Technologies of Expertise: Opioids and Pain Management’s Credibility Crisis

Journalistic accounts of the opioid crisis often paint prescription opioids as the instrument of profit-minded pharmaceutical companies who enlisted pain specialists to overprescribe addictive drugs. Broadening beyond a focus on pharmaceutical power, this article offers a comparative-historical explanation, rooted in inter- and intra-professional dynamics, of the global increase in rates of opioid prescribing. Through archival analysis and in-depth interviews with pain specialists and public-health officials in the United States and France, I explain how and why opioids emerged as the “right tool for the job” of pain relief in the 1980s and 1990s, affecting how pain science is produced, pain management is administered, and a right to pain relief is promised in different national contexts. I argue that opioids, selected and destigmatized as the technology for pain relief, helped establish a global network of pain expertise, linking a fledgling field of pain specialists to the resources of global-health governance, public-health administration, humanitarian organizations, and pharmaceutical companies. I then compare how U.S. and French pain specialists leveraged opioids to strengthen the boundaries of their emergent fields. Pain specialists’ differing degrees of autonomy in each country’s network of pain expertise shaped the extent to which opioids could dominate pain management and lead to crisis. Tracing the relationship between opioids and pain expertise, I show how technologies can drive crises of expert credibility if and when they escape the control of the networked fields that selected them.

The runaway evolution of SARS-CoV-2 leading to the highly evolved Delta strain

In new epidemics after the host shift, the pathogens may experience accelerated evolution driven by novel selective pressures. When the accelerated evolution enters a positive feedback loop with the expanding epidemics, the pathogen's runaway evolution may be triggered. To test this possibility in COVID-19, we analyze the extensive databases and identify 5 major waves of strains, one replacing the previous one in 2020-2021. The mutations differ entirely between waves and the number of mutations continues to increase, from 3-4 to 21-31. The latest wave is the Delta strain which accrues 31 new mutations to become highly prevalent. Interestingly, these new mutations in Delta strain emerge in multiple stages with each stage driven by 6-12 coding mutations that form a fitness group. In short, the evolution of SARS-CoV-2 from the oldest to the youngest wave, and from the earlier to the later stages of the Delta wave, is a process of acceleration with more and more mutations. The global increase in the viral population size (M(t), at time t) and the mutation accumulation (R(t)) may have indeed triggered the runaway evolution in late 2020, leading to the highly evolved Alpha and then Delta strain. To suppress the pandemic, it is crucial to break the positive feedback loop between M(t) and R(t), neither of which has yet to be effectively dampened by late 2021. New waves beyond Delta, hence, should not be surprising.

Promise and peril-defining ethical telehealth practice from the clinician and patient perspective: A qualitative study

Objectives We undertook a qualitative study to examine and compare the experience of ethical principles by telehealth practitioners and patients in relation to service delivery theory. The study was conducted prior to and during the recent global increase in the use of telehealth services due to the COVID-19 pandemic, Methods We conducted semi-structured interviews with 20 telehealth practitioners and patients using constructionist grounded theory methods to collect and analyse data. Twenty-five axial coded data categories were then unified and aligned through selective coding with the Beauchamp and Childress (2013) framework of biomedical ethics. The groups were then compared. Results Thirteen categories aligned to the ethical framework were identified for practitioners and 12 for patients. Variance existed between the groups. Practitioner results were non-maleficence 4/13 or (31%), beneficence 4/13 (31%), professional–patient relationships 3/12 (22%), autonomy 1/13 (8%) and justice 1/13 (8%). Patient data results were non-maleficence 4/12 (33%), professional–patient relationships 3/12 (33%), autonomy 2/12 (18%), beneficence 1/12 (8%) and justice 1/12 (8%). Conclusions Ethical principles are experienced differently between telehealth practitioners and patients. These differences can impact the quality and safety of care. Practitioners feel telehealth provides better care overall than patients do. Patients felt telehealth may force a greater share of costs and burdens onto them and reduce equity. Both patients and practitioners felt telehealth can be more harmful than face-to-face service delivery when it creates new or increased risk of harms. Building sufficient trust and mutual understanding are equally important to patients as privacy and confidentiality.

Association Between Blood Pressure And Lung Function In Chinese Children: The Seven Northeastern Cities Study

Background: A global increase in asthma and COPD incidence has occurred, the cause is unknown. One potential relationship that has yet to be explored is the interaction between blood pressure (BP) and lung function in children 5-17 years old. Our purpose is to assess the relationship between hypotension, hypertension, and lung function in children 5 to 17 years old. Methods: Participants were recruited from elementary and middle schools from 7 cities in northeastern China (N=6,797). BP was categorized into 3 groups: hypotensive (<5th percentile or <90mmHg if children >10 years), normotensive and hypertensive (>95th percentile) based on American Academy of Pediatrics standards. Spirometry measured lung function in forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), peak expiratory flow (PEF), and maximum mid expiratory flow (MMEF). Associations were assessed using logistic regression analysis. Results: Decreases in FVC , FEV1, PEF, and MMEF were noted in hypotensive children. Higher FVC, FEV1, PEF, and MMEF were noted among children ³ 10 with hypertension, while children <10 years, only had increased FVC compared to normotensive children. Statistically significant interactions between hypotension and PEF < 75% (OR:2.31; 95% CI: 1.17-4.23), were seen for children < 10 years. Conclusions: Our findings suggest that, in this study population, hypotension may be associated with decreased lung function, and the increased lung function may be associated with hypertension in children. Future studies are needed to confirm temporality as this is the first study to explore these relationships in children which requires in depth investigation.

Extracts of Amazonian Fungi With Larvicidal Activities Against Aedes aegypti

The global increase in diseases transmitted by the vector Aedes aegypti, new and re-emerging, underscores the need for alternative and more effective methods of controlling mosquitoes. Our aim was to identify fungal strains from the Amazon rain forest that produce metabolites with larvicidal activity against Aedes aegypti. Thirty-six fungal strains belonging to 23 different genera of fungi, isolated from water samples collected in the state of Amazonas, Brazil were cultivated. The liquid medium was separated from the mycelium by filtration. Medium fractions were extracted with ethyl acetate and isopropanol 9:1 volume:volume, and the mycelia with ethyl acetate and methanol 1:1. The extracts were vacuum dried and the larvicidal activity was evaluated in selective bioassays containing 500 μg/ml of the dried fungal extracts. Larval mortality was evaluated up to 72 h. None of the mycelium extracts showed larvicidal activity greater than 50% at 72 h. In contrast, 15 culture medium extracts had larvicidal activity equal to or greater than 50% and eight killed more than 90% of the larvae within 72 h. These eight extracts from fungi belonging to seven different genera (Aspergillus, Cladosporium, Trichoderma, Diaporthe, Albifimbria, Emmia, and Sarocladium) were selected for the determination of LC50 and LC90. Albifimbria lateralis (1160) medium extracts presented the lowest LC50 value (0.268 μg/ml) after 24 h exposure. Diaporthe ueckerae (1203) medium extracts presented the lowest value of LC90 (2.928 μg/ml) at 24 h, the lowest values of LC50 (0.108 μg/ml) and LC90 (0.894 μg/ml) at 48 h and also at 72 h (LC50 = 0.062 μg/ml and LC90 = 0.476 μg/ml). Extracts from Al. lateralis (1160) and D. ueckerae (1203) showed potential for developing new, naturally derived products, to be applied in integrated vector management programs against Ae. aegypti.

Spatio-Temporal Patterns of Increasing Illegal Livestock Grazing over Three Decades at Moyowosi Kigosi Game Reserve, Tanzania

The global increase of livestock has caused illegal intrusion of livestock into protected areas. Until now, hotspot areas of illegal grazing have rarely been mapped, long-term monitoring data are missing, and little is known about the drivers of illegal grazing. We localized hotspots of illegal grazing and identified factors that influenced spatio-temporal patterns of illegal grazing over three decades in the Moyowosi Kigosi Game Reserve (MKGR), Tanzania. We used questionnaires with local pastoralists (N = 159), georeferenced aerial survey data and ranger reports from 1990–2019 to understand the reasons for illegal grazing in the area. We found that hotspots of illegal grazing occurred initially within 0–20 km of the boundary (H (3) = 137, p < 0.001; (H (3) = 32, p < 0.001) and encroached further into the protected area with time (H (3) = 11.3, p = 0.010); (H (2) = 59.0, p < 0.001). Further, livestock herd sizes decreased with increasing distance from the boundary (R = −0.20, p = 0.020; R = −0.40, p = 0.010). Most interviewees (81%) claimed that they face challenges of reduced foraging land in the wet season, caused by increasing land used for cultivation, which drives them into the MKGR to feed their livestock. We conclude that there is spatio-temporal consistency in the illegal livestock intrusion over three decades, and hotspot areas are located along the boundary of the MKGR. We suggest focusing patrols at these hotspot areas, especially during the wet season, to use limited law enforcement resources effectively.

Implementation of the course Practice Teaching of the Japanese Language and Culture

Considering the global increase in the number of Japanese language learners, the need to establish educational institutions (primary, secondary, higher education, non-school education) for Japanese language learning also arose in Croatia and, subsequently, the necessity to foster a new generation of qualified teachers with sufficient theoretical and practical background in teaching Japanese as a foreign language. The purpose of this paper is to examine and describe the process of implementing the graduate course Practice Teaching of the Japanese Language and Culture, along with its challenges such as online classes due to the Covid-19 pandemic. The paper discusses the role of teachers as facilitators, the role of students as trainees and the role of learners, i.e. the participants of an intensive two-week Japanese language course, which is part of the abovementioned graduate course. Furthermore, the paper discusses the learner survey and the trainee self-evaluation report with respect to the improvement of their knowledge.

Bacteriophages as an Alternative Method for Control of Zoonotic and Foodborne Pathogens

The global increase in multidrug-resistant infections caused by various pathogens has raised concerns in human and veterinary medicine. This has renewed interest in the development of alternative methods to antibiotics, including the use of bacteriophages for controlling bacterial infections. The aim of this review is to present potential uses of bacteriophages as an alternative to antibiotics in the control of bacterial infections caused by multidrug-resistant bacteria posing a risk to humans, with particular emphasis on foodborne and zoonotic pathogens. A varied therapeutic and immunomodulatory (activation or suppression) effect of bacteriophages on humoral and cellular immune response mechanisms has been demonstrated. The antibiotic resistance crisis caused by global antimicrobial resistance among bacteria creates a compelling need for alternative safe and selectively effective antibacterial agents. Bacteriophages have many properties indicating their potential suitability as therapeutic and/or prophylactic agents. In many cases, bacteriophages can also be used in food quality control against microorganisms such as Salmonella, Escherichia coli, Listeria, Campylobacter and others. Future research will provide potential alternative solutions using bacteriophages to treat infections caused by multidrug-resistant bacteria.

Compliance to GMP guidelines for Herbal Manufacturers in East Africa: A Position Paper

With the global increase in the use of traditional and complementary remedies for the prevention and treatment of illness, the quality and safety of these medicines have become a significant concern for all regulatory authorities. Herbal medicines are the most commonly used form of traditional and complementary medicines in the world and the efficacy and safety of herbal medicines, like conventional medicines, largely depends on their quality from planting to harvesting, preprocessing and final processing. Due to the inherent complexity of herbal medicines, often containing an array of active compounds, the primary processing of herbal medicines has a direct influence on their quality. Quality concerns are the reason why the medicines regulatory agencies insist that manufacturers of medicines strictly follow Good Manufacturing Practices since it is an essential tool to prevent instances of contamination, mix-ups, deviations, failures and errors. However, a strict application of GMP requirements is expensive and would drive the prices of the manufactured products up. As a result, a maturity level grading of facilities is proposed as a way of justifying the costs incurred for manufacturers desiring to reach a broader market and investing in continuous improvement. 36 Good Manufacturing Practice (GMP) inspection reports of local herbal manufacturers conducted by National Drug Authority were analyzed to establish the type and extent of deficiencies to GMP requirements for local herbal manufacturers in Uganda. The different GMP chapters and related sub-parameters constituted the variables used for the analysis of conformity to requirements. The primary outcome variable was the conclusion regarding compliance or noncompliance of the inspected local herbal manufacturing facility. GMP parameters that were frequently defaulted by local herbal manufacturers and the corresponding frequencies were identified. The Pearson Chi-square test was applied independently on each category to find the association that existed between conformity and the questions in each category. Only 22% (8) of the 30 inspected facilities were found to comply with GMP requirements, as per National Drug Authority (NDA) guidelines; while the majority of the facilities, 28 (78%), were found not to comply. Of the facilities inspected, 25 were undergoing GMP inspection for the first time. A total of 1,236 deficiency observations were made in the 36 inspection reports reviewed for the study. The mean for all deficiencies was 34.3, and the standard deviation was 15.829. 91.5% of the facilities did not have mechanisms for a record of market complaints; 80.9% did not meet documentation requirements; 78.9% did not have quality control measures in place, and 65.7% did not meet stores requirements. By encouraging a culture of self/voluntary improvement through the introduction of listing of manufacturers based on a maturity level grading, the National Drug Authority will improve the Herbal Medicines sector as per the mandate of improving the herbal medicine industry. Also, increased sensitization of all relevant stakeholders regarding the requirements for GMP should be intensified.