.gov.gh/">Ghana Statistical Services</a> in 2017 revealed that only 0.36% of the nearly 60,000 respondents had ever enrolled in a private health insurance programme. </p>
<p>One motivation for subscribing to the National Health Insurance Scheme would be if non-subscribers made higher out-of-pocket payments for healthcare than subscribers. If scheme members paid little or nothing and non-members paid more, then non-members might be motivated to enrol on the scheme. </p>
<p>But this is not often the case. The <a href="https://www.statsghana.gov.gh/gssmain/fileUpload/pressrelease/GLSS7%20MAIN%20REPORT_FINAL.pd">2017 survey</a> revealed that health insurance paid out only 16.7% of the medical expenses of the ill or injured across the country. </p>
<p>Contrary to expectation, our <a href="https://link.springer.com/article/10.1007/s11150-022-09621-x">research</a> found that Ghana’s national health insurance did not reduce out-of-pocket payments for those who had subscribed. Thus, the scheme may not be achieving its objective of eliminating the cash and carry system. </p>
<h2>Why enrolment doesn’t pay</h2>
<p>The National Health Insurance Scheme in Ghana has historically been bedevilled by several challenges in practice. Previous <a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-016-1758-y">research</a> has reported that it is not uncommon for health facilities to charge both formal and informal fees even to insured clients. </p>
<p>Health facilities prefer to attend to patients who pay for treatment in cash rather than those who rely on their national health insurance policy to pay. That’s because they must complete tedious paperwork and wait for a long time before the scheme reimburses them. </p>
<p>This forces patients wanting more timely and better quality of care to make these payments – overt or otherwise – sometimes completely forgoing the use of their national health insurance policies. </p>
<p>The medicines which the scheme covers run out quickly or are unavailable. So patients, insured or not, end up having to buy medicines themselves either from the health facility they visit or from private retail pharmacies. </p>
<h2>Some positive news</h2>
<p>There were some positive findings from our research, however. We found that very poor households were more likely to enrol in health insurance than other households. This is perhaps because they are exempt from paying insurance premiums. </p>
<p>This suggests that the national scheme is achieving one of its objectives: increasing access to healthcare for the poor. </p>
<p>Although the scheme does not lower health expenditures for members, it might enable them to receive a greater “quantity” of healthcare, since at least some of their health expenses are likely to be covered by insurance.</p>
<h2>What should be done?</h2>
<p>If provider facilities did not discriminate against patients on the basis of who was willing to make a cash payment, and enrolled members did not have to buy the medicines they needed, people would be confident in using their insurance policies and might spend less out of pocket. </p>
<p>That might rake in more scheme members, which would increase the financial base of the scheme to keep it running effectively.</p><img src="https://counter.theconversation.com/content/210145/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kwame Adjei-Mantey does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Ghana’s public health insurance scheme was designed to provide basic care for all. But in reality those who would rather pay upfront than enrol get better treatment.Kwame Adjei-Mantey, Economist and Lecturer, University of Environment and Sustainable Development, Ghana; Research Fellow, Future Africa Institute, University of Pretoria, University of PretoriaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2112312023-08-10T13:58:23Z2023-08-10T13:58:23ZLion farming in South Africa: fresh evidence adds weight to fears of link with illegal bone trade<figure><img src="https://images.theconversation.com/files/541988/original/file-20230809-29-vnsu56.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">GettyImages</span> </figcaption></figure><p>In South Africa an estimated <a href="https://www.conservationaction.co.za/answer-to-south-african-parlimentary-question-noting-there-are-approximately-7979-lions-in-captivity-in-366-facilities/">8,000 lions</a> are bred and kept in captivity for commercial purposes in more than 350 facilities. This is far more than the country’s wild population, estimated at <a href="https://h8l0bb.p3cdn1.secureserver.net/wp-content/uploads/2022/11/31.-African-Lion-Panthera-leo_LC.pdf">3,500 individuals</a>.</p>
<p>These big cats are exploited in a variety of different ways including interactive cub “petting” tourism, <a href="https://www.cambridge.org/core/journals/african-studies-review/article/abs/moving-targets-the-canned-hunting-of-captivebred-lions-in-south-africa/929CD0F7D4825D9DB6CD52DEEE1B9B27">“canned” trophy hunting</a> (where the lions are hunted in small enclosures with no chance of escape), <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0217409">live exports</a>, and the supply of body parts for use in <a href="https://www.frontiersin.org/articles/10.3389/fevo.2022.906398/full">traditional</a> <a href="https://www.sciencedirect.com/science/article/pii/S1617138120301205?via%3Dihub">medicine</a>. </p>
<p>Despite <a href="https://theconversation.com/lions-are-still-being-farmed-in-south-africa-for-hunters-and-tourism-they-shouldnt-be-208584">ongoing controversy</a> surrounding this industry – in particular related to reports of <a href="https://www.nationalgeographic.com/animals/article/lion-farm-south-africa">animal cruelty</a> and risks to <a href="https://www.mdpi.com/2076-2615/10/9/1692">public health</a> – the commercial captive breeding and canned hunting of lions in South Africa is <a href="https://theconversation.com/lions-are-still-being-farmed-in-south-africa-for-hunters-and-tourism-they-shouldnt-be-208584">still legal</a>. </p>
<p>By contrast, the export of lion bones, claws, skulls, and teeth originating from lion farms is currently illegal. This follows a <a href="http://www.saflii.org/za/cases/ZAGPPHC/2019/337.html">high court declaration</a> in 2019 in which the lion bone export quota was declared unconstitutional. Subsequently, no official
<a href="https://speciesplus.net/species#/taxon_concepts/6353/legal">CITES export quotas</a> for lion skeletons have been set.</p>
<p>We are wildlife researchers who have been focused on various aspects of South Africa’s commercial captive lion industry including its <a href="https://www.cambridge.org/core/journals/animal-welfare/article/welfare-concerns-associated-with-captive-lions-panthera-leo-and-the-implications-for-commercial-lion-farms-in-south-africa/BDD074F3A15EB226827F1BCE78AEE8ED">potential impacts</a>, how it is <a href="https://natureconservation.pensoft.net/article/85292/">being regulated</a>, and what may be influencing <a href="https://www.sciencedirect.com/science/article/pii/S0006320719313448">consumer demand</a>. </p>
<p>We also work with <a href="https://www.worldanimalprotection.org/">World Animal Protection</a>, an animal protection organisation, that has released a <a href="https://www.worldanimalprotection.org/sites/default/files/media/SALions-Report23.pdf">new report</a> on the industry, which we contributed to. The report adds credence to <a href="https://www.nationalgeographic.com/animals/article/who-buys-lion-bones-inside-south-africas-skeleton-trade">pre-existing</a> <a href="https://www.wildcru.org/wp-content/uploads/2015/07/Bones_of_contention.pdf">concerns</a> <a href="https://mg.co.za/article/2019-08-06-nspca-wins-lion-bone-trade-case-against-department/">about</a> <a href="https://www.occrp.org/en/investigations/inside-south-africas-brutal-lion-bone-trade">how</a> some of these types of facilities operate. </p>
<p>Specifically, that some are using legal activities – like captive breeding and canned hunting – to fuel (and potentially cover) their involvement in the illegal international big cat bone trade. Lion bones are sought after for use in <a href="https://www.frontiersin.org/articles/10.3389/fevo.2022.906398/full">traditional</a> <a href="https://www.sciencedirect.com/science/article/pii/S1617138120301205?via%3Dihub">medicine</a>. </p>
<p>This finding adds more weight to <a href="https://cites.org/sites/default/files/eng/com/ac/30/Inf/E-AC30-Inf-15x.pdf">various</a> <a href="https://www.occrp.org/en/investigations/inside-south-africas-brutal-lion-bone-trade">reports</a> about the <a href="https://www.wildcru.org/wp-content/uploads/2015/07/Bones_of_contention.pdf">illegal</a> <a href="https://www.nationalgeographic.com/animals/article/who-buys-lion-bones-inside-south-africas-skeleton-trade">trade in lion</a> bones over the years.</p>
<h2>A nexus of legal and illegal trade</h2>
<p>Many of South Africa’s captive lion facilities are open to the public who pay to see and have direct contact with the big cats. However, others are situated in remote locations and operate ‘off grid’. They are closed to the public.</p>
<p>As part of our ongoing research into this industry, in late 2022, we received disturbing intelligence from anonymous sources employed by some of these ‘off grid’ lion farms. This information formed the basis of the new World Animal Protection <a href="https://www.worldanimalprotection.org/sites/default/files/media/SALions-Report23.pdf">report</a>.</p>
<p>When dealing with issues involving wildlife and illegality, researchers often rely on sources whose identity must be kept hidden for their own protection. Recent studies carried out in this way include those focused on the illegal <a href="https://www.nationalgeographic.com/animals/article/wildlife-watch-news-jaguar-poaching-trafficking-suriname?loggedin=true&rnd=1691567470159">killing</a>, <a href="https://crimesciencejournal.biomedcentral.com/articles/10.1186/s40163-019-0101-4">processing</a>, and <a href="https://www.cambridge.org/core/journals/oryx/article/going-over-the-wall-insights-into-the-illegal-production-of-jaguar-products-in-a-bolivian-prison/14883C21875144A43E5AF6DFCEC72A02">trade</a> of jaguar parts in South America. </p>
<p>The South African sources told us about the involvement of captive lion facilities in the international big cat bone trade. Essentially, there’s a well-established and effective legal operation which is plugged into an illicit trade network.</p>
<p>Whereas after a canned trophy hunt the skin, paws, and skull of lions are prized trophies by hunters, the lion’s bones are coveted by illegal wildlife traffickers.</p>
<p>In some cases, entire carcasses are left intact and are packed into cardboard boxes ready for shipment and for Asian bone buyers to collect. The reason this is done is to certify authenticity (that it is a lion carcass) and ensure tracking devices have not been inserted into the bones. </p>
<p>Sources also described how these facilities use various tools and tactics, such as security cameras, patrols and messaging apps to avoid detection during inspections. </p>
<h2>A way forward</h2>
<p>The fact that the commercial captive lion bone trade in South Africa is juxtaposed within a network of dealers that operate both legally and illegally is nothing new. In fact, illegal and unethical activities associated with the industry were a contributing factor which led a team of relevant experts (including traditional leaders, lion farmers and scientists) <a href="https://www.dffe.gov.za/sites/default/files/reports/2020-12-22_high-levelpanel_report.pdf">to conclude in a report released in 2020 that</a> it was “tarnishing the country’s reputation with political and economic risks”.</p>
<p>Consequently, the South African Government <a href="https://www.dffe.gov.za/speeches/creecy_releaseofhlpreport_pretoria?fbclid=IwAR071TG1zwa1IX5kpFLvubD6NEhQfmculxdT6rYLBdh-TVPpY6jQn7RHKhU">announced its intention</a>, with cabinet’s approval, to immediately halt the “domestication and exploitation of lions, and to ultimately close all captive lion facilities in South Africa”. But nothing has changed so far. The captive breeding and canned hunting of lions has continued.</p>
<p>Moreover, in late 2022, a <a href="https://www.gov.za/speeches/minister-barbara-creecy-appoints-ministerial-task-team-identify-and-recommend-voluntary">ministerial task team</a> was asked to “develop and implement a voluntary exit strategy and pathways for captive lion facilities”. This raised serious questions about whether the government was wavering in its stated intention to shut down the commercial captive lion breeding.</p>
<p>But given the intertwined legal and illegal aspects of this industry, it is highly doubtful whether a voluntary phasing out of the industry will be enough to stop the commercial exploitation of lions in South Africa.</p>
<p>Instead, there should be a strategy which includes a <a href="https://www.mdpi.com/2076-2615/11/6/1717">mandatory time bound termination</a> of the lion farming industry in its entirety.</p>
<p>In the interim, to help enforcement agencies manage and ensure facilities comply with the law during an effective phase out, the industry needs to be fully audited, with all facilities officially registered.</p>
<p>To help prevent legal trade being used as a cover for illegal trade, farms should be required to stop breeding more lions. In addition, proper plans must be put in place to prevent the stockpiling of lion bones.</p>
<hr>
<figure class="align-right ">
<img alt="Imagine weekly climate newsletter" src="https://images.theconversation.com/files/434988/original/file-20211201-21-13avx6y.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/434988/original/file-20211201-21-13avx6y.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/434988/original/file-20211201-21-13avx6y.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/434988/original/file-20211201-21-13avx6y.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/434988/original/file-20211201-21-13avx6y.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/434988/original/file-20211201-21-13avx6y.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/434988/original/file-20211201-21-13avx6y.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<p class="fine-print"><em><span>Neil D’Cruze works for an international NGO, World Animal Protection as the Global Head of Wildlife Research.</span></em></p><p class="fine-print"><em><span>Angie Elwin works for an international NGO, World Animal Protection as a Wildlife Research Manager.</span></em></p>South Africa’s legal commercial lion industry is helping to act as a cover for the illegal international big cat bone trade.Neil D’Cruze, Global Head of Wildlife Research, World Animal Protection, and Visiting Researcher, Wildlife Conservation Research Unit (WildCRU), University of OxfordAngie Elwin, Wildlife Research Manager at World Animal Protection and Visiting Research Fellow, Manchester Metropolitan UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2102642023-08-07T13:59:43Z2023-08-07T13:59:43ZSickle cell disease is rife in west Africa - a fresh approach is needed to combat it<figure><img src="https://images.theconversation.com/files/540050/original/file-20230730-118174-i20d5f.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Sub-Saharan Africa is the region with the highest prevalence of sickle cell disease</span> <span class="attribution"><span class="source">Wikimedia Commons</span></span></figcaption></figure><p><a href="https://www.nhlbi.nih.gov/health/sickle-cell-disease">Sickle cell disease</a> refers to a group of inherited blood disorders with symptoms like anaemia and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7028373/">blocked blood vessels</a>. About <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10239624/#:%7E:text=About%2080%25%20of%20sickle%20cell,from%2050%25%20to%2080%25.&text=The%20high%20burden%20of%20the,comprehensive%20healthcare%20in%20the%20region.">80%</a> of the world’s sickle cell disease cases occur in sub-Saharan Africa. Lack of access to comprehensive healthcare in the region adds to the burden of the disease.</p>
<p>Nigeria has the <a href="https://www.tandfonline.com/doi/full/10.2147/JBM.S406196">largest population</a> of individuals with the condition globally. <a href="https://www.tandfonline.com/doi/full/10.2147/JBM.S406196">Reports</a> indicate that about 25% of Nigerians carry the gene that causes it and 2% to 3% of the population suffer from sickle cell disease. </p>
<p>The <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10239624/#:%7E:text=About%2080%25%20of%20sickle%20cell,from%2050%25%20to%2080%25.&text=The%20high%20burden%20of%20the,comprehensive%20healthcare%20in%20the%20region.">mortality rate</a> for children ranges from 50% to 80%. Clinical presentations vary among sickle cell patients. Some include leg ulcers, fatigue, dizziness and end organ damage. </p>
<p>My team <a href="https://www.niprd.gov.ng/dr-obi-adigwe-biography/">and I</a> at Nigeria’s <a href="https://www.niprd.gov.ng/">National Institute for Pharmaceutical Research and Development</a> undertook a <a href="https://www.tandfonline.com/doi/full/10.2147/JBM.S406196">critical review</a> to investigate the challenges associated with sickle cell disease in sub-Saharan Africa. </p>
<p>We urge governments and relevant stakeholders in this region to prioritise policies that can underpin effective management of the disease. We recommend implementing relevant strategies that will reduce the burden whilst targeting total elimination. These include counselling about how genetic conditions might affect a family. We propose premarital genotype screening and comprehensive health insurance coverage for all sickle cell disease patients. </p>
<h2>Gaps in the management of sickle cell disease</h2>
<p>Our <a href="https://www.tandfonline.com/doi/full/10.2147/JBM.S406196">review</a> focused on publications in English language journals between 2003 and 2021. The review provided insight on relevant medical interventions and helped to identify prospects for overcoming the burden of sickle cell disease.</p>
<p>We found that most of the studies in this area were undertaken in the West African region. </p>
<p>Some centred on hydroxyurea in the management of the condition. This drug treats anaemia by helping to prevent the formation of sickle-shaped red blood cells. It has <a href="https://pubmed.ncbi.nlm.nih.gov/12542474/">contributed</a> towards reducing the burden of the disease globally. Furthermore, it was observed that the drug has robust efficacy and safety in the treatment of children with sickle cell anaemia.</p>
<p>Niprisan has also <a href="https://www.sciencedirect.com/science/article/abs/pii/S0011393X01800394">proven </a> to be effective in the management of sickle cell disease. This intervention is classified as a phytomedicine, which refers to medicines derived from plants in their original state. Developed by Nigeria’s National Institute for Pharmaceutical Research and Development, it contributed towards reducing the number of hospital admissions among patients. </p>
<p>A review of 55 publications found that access to comprehensive management of sickle cell disease was lacking. Specific interventions such as neonatal screening, early diagnosis and preventive penicillin therapy (an important part of infection prevention in sickle cell disease) were not readily available in countries like Nigeria and the Democratic Republic of Congo.</p>
<p>A lack of adequate knowledge about sickle cell disease in countries like Nigeria, DR Congo, Cameroon and Nigeria contributed to the high prevalence of the condition. A more informed populace will reduce the disease burden. Similarly, poor prioritisation of premarital genetic counselling and screening severely limited its utility in the prevention of the condition. In countries like Cyprus, Greece and Italy, premarital genetic testing is <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8554897/">standard practice</a>. However, in most of the reviewed countries, most couples were not aware of genetic counselling. Others did not know the location of facilities which offered the service. </p>
<p>Sickle cell related interventions are expensive. It exposes families to financial hardships as most have to seek loans to pay hospital bills and other healthcare costs. In Nigeria for example, the findings of a <a href="https://pubmed.ncbi.nlm.nih.gov/26622186/">study</a> showed that few participants (7.2%) were enrolled in the National Health Insurance Scheme. Monthly household income ranged from ₦12,500 (US$27.15) to ₦330,000 ($716.64), whilst health expenditure was between ₦2500 ($5.43) and ₦215,000 ($466.90). Kenya also has similar examples. Health insurance can be an invaluable tool that can help ease the financial burden associated with the management of sickle cell disease.</p>
<h2>Saving West African lives</h2>
<p>There is a need to increase public awareness regarding sickle cell disease. This will correct some of the negative attitudes and wrong practices such as disregard for sickle cell screening prior to marriages, as well as a willingness to marry amongst individuals with genotype incompatibility. Campaigns should be targeted at correcting misconceptions that the disease is a death warrant and contagious. </p>
<p>People should know it is possible to live a long life with proper healthcare after diagnosis.</p>
<p>Campaigns aimed at improving relevant knowledge, alongside pre-marital screening and counselling, could significantly reduce the prevalence of the disease in West Africa. One idea could be to use public figures such as musicians, actors and social media celebrities in public awareness campaigns. </p>
<p>Countries with a high burden like Nigeria also need:</p>
<ul>
<li><p>adequately equipped and revitalised health facilities</p></li>
<li><p>regular training of healthcare practitioners</p></li>
<li><p>comprehensive health insurance coverage for all sickle cell disease patients</p></li>
<li><p>higher prioritisation as well as increased investment in research and development. </p></li>
</ul>
<p>Given the high prevalence of sickle cell disease in the region, the continent should lead initiatives to end the disease. New multidisciplinary programmes for affected populations need to be considered. Strategies to prevent, reduce, eliminate and manage the disease have to be integrated and pursued aggressively. </p>
<p>A fresh approach needs to harness political will with science-led interventions. Collaboration with private sector entities, development partners and philanthropists must be improved and embedded in strategies. Funding for research and other evidence-based interventions is abysmal – resources must be mobilised to these areas.</p>
<p><em>Godspower Onavbavba, a researcher at the NIPRD contributed to this article</em></p><img src="https://counter.theconversation.com/content/210264/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Obi Peter Adigwe does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The sickle cell disease burden in west Africa is among the highest in the world.Obi Peter Adigwe, Director General, National Institute for Pharmaceutical Research and DevelopmentLicensed as Creative Commons – attribution, no derivatives.