Search Engines and Generative Artificial Intelligence Integration: Public Health Risks and Recommendations to Safeguard Consumers Online

BACKGROUND

The online pharmacy market is growing, with legitimate online pharmacies offering advantages such as convenience and accessibility. However, this increased demand has attracted malicious actors into this space, leading to the proliferation of illegal vendors that use deceptive techniques to rank higher in search results and pose serious public health risks by dispensing substandard or falsified medicines. Search engine providers have started integrating generative artificial intelligence (AI) into search engine interfaces, which could revolutionize search by delivering more personalized results through a user-friendly experience. However, improper integration of these new technologies carries potential risks and could further exacerbate the risks posed by illicit online pharmacies by inadvertently directing users to illegal vendors.

OBJECTIVE

The role of generative AI integration in reshaping search engine results, particularly related to online pharmacies, has not yet been studied. Our objective was to identify, determine the prevalence of, and characterize illegal online pharmacy recommendations within the AI-generated search results and recommendations.

METHODS

We conducted a comparative assessment of AI-generated recommendations from Google's Search Generative Experience (SGE) and Microsoft Bing's Chat, focusing on popular and well-known medicines representing multiple therapeutic categories including controlled substances. Websites were individually examined to determine legitimacy, and known illegal vendors were identified by cross-referencing with the National Association of Boards of Pharmacy and LegitScript databases.

RESULTS

Of the 262 websites recommended in the AI-generated search results, 47.33% (124/262) belonged to active online pharmacies, with 31.29% (82/262) leading to legitimate ones. However, 19.04% (24/126) of Bing Chat's and 13.23% (18/136) of Google SGE's recommendations directed users to illegal vendors, including for controlled substances. The proportion of illegal pharmacies varied by drug and search engine. A significant difference was observed in the distribution of illegal websites between search engines. The prevalence of links leading to illegal online pharmacies selling prescription medications was significantly higher (P=.001) in Bing Chat (21/86, 24%) compared to Google SGE (6/92, 6%). Regarding the suggestions for controlled substances, suggestions generated by Google led to a significantly higher number of rogue sellers (12/44, 27%; P=.02) compared to Bing (3/40, 7%).

CONCLUSIONS

While the integration of generative AI into search engines offers promising potential, it also poses significant risks. This is the first study to shed light on the vulnerabilities within these platforms while highlighting the potential public health implications associated with their inadvertent promotion of illegal pharmacies. We found a concerning proportion of AI-generated recommendations that led to illegal online pharmacies, which could not only potentially increase their traffic but also further exacerbate existing public health risks. Rigorous oversight and proper safeguards are urgently needed in generative search to mitigate consumer risks, making sure to actively guide users to verified pharmacies and prioritize legitimate sources while excluding illegal vendors from recommendations.

Illegal Trade in Exotic Animals and Its Impacts in Slovenia-A Case Study

Currently, the illegal wildlife trade is one of the most profitable illegal enterprises in the world. The aim of our study was to determine the situation with respect to wildlife trade in Slovenia, which is mainly a transit country, before changes to the Schengen borders came into effect. The volume of trade is significant but not extensive. The most common endangered species involved in illegal trade in Slovenia are the brown bear, the peregrine falcon, the date mussel, the lady's slipper orchid, the common snowdrop, the cyclamen, the sea turtle, the otter, and various reptile species. The smuggling of shells (date shells), ivory (ivory products), certain plants, and various hunting trophies (bears, big cats) has decreased in recent years. Nevertheless, counteracting crimes continues to be important for the conservation of some species in Slovenia, notably the lynx, and for the reduction of poaching. Improvements are needed in the detection and prevention of wildlife crime, especially in light of changes made to the Schengen borders and the consequent inclusion of new trading partners for Slovenia. The lack of people properly trained to identify, detect, and investigate wildlife crime is especially acute.

Pharmacy Student Perceptions and Knowledge of Online Pharmacy Use

Objective. Currently, there is no set of accreditation standards for integrating the dangers of illegal online pharmacies into Doctor of Pharmacy (PharmD) curricula. As a result, many pharmacists are unable to recognize the differences between a legal and illegal online pharmacy or educate patients on the dangers of online pharmacies. The objectives of this study were to assess gaps in student pharmacists' knowledge and to assess the impact of adding education regarding online pharmacies into PharmD programs.Methods. A pre- and postsurvey design was developed. Data were collected through an electronic questionnaire distributed to second-year pharmacy (P2) students to evaluate student knowledge gaps at baseline and after education on illegal online pharmacies.Results. A total of 102 students responded to the presurvey, with 93 (91%) consenting to participate. Out of 100 respondents to the postsurvey, 84 (84%) students consented. Approximately 87% (81/93) of respondents indicated some awareness of prescription medications being purchased online. Most students (89%, 77/86) stated that they do not believe the university has provided adequate curriculum on illegal online pharmacies and counterfeit medications. After receiving education on the relevant topics, 64% (55/85) stated they now felt their education was adequate.Conclusion. Although pharmacy students were aware of the existence of illegal online pharmacies, they were not aware of the significance of this patient safety issue or how to accurately identify suspicious websites. It is imperative that PharmD programs incorporate formal education on the risks that illegal online pharmacies pose to patient and medication safety.

Accessing vulnerable undocumented migrants through a healthcare clinic including a community outreach programme: a 12-year retrospective cohort study in Denmark

BACKGROUND

Little is known about the healthcare needs of the increasing number of undocumented migrants in Europe. We aimed to gain knowledge about undocumented migrants use of a free healthcare clinic including an outreach programme in Denmark.

METHODS

We conducted a retrospective cohort study of all patients registered in the database at the AmiAmi healthcare clinic in Fredericia, Denmark, 1 January 2006-30 July 2019.

RESULTS

In all, 579 patients from 47 different countries were included, of which 525 (90.7%) were cis-women (= assigned female sex at birth and identifies as female). They had a total of 3135 consultations (median 3, interquartile range 2-6), and 19% used the clinic over a period of >2 years. In all, 820 consultations (26%) were done as part of the outreach programme, and the number of outreach contacts increased significantly over the study period (P < 0.001). Of 738 tests for sexually transmitted infections (STIs), 76 (13.1%) patients were found positive for one or several STIs. Transgender women and cross-dressing men had significantly higher risk of STIs (25.8% vs 10.3%, P = 0.007) compared with cis-women. Of 94 patients referred to the public healthcare system, the majority (n = 64) was referred to the department of gynaecology during pregnancy or for induced abortion. A total of 52 patients (9.0%) reported being submitted to abuse or violence while in Denmark, and another 24 (4.1%) were registered as victims of human trafficking.

CONCLUSIONS

Our results highlight the multifaceted healthcare needs of undocumented migrants, with an increasing use of healthcare services over the study period. It underlines the importance of outreach programmes to reach this patient group at their place of work or stay. Finally, it emphasizes that transgender female and cross-dressing male sex workers are an especially vulnerable group with higher risk of human immunodeficiency virus and other STIs compared with cis-women.

Behavior in Avalanche Terrain: An Exploratory Study of Illegal Snowmobiling in Norway

Snowmobilers make a grim and significant contribution to avalanche fatality statistics in Norway. However, there is limited knowledge on the behavior of this group in avalanche terrain and the factors influencing this behavior. Our study documents what snowmobilers do and not do in avalanche terrain, how their behavior relates to managing complex avalanche conditions and if there is a mismatch between avalanche competence, education and riding preferences. This ethnographic study observed snowmobiler tracks and thus avalanche terrain usage in Northern Norway during 2018 and 2019, supported by open-ended conversations with target group riders. Results show that high-marking lost popularity to technical riding, which seems to be perceived as safer despite increased exposure to complex avalanche terrain and conditions with persistent weak layers in the snowpack. The detected mismatch between preferences and avalanche knowledge/attitude will remain an obstacle to future accident prevention efforts unless behavioral changes are addressed. This study of a predominantly illegal activity sheds light on how to explore and observe hard-to-reach illegal activities and should be of interest to a wider audience from other research disciplines.

Eco-Crimes and Ecocide at Sea: Toward a New Blue Criminology

This essay adopts an interdisciplinary approach to consider the meaning of "eco-crime" in the aquatic environment and draws on marine science, the study of criminal law and environmental law, and the criminology of environmental harms. It reviews examples of actions and behaviors of concern, such as offences committed by transnational organized crime and the legal and illegal over-exploitation of marine resources, and it discusses responses related to protection, prosecution and punishment, including proposals for an internationally accepted and enforced law of ecocide. One key element of the policy and practice of ending ecocide is the call to prioritize the adoption of technologies that are benign and renewable. Our essay concludes with a description of the "Almadraba" method of fishing to illustrate that there are ways in which the principles of sustainability and restoration can be applied in an ethical and just way in the context of modern fisheries.

Drug-Resistant Tuberculosis in Pet Ring-Tailed Lemur, Madagascar

We diagnosed tuberculosis in an illegally wild-captured pet ring-tailed lemur manifesting lethargy, anorexia, and cervical lymphadenopathy. Whole-genome sequencing confirmed the Mycobacterium tuberculosis isolate belonged to lineage 3 and harbored streptomycin resistance. We recommend reverse zoonosis prevention and determination of whether lemurs are able to maintain M. tuberculosis infection.

Beyond illegality: Primary healthcare providers' perspectives on elimination of female genital mutilation/cutting

AIMS AND OBJECTIVES

To report primary healthcare providers' perspectives on elimination of female genital mutilation/cutting (FGM/C).

BACKGROUND

Eradication of FGM/C by 2030 is one of the United Nations Sustainable Development goals. World Health Organization recognises the unique role of nurses and other primary healthcare providers. However, their voices on the current legislative approach are underreported. These voices are important in informing directions that can expedite achievement of the global goal.

DESIGN

Qualitative interpretivist phenomenology.

METHODS

This qualitative study used purposive sampling approach and involved 19 individual interviews conducted face to face or by telephone with Australian primary healthcare providers. Data collected between October and December 2019 were transcribed verbatim and thematically analysed. Three themes exploring Australian healthcare providers' perspectives on elimination of FGM/C were identified, namely understanding Australian laws against FGM/C; perspectives on culturally sensitive education; and exploring public awareness raising activities in Australia. This study was guided by Consolidated Criteria for Reporting Qualitative Research, the checklist for qualitative studies.

RESULTS

"Understanding Australian laws against FGM/C" identified participants' knowledge that FGM/C is illegal in Australia and that mandatory reporting applies if a child is or at risk of being taken oversees for the procedure. Through "Perspectives on culturally sensitive education," the participants argued that education is the key to questioning the practice of FGM/C. "Exploring public awareness-raising activities in Australia" described the need for collective action germane to FGM/C eradication.

CONCLUSIONS

This study emphasised that laws and legislation prohibiting FGM/C need to be complemented with culturally sensitive education and public awareness-raising activities, to produce optimal outcome for the elimination of FGM/C in Australia.

RELEVANCE TO CLINICAL PRACTICE

Voices of these healthcare providers are crucial for FGM/C to be eradicated. Listening and acting on these voices are important in achieving the global sustainable development goal of eradicating FGM/C.

Occurrence and predictors of abortion among women of the reproductive age group in a block of Darjeeling District, West Bengal, India

Background

Despite being a sensitive and less explored issue, abortion is a major preventable cause of maternal morbidity and mortality affecting millions of women in developing countries.

Objectives

The study aimed to determine the occurrence, nature, and predictors of abortion among women in the reproductive age group in Naxalbari block of Darjeeling district.

Methods

A community-based cross-sectional study was conducted in Naxalbari block of Darjeeling district, West Bengal, India, from May 2015 to April 2016, among 420 women aged 15-49 years selected from 30 villages by cluster sampling technique. A predesigned, pretested interview schedule validated in the local vernacular was used. Binary logistic regression was used for finding out predictors of abortion among ever-pregnant women.

Results

Lifetime occurrence of abortion was 33.6%. Among total 178 events of abortion, 51.7% were spontaneous and 48.3% induced. Majority of spontaneous abortions events were attended by a doctor (73.9%). About 59.3% of induced abortions were illegal, and unwanted pregnancy was major reason (62.4%) for induced abortion. Private facilities and over the counter drugs were preferred. Lower education, nuclear family, number of children <2, not having male child, domestic violence during pregnancy were significant predictors of abortion.

Conclusions

Illegal abortions were highly prevalent in the area. Unwanted pregnancies hint toward unmet needs of family planning. Stigma and poor awareness were the root cause of not visiting a health facility in case of abortions. Building up of better infrastructure, better orientation of frontline workers, non-judgemental and confidential services will attract women to in government facilities.

illegal injectable fillers: The adverse effects comparison study

BACKGROUND

Over the past decades, soft-tissue filler injections have become an essential part of cosmetic practice worldwide. Due to the increasing demand, unlicensed practitioners venture in performing this minimally invasive procedure, injecting illegal fillers that pose serious complications.

OBJECTIVES

To compare the adverse effects of legal and illegal soft-tissue fillers injected by licensed and unlicensed practitioners.

MATERIALS AND METHODS

A 10-year retrospective, descriptive, single-center study conducted at the outpatient dermatology department and skin laser center at Siriraj Hospital from January 2009 to December 2019. Patients were identified as having treatment-related complications. Their demographic data, clinical history, and injection history were reviewed.

RESULTS

Forty patients with mean age of 37 years old were included in the study. Thirty-five of them (87.5%) were female. Illegal soft-tissue fillers were used in 28 patients (70%) and were performed by unlicensed practitioners (18 cases, 64.3%, P = .001). Adverse effects from illegal fillers (26 cases, 92.9%) developed longer than legal fillers (7 cases, 58.3%) (P = .017). Symptoms significantly lasted longer in patients injected with illegal fillers, 10 (0.07-288) weeks, as compared to patients injected with legal fillers 0.75 (0.14-72) weeks (P = .01). Injections from illegal fillers resulted to foreign body reaction (22 cases, 78.6%) and infections (6 cases, 21.4%). Vascular complications were identified in legal fillers injections (5 cases, 41.7%).

CONCLUSIONS

The incidence of adverse effects and complications from soft-tissue filler injections are superior when performed by novice injectors and unlicensed practitioners using illegal fillers. Proper training of filler injections, selection of appropriate fillers, and early recognition of adverse effects are critically important to the success of treatments.

Characterizing efforts to reduce consumer demand for wildlife products

The unsustainable trade in wildlife is a key threat to Earth's biodiversity. Efforts to mitigate this threat have traditionally focused on regulation and enforcement, and there is a growing interest in campaigns to reduce consumer demand for wildlife products. We aimed to characterize these behavior-change campaigns and the evidence of their impacts. We searched peer-reviewed and grey literature repositories and over 200 institutional websites to retrieve information on demand-reduction campaigns. We found 236 campaigns, mainly in the grey literature. Since the 1970s, the number of campaigns increased, although for over 15% a start date could not be found. Asia was the primary focus, although at the national level the United States was where most campaigns took place. Campaigns most often focused on a single species of mammal; other vertebrates groups, with the exception of sharks, received limited attention. Many campaigns focused on broad themes, such as the wildlife trade in general or seafood. Thirty-seven percent of campaigns reported some information on their inputs, 98% on strategies, 70% on outputs, 37% on outcomes (i.e., changes in the target audience), and 9% on impacts (i.e., biological changes or threat reduction). Information on outcomes and impacts was largely anecdotal or based on research designs that are at a high risk of bias, such as pre- and postcampaign comparisons. It was unclear whether demand-reduction campaigns had direct behavioral or biological impacts. The lack of robust impact evaluation made it difficult to draw insights to inform future efforts, a crucial part of effectively addressing complex issues, such as the wildlife trade. If demand-reduction campaigns are to become a cornerstone of the efforts to mitigate the unsustainable trade in wildlife, conservationists need to adopt more rigorous impact evaluation and a more collaborative approach that fosters the sharing of data and insights.

Listeria monocytogenes Isolated from Illegally Imported Food Products into the European Union Harbor Different Virulence Factor Variants

Unregulated international flow of foods poses a danger to human health, as it may be contaminated with pathogens. Recent studies have investigated neglected routes of pathogen transmission and reported the occurrence of Listeria monocytogenes in food illegally imported into the European Union (EU), either confiscated at four international airports or sold illegally on the Romanian black market. In this study we investigated the genotype diversity and the amino acid sequence variability of three main virulence factors of 57 L. monocytogenes isolates. These isolates were derived from 1474 food samples illegally imported into the EU and originated from 17 different countries. Multilocus sequence typing revealed 16 different sequence types (STs) indicating moderate genotype diversity. The most prevalent STs were ST2, ST9, and ST121. The pulsed-field gel electrophoresis (PFGE) analysis resulted in 34 unique pulsotypes. PFGE types assigned to the most prevalent STs (ST2, ST9, and ST121) were highly related in their genetic fingerprint. Internalin A (InlA) was present in 20 variants, including six truncated InlA variants, all harbored by isolates of ST9 and ST121. We detected eight ST-specific listeriolysin O (LLO) variants, and among them, one truncated form. The actin-assembly-inducing protein ActA was present in 15 different ST-specific variants, including four ActA variants with an internal truncation. In conclusion, this study shows that L. monocytogenes, isolated from illegally imported food, have moderate genotype diversity, but diverse virulence factors variants, mainly of InlA.

Medication patterns and fertility rates in a cohort of anabolic steroid users

BACKGROUND

To describe self-reported medication patterns and fertility rates in a population of anabolic steroid (AS) users.

METHODS

We reviewed data from an online survey of AS users and identified a sub-group who had attempted to achieve a pregnancy with their partners while using AS. The online survey consisted of questions addressing demographics, AS use, ancillary medications, and fertility outcomes.

RESULTS

A total of 97 men (of 231 total respondents) had attempted to achieve a pregnancy while taking AS and comprise the current cohort. The majority of men were 25-44 years old (63.9%), married (75.5%) and Caucasian (88.7%). Ancillary drug use was common with only 5.2% denying drug use other than ASs. The most common reported ancillary drugs were antiestrogens (89.7%) and sexual enhancement medications (SEMs) (68%). The fertility rate was 92.8%, with 82.4% achieving pregnancy within one year. Interestingly, only 13.5% sought fertility evaluation with treatment required in 8.3%. Age at initiation of AS use, maximum dosage utilized, yearly duration of supplementation, and number of years using steroids were not associated with a prolonged duration to pregnancy or decreased rate of pregnancy.

CONCLUSIONS

Despite continued use of ASs, this cohort's self-reported fertility rates are unexpectedly high. This is presumably related to cycling of therapy and concomitant use of fertility preserving medications.

Sedative and Analgesic Drugs Online: A Content Analysis of the Supply and Demand Information Available in Thailand

BACKGROUND

Evidence from other countries has suggested that many controlled drugs are also offered online, even though it is illegal to sell these drugs without a license.

OBJECTIVES

To evaluate the current contents related to the supply and demand of sedatives and analgesic drugs available online in Thailand, with a particular focus on Facebook.

METHODS

A team of reviewers manually searched for data by entering keywords related to analgesic drugs and sedatives. The contents of the website were screened for supply and demand-related information.

FINDINGS

A total of 5,352 websites were found publicly available. The number of websites and Facebook pages containing the information potentially related to the supply and demand of analgesic drugs and sedatives was limited. Nine websites sold sedatives, and six websites sold analgesics directly. Fourteen Facebook pages were found, including 7 sedative pages and 7 analgesic pages. Within one year, the three remaining active pages multiplied in the number of followers by three- to nine-fold. The most popular Facebook page had over 2,900 followers.

CONCLUSIONS

Both the internet and social media contain sites and pages where sedatives and analgesics are illegally advertised. These websites are searchable through common search engines. Although the number of websites is limited, the number of followers on these Facebook pages does suggest a growing number of people who are interested in such pages. Our study emphasized the importance of monitoring and developing potential plans relative to the online marketing of prescription drugs in Thailand.

Mismeasured mortality: correcting estimates of wolf poaching in the United States

Measuring rates and causes of mortalities is important in animal ecology and management. Observing the fates of known individuals is a common method of estimating life history variables, including mortality patterns. It has long been assumed that data lost when known animals disappear were unbiased. We test and reject this assumption under conditions common to most, if not all, studies using marked animals. We illustrate the bias for 4 endangered wolf populations in the United States by reanalyzing data and assumptions about the known and unknown fates of marked wolves to calculate the degree to which risks of different causes of death were mismeasured. We find that, when using traditional methods, the relative risk of mortality from legal killing measured as a proportion of all known fates was overestimated by 0.05–0.16 and the relative risk of poaching was underestimated by 0.17–0.44. We show that published government estimates are affected by these biases and, importantly, are underestimating the risk of poaching. The underestimates have obscured the magnitude of poaching as the major threat to endangered wolf populations. We offer methods to correct estimates of mortality risk for marked animals of any taxon and describe the conditions under which traditional methods produce more or less bias. We also show how correcting past and future estimates of mortality parameters can address uncertainty about wildlife populations and increase the predictability and sustainability of wildlife management interventions.

Medico-legal evaluation of firearm injuries--an original study from India with review of literature

Firearm (FA) injuries pose great health burden and presents enormous challenge for health and national economies. This study was undertaken to analyze the characteristics of fatal gunshot injuries, their pattern, associated factors, and postmortem findings in central India, to provide data for such fatalities in this region, which has not been reported earlier. This is a descriptive, retrospective cross-sectional study carried out on the victims of FA injuries referred to the mortuary. Of the autopsies conducted during study, 2.09% were firearm-related deaths. Of the cases, males (92.42%) notably outnumbered females in a ratio of 12.2:1. Homicidal attacks were maximum, and unlicensed, illegal country-made weapons were the preferred choice. Suicides were least. Result signifies that illegal country-made weapons should be strictly limited to save the precious lives. A holistic approach encompassing public awareness, behavioral modification, and stringent management of law and order is the need of the hour.

An overview of waste crime, its characteristics, and the vulnerability of the EU waste sector

While waste is increasingly viewed as a resource to be globally traded, increased regulatory control on waste across Europe has created the conditions where waste crime now operates alongside a legitimate waste sector. Waste crime,is an environmental crime and a form of white-collar crime, which exploits the physical characteristics of waste, the complexity of the collection and downstream infrastructure, and the market opportunities for profit. This paper highlights some of the factors which make the waste sector vulnerable to waste crime. These factors include new legislation and its weak regulatory enforcement, the economics of waste treatment, where legal and safe treatment of waste can be more expensive than illegal operations, the complexity of the waste sector and the different actors who can have some involvement, directly or indirectly, in the movement of illegal wastes, and finally that waste can be hidden or disguised and creates an opportunity for illegal businesses to operate alongside legitimate waste operators. The study also considers waste crime from the perspective of particular waste streams that are often associated with illegal shipment or through illegal treatment and disposal. For each, the nature of the crime which occurs is shown to differ, but for each, vulnerabilities to waste crime are evident. The paper also describes some approaches which can be adopted by regulators and those involved in developing new legislation for identifying where opportunities for waste crime occurs and how to prevent it.