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Abstract Plasmodium falciparum malaria contributes to a significant global disease burden. Circumsporozoite protein (CSP), the most abundant sporozoite stage antigen, is a prime vaccine candidate. Inhibitory monoclonal antibodies (mAbs) against CSP map to either a short junctional sequence or the central (NPNA)n repeat region. We compared in vitro and in vivo activities of six CSP-specific mAbs derived from human recipients of a recombinant CSP vaccine RTS,S/AS01 (mAbs 317 and 311); an irradiated whole sporozoite vaccine PfSPZ (mAbs CIS43 and MGG4); or individuals exposed to malaria (mAbs 580 and 663). RTS,S mAb 317 that specifically binds the (NPNA)n epitope, had the highest affinity and it elicited the best sterile protection in mice. The most potent inhibitor of sporozoite invasion in vitro was mAb CIS43 which shows dual-specific binding to the junctional sequence and (NPNA)n. In vivo mouse protection was associated with the mAb reactivity to the NANPx6 peptide, the in vitro inhibition of sporozoite invasion activity, and kinetic parameters measured using intact mAbs or their Fab fragments. Buried surface area between mAb and its target epitope was also associated with in vivo protection. Association and disconnects between in vitro and in vivo readouts has important implications for the design and down-selection of the next generation of CSP based interventions.

Abstract Background Powered exoskeletons provide a way to stand and walk for people with severe spinal cord injury. Here, we used the ReWalk exoskeleton to determine the training dosage required for walking proficiency, the sensory and motor changes in the nervous system with training, and the functionality of the device in a home-like environment. Methods Participants with chronic (> 1 yr) motor complete or incomplete spinal cord injury, who were primarily wheelchair users, were trained to walk in the ReWalk for 12 weeks. Measures were taken before, during, immediately after, and 2–3 months after training. Measures included walking progression, sitting balance, skin sensation, spasticity, and strength of the corticospinal tracts. Results Twelve participants were enrolled with 10 completing training. Training progression and walking ability: The progression in training indicated about 45 sessions to reach 80% of final performance in training. By the end of training, participants walked at speeds of 0.28–0.60 m/s, and distances of 0.74–1.97 km in 1 h. The effort of walking was about 3.3 times that for manual wheelchair propulsion. One non-walker with an incomplete injury became a walker without the ReWalk after training. Sensory and motor measures: Sitting balance was improved in some, as seen from the limits of stability and sway speed. Neuropathic pain showed no long term changes. Change in spasticity was mixed with suggestion of differences between those with high versus low spasticity prior to training. The strength of motor pathways from the brain to back extensor muscles remained unchanged. Adverse events: Minor adverse events were encountered by the participants and trainer (skin abrasions, non-injurious falls). Field testing: The majority of participants could walk on uneven surfaces outdoors. Some limitations were encountered in home-like environments. Conclusion For individuals with severe SCI, walking proficiency in the ReWalk requires about 45 sessions of training. The training was accompanied by functional improvements in some, especially in people with incomplete injuries. Trial registration NCT02322125 Registered 22 December 2014.

Abstract Background Despite growing evidence of a critical link between neuromodulation technologies and neuroplastic recovery, the underlying mechanisms of these technologies remain elusive. Objective To investigate physiological evidence of central nervous system (CNS) changes in humans during translingual neurostimulation (TLNS). Methods We used high-density electroencephalography (EEG) to measure changes in resting brain activity before, during, and after high frequency (HF) and low frequency (LF) TLNS. Results Wavelet power analysis around Cz and microstate analysis revealed significant changes after 20 min of stimulation compared to baseline. A secondary effect of exposure order was also identified, indicating a differential neuromodulatory influence of HF TLNS relative to LF TLNS on alpha and theta signal power. Conclusions These results further our understanding of the effects of TLNS on underlying resting brain activity, which in the long-term may contribute to the critical link between clinical effect and changes in brain activity.

Using a longitudinal case study design, we have tracked the recovery of motor function following severe traumatic brain injury (TBI) through a multimodal neuroimaging approach. In 2006, Canadian Soldier Captain (retired) Trevor Greene (TG) was attacked with an axe to the head while on tour in Afghanistan. TG continues intensive daily rehabilitation, which recently included the integration of physical therapy (PT) with neuromodulation using translingual neurostimulation (TLNS) to facilitate neuroplasticity. Recent findings with PT + TLNS demonstrated that recovery of motor function occurred beyond conventional time limits, currently extending past 14-years post-injury. To investigate whether PT + TLNS similarly resulted in associated cognitive function improvements, we examined event-related potentials (ERPs) with the brain vital signs framework. In parallel with motor function improvements, brain vital signs detected significant increases in basic attention (as measured by P300 response amplitude) and cognitive processing (as measured by contextual N400 response amplitude). These objective cognitive improvements corresponded with TG’s self-reported improvements, including a noteworthy and consistent reduction in ongoing symptoms of post-traumatic stress disorder (PTSD). The findings provide valuable insight into the potential importance of non-invasive neuromodulation in cognitive rehabilitation, in addition to initial indications for physical rehabilitation.

Competing Interests: Declaration of interests In the past 5 years, HW received grant funding for gambling-related research by the Economic and Social Research Council, National Institute for Health Research, Wellcome Trust, the Gambling Commission (including their regulatory settlement fund), Office of Health Disparities and Improvements–Public Health England, Greater London Authority, Greater Manchester Combined Authority, Blackburn with Darwen Local Authority, and the Department of Digital Culture Media and Sport; received funding from GambleAware for a project on gambling and suicide in 2018–19; received consulting fees from the Institute of Public Health, Ireland, and the National Institute for Economic and Social Research; received payment for delivery of seminars from McGill University, the University of Birmingham, Johns Hopkins University, and from the British Broadcasting Corporation; has been paid as an expert witness by Lambeth and Middlesborough Borough Councils; received travel costs paid by Gambling Regulators European Forum, the Turkish Green Crescent Society, Alberta Gambling Research Institute, the REITOX Academy (administered through the Austrian National Public Health Institute), and the University of Helsinki; served as Deputy Chair of the Advisory Board for Safer Gambling between 2015 and 2020, remunerated by the Gambling Commission; is a Member of the WHO panel on gambling (ongoing) and provided unpaid advice on research to GamCare for their Safer Gambling Standard (from 2019 until mid-2021); runs a research consultancy for public and third-sector bodies only; has not, and does not, provide consultancy services to gambling industry actors; in researching the gambling industry and their practices, HW declares occasional attendance at events where gambling industry actors are present (including industry-sponsored conferences); as part of her work on the Gambling Survey for Great Britain, HW is required by the Gambling Commission (the funder) to participate in events disseminating research findings to their stakeholders, which includes the industry; her attendance at events where industry is present is independently funded and does not involve collaborations or partnerships with industry. AR discloses grant funding for gambling-related projects from Suicide Prevention Australia, The Winston Churchill Memorial Trust, Australia's National Research Organisation for Women's Safety, Victorian Responsible Gambling Foundation, Federation University Australia, and membership of the WHO panel on gambling; received funding for travel for the 2019 WHO meeting by the Turkish Green Crescent Society; received consultancy funding from WHO to prepare a factsheet on Gambling and conducted a paid peer reviews for Auckland University of Technology and the British Academic Forum for the Study of Gambling, administered via Gambling Research Exchange Ontario and funded through regulatory settlements. VM discloses grant funding for gambling-related projects from the Academy of Finland (projects 349589, 31834), the Finnish Ministry of Social Affairs and Health, and the Finnish Ministry of Justice; as a member of the Gambling Harms Evaluation Committee (2021–ongoing) and the Indicators for Gambling Harms work group (2019–21) under the Finnish Ministry of Social Affairs and Health, she interacts with the Finnish gambling monopoly to evaluate company products and practices and to analyse company data; discloses a fee for delivering a webinar from Bochum University, paid peer review from Routledge, and funding for travel from the Finnish Foundation for Alcohol Studies, University of Bergen, and the Council of Europe; provides consultation for public and third-sector actors, but not the gambling industry. CL discloses funding in the past 5 years for gambling-related research from the Royal Society for Public Health, Australian Research Council, Foundation for Alcohol Research and Education, and Victorian Responsible Gambling Foundation; provided a paid consultancy report on electronic gambling machines gambling for a 2023 appeal against a decision of the Northern Territory (Australia) Licensing Commission to expand electronic gambling machine availability in venues in Alice Springs; received travel support from the Turkish Green Crescent Society to attend a WHO meeting in 2019 and travel support from Monash University to attend the Fourth WHO Forum on Alcohol, Drugs and Addictive Behaviours and to attend a Commission meeting in London; is a member of the WHO panel on gambling and was engaged as a consultant in 2023 to prepare a WHO Technical Brief on gambling and gambling disorder; is an Editorial Board Member of Critical Gambling studies; provided submissions to Royal Commissions and Inquiries into casinos and electronic gambling machine venues in the Australian states of Victoria, New South Wales, and Western Australia, and has been consulted by Ministers and Ministerial staff for the governments of New South Wales, Victoria, and the Australian Government in relation to reform of gambling regulation, in an unpaid capacity; provides policy advice to local governments and non-governmental organisations in relation to reform of gambling regulation (unpaid); does not provide advice to the gambling industry or members of its ecosystem. GR discloses funding for gambling-related projects from The British Academy, the Economic and Social Research Council, the National Institute for Health Research, The Medical Research Council, the Glasgow Centre for International Development, the Department of Culture Media and Sport; acted as an advisor for a project on gambling advertising carried out by the Institute of Social Marketing at the University of Stirling in 2018, funded by GambleAware; was a Commissioner on the Howard League for Penal Reform's Commission on Crime and Gambling Related Harms 2019–22; is currently a member of the WHO panel on gambling and an Associate Editor of the journal Critical Gambling Studies; and received travel and accommodation expenses paid by the Turkish Green Crescent Society, the University of Helsinki Centre for Research on Addiction, Control and Governance–Finnish Ministry of Social Affairs and Health, the University of Sydney (via the Australian Research Council), the University of Bremen, the Ruhr Universität, Bochum, Scottish Parliament, the UK Society for the Study of Addiction, and the Howard League for Crime and Penal Reform's Commission on Crime and Gambling Related Harms (via the Gambling Commission). CB discloses grant funding for gambling-related projects from The British Academy, The Economic and Social Research Council, the National Institute of Health Research, Blackburn with Darwen Local Authority, and the Department of Culture Media and Sport. KS discloses grant funding for gambling-related projects from the Indonesian Ministry of Research and Technology and the University of Indonesia; and is a member of the WHO panel on gambling. RV discloses grant funding for gambling-related projects from Massachusetts Gaming Commission, Connecticut Dept of Mental Health & Addiction Services, the Evergreen Council for Problem Gambling, The University of Massachusetts Donahue Institute, Gambling Research Exchange Ontario, NORC Boston, North Dakota Department of Health & Human Services, British Gambling Commission, Public Health Agency of Sweden, Canadian Centre on Substance Abuse and the Center for Gambling Studies, and Rutgers University; received consultancy fees from for gambling-related research from the National Centre for Social Research (UK), Gambling Research Exchange Ontario, and the Karolinska Institute; received honorarium from McGill University for delivery of a webinar, from the Evergreen Council on Problem Gambling, the Institut fur Glucksspiel und Gesellschaft, and New York State Council on Problem Gambling; and received travel costs from the Alberta Gambling Research Institute in 2022 and 2023 and from the Nigerian National Lotteries Regulatory Commission in 2023. DU discloses funding for gambling-related projects from the Wellcome Trust (via a fellowship award to HW) and Blackburn with Darwen Local Authority. BB discloses funding for gambling-related projects from the Wellcome Trust (via a fellowship award to HW), the National Institute for Health Research, and Blackburn with Darwen Local Authority; and is a member of the Academic Forum for Gambling Research, with remuneration provided by the Gambling Commission, via Gambling Research Exchange Ontario. VK discloses funding for gambling-related projects from the Wellcome Trust (via a fellowship award to HW), the Gambling Commission, and Gambling Research Exchange Ontario; and has received funding for travel from the RANGES network, funded by the Canadian government. JR discloses funding from Canadian Institutes of Health Research, US National Institutes of Health, EU, and WHO; and has received funding for travel from WHO. LD received untied educational grant funding from Indivior and Seqirus for the study of new opioid medications in Australia, in the past 5 years. SS has been a senior advisor to McKinsey Health Institute since 2023 for issues on mental health. JQ is employed by the School of Public Health, University of Hong Kong; the School of Public Health receives funding from the Hong Kong Jockey Club Charities Trust outside of this project. JSY received funding for gambling-related research by the British Academy in 2020. VP was a staff member of WHO until 2024. All other authors declare no competing interests.

Background: Anticoagulants are life-saving medicines that can prevent strokes for patients diagnosed with atrial fibrillation (AF) as well as treating patients with venous thromboembolism (VTE), but when used incorrectly, they are frequently associated with patient harm., Aim: To evaluate the impact of community pharmacy teams on optimising patient knowledge and awareness and improving medication safety from the use of anticoagulants., Methods: Two national audits, consisting of 17 questions assessing and improving patients' understanding of anticoagulant therapy, identifying high-risk patients, and contacting prescribers when clinically appropriate were incentivised for England's community pharmacies in 2021-2022 and 2023-2024 using the Pharmacy Quality Scheme (PQS) commissioned by NHS England., Results: Approximately 11,000 community pharmacies audited just under a quarter of a million patients in total, whilst making almost 150,000 interventions for patients taking oral anticoagulants, i.e., identifying and addressing medication issues which could increase the risk of bleeding/harm. Out of the 111,195 patients audited in 2021-2022, only 24,545 (23%) patients were prescribed vitamin K antagonists. The remaining patients were prescribed direct oral anticoagulants (DOACs). By 2023-2024, this decreased to 17,043 (16%) patients. Most patients knew that they were prescribed an anticoagulant (95.6%, 106,255 in 2021-2022 and 96.5%, 101,006 in 2023-2024, p < 0.001)., Discussion: The audits resulted in a statistically significant increase in patients with a standard yellow anticoagulant alert card, as identified in audit 2 (73,901 66.5% in 2021-2022 to 76,735, 73.3% in 2023-2024, p < 0.001). Furthermore, fewer patients were prescribed concurrent antiplatelets with an anticoagulant (6021; 4.6% in 2021-2022 to 4975; 4% in 2023-2024, p < 0.001). Although there was an increase in the number of patients prescribed NSAIDs with anticoagulants, more of these patients were also prescribed gastroprotection concurrently (927 77.2% in 2021-2022 to 1457 84.1% in 2023-2024, p < 0.05). The majority of patients on warfarin had their blood checked within 12 weeks. Further there was an increase for these patients in the percentage of people prescribed VKAs who knew dietary changes can affect their anticoagulant medicine (16,764 67.4% in 2021-2022 to 12,594 73.9% in 2023-2024 p < 0.001)., Conclusions: Community pharmacy teams are well placed in educating and counselling patients on the safe use of anticoagulants and ensuring that all patients are correctly monitored.

Stigma reduces access to alcohol and other drug (AOD) support. This systematic review explored perceptions and experiences of stigma associated with AOD use among migrant and ethnic minority groups. Qualitative studies published in English were identified using six databases. Two reviewers screened and critically appraised articles using the Joanna Briggs Institute Critical Appraisal Checklist for qualitative studies. Data were synthesised using best fit framework synthesis. Twenty-three studies were included. Stigma drivers and facilitators included stereotypes, socio-cultural norms, legal responses and precarious lived experiences. Stigma intersected with gender, citizenship, race and ethnicity and manifested though shame, exclusion, secondary stigma and discrimination in treatment. Outcomes and impacts included avoidance of services, emotional distress, isolation and loneliness. This review identified similar stigma experiences to other populations, however outcomes were complicated by precarious lived experiences and multiple stigmatised identities. Multi-level interventions are required to reduce AOD-related stigma for migrant and ethnic minority groups., (© 2023. The Author(s).)

The National Health Protection (NHP) of Indonesia is a pro-poor social health insurance as the government pays the monthly premium for the poor. A waste picker is classified as an urban poor group needing affordable or free access to health care. This study explores the extent to which the NHP protects the health of waste pickers and provides them with quality health care. For this mixed-method study, 342 waste pickers completed the survey, 40 engaged in interviews, and 15 participated in Natural Group Discussions. The study found that 20% of waste pickers were not enrolled in NHP due to issues such as incorrect validation of poverty, discrimination, illegal fees, nepotism, unaffordable premiums, and lack of interest in purchasing the health plan. Among those who were enrolled, waste pickers expressed satisfaction with the health care they received and the behavior of the staff. However, they did criticize certain aspects such as waiting times, service gaps between full-paying and subsidized patients, suspicion of the quality of medicines, complicated medical administration procedures, and inflexibility of the capitation system. The study concludes that despite the NHP, poor groups remain vulnerable to accessing free health care., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Internationally, the prevalence of gambling disorder has been reported to be higher among homeless people than the general population; however, little is known about the factors associated with gambling disorder in this population. The present study aimed to investigate the prevalence of gambling disorder and its associated factors among homeless men using shelters in Osaka City. A cross-sectional survey was conducted from 30 to 2018 to 4 January 2019, using the 2017 Japanese National Survey of Gambling (JNSG) questionnaire, supplemented with questions about homeless experiences, drinking, and smoking. Using the South Oaks Gambling Screen, the presence of gambling disorder was determined by a score ≥ 5 out of 20. Multivariate logistic regression was conducted to explore factors associated with lifetime gambling disorder. Lifetime and past-year prevalence of gambling disorder among 103 participants was 43.7% (95% confidence interval [CI]: 34.5-53.3) and 3.9% (95% CI: 1.5-9.6), respectively, which are higher than the 6.7% and 1.5% found among men in the 2017 JNSG. Reasons reported for currently gambling less were primarily financial. Factors associated with lifetime GD included "more than 20 years since the first incidence of homelessness" (adjusted odds ratio [AOR]: 4.97, 95% CI: 1.50-16.45) and "more than five incidences of homelessness" (AOR: 4.51, 95% CI: 1.06-19.26). When homeless individuals with gambling disorder try to rebuild and stabilize their lives, the presence or resurgence of gambling disorder may hinder the process and pose a risk of recurring homelessness. Comprehensive support services for homeless individuals with gambling disorder are required. (250 words)., (© 2022. The Author(s).)

Introduction: Excessive alcohol use is associated with non-communicable diseases and social problems, such as work absence, financial problems and family violence. Expenditure and expenditure shares on alcohol are valuable measures to monitor financial activities on this risk behaviour. The aim of this paper is to report trends in alcohol expenditure in Australia over the last two decades., Methods: Data are from six waves of Australian Household Expenditure Surveys from 1984 to 2015-2016. We explored trends of alcohol expenditure among Australians and in different socio-demographic groups in the last 30 years. We further examined changes of expenditure on different on- and off-premises beverages over time., Results: Absolute alcohol expenditure has remained the same between the 1980s and 2016, after accounting for inflation. However, a declining trend in relative alcohol expenditure as a proportion of total household expenditure was found across nearly all demographic groups (e.g., sex, age, employment, household income), except for women aged 45-54, who showed an increasing trend of alcohol expenditure after 1998-1999., Discussion and Conclusions: The current study shows declines in relative alcohol expenditure, which may reflect declines in alcohol's relative importance within the elements of the person's lifestyle they need to pay for and/or increased awareness of alcohol's health and social harms. Further longitudinal analysis should explore additional predictors of household expenditure on alcohol. Results suggest that current bi-annual indexation increases in alcohol tax should account for increases in income to ensure the effectiveness of pricing. Moreover, attention is needed to address drinking among middle-aged females., (© 2023 The Authors. Drug and Alcohol Review published by John Wiley & Sons Australia, Ltd on behalf of Australasian Professional Society on Alcohol and other Drugs.)

Introduction: Losses disguised as wins (LDWs) are a salient type of losing outcome common to electronic gambling machines (EGMs). These events occur when a gambling payout is less than the amount wagered (i.e., a net loss) but is nonetheless accompanied by the sounds and animations that accompany genuine wins. Previous lab-based studies have reported that participants tend to overestimate genuine wins when LDWs are present. This study reports an independent replication of these findings in a large online sample that included a substantial number of individuals reporting high-risk gambling and frequent EGM users., Methods: This online study recruited a sample of 940 participants who were randomly assigned to view one of two brief videos. Each video displayed a short period of simulated online slot machine gambling and included 2 genuine wins and either 3 or 0 LDWs. Participants were asked to estimate the number of times a win occurred that was more than the amount bet . Participants also completed the Problem Gambling Severity Index., Results: The mean estimated number of genuine wins was significantly larger for the condition displaying LDWs, 3.02 [95% CI = 2.82, 3.21] than the control condition, 2.14 [1.98, 2.30], t (887.66) = 6.78, d  = 0.44, p <.001., Conclusions: We replicated the LDW-triggered win overestimation effect previously reported in lab-based experiments that have recruited smaller samples. This effect was robust in both low-risk and high-risk groups, indicating that even experienced gamblers remain susceptible. Exploratory modelling suggested only a minority of individuals were uninfluenced by LDWs., Competing Interests: The authors declare that they have no conflict of interest in relation to the publication of this article. None of the authors have knowingly received direct research funding from the gambling, tobacco, or alcohol industries, nor from any industry-sponsored organisation, or any other commercial entity that may stand to gain or lose financially through the publication of this manuscript. None of the authors have any personal financial interest in these industries. Dan Myles is supported by an Australian Government Research Training Program PhD Scholarship as well as a Gambling Research Capacity Grant from the New South Wales Office of Responsible Gambling. The New South Wales Department of Health Office of Responsible Gambling derive resources in part through hypothecated taxes on gambling revenue. Daniel Bennett has previously received funding from the National Health and Medical Research Council, the American-Australian Association, and the Monash-Warwick Alliance. Adrian Carter is supported by a National Health and Medical Research Council of Australia Career Development Fellowship and Monash University. Murat Yücel has received funding from the National Health and Medical Research Council of Australia, the Australian Research Council, the David Winston Turner Endowment Fund, and Monash University. He has also received funding from the law firms in relation to expert witness report/statement. Cassandra de Lacy-Vawdon was supported by an Australian Government Research Training Program PhD Scholarship and a Monash Graduate Excellence Scholarship while undertaking this study. Charles Livingstone has received funding from the Victorian Responsible Gambling Foundation, the (former) Victorian Gambling Research Panel, and the South Australian Independent Gambling Authority (the funds for which were derived from hypothecation of gambling tax revenue to research purposes), from the Australian and New Zealand School of Government and the Foundation for Alcohol Research and Education, and from non-government organisations for research into multiple aspects of poker machine gambling, including regulatory reform, existing harm minimisation practices, and technical characteristics of gambling forms. He has received travel and co-operation grants from the Alberta Problem Gambling Research Institute, the Finnish Institute for Public Health, the Finnish Alcohol Research Foundation, the Ontario Problem Gambling Research Committee, the Turkish Red Crescent Society, and the Problem Gambling Foundation of New Zealand. He was a Chief Investigator on an Australian Research Council funded project researching mechanisms of influence on government by the tobacco, alcohol, and gambling industries. He has undertaken consultancy research for local governments and non-government organisations in Australia and the UK seeking to restrict or reduce the concentration of poker machines and gambling impacts and was a member of the Australian government's Ministerial Expert Advisory Group on Gambling in 2010-11. He is a member of the Lancet Public Health Commission into gambling, and of the World Health Organisation expert group on gambling and gambling harm., (© 2023 The Authors.)

Introduction: Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used for their analgesic and anti-inflammatory action, but the gastrointestinal (GI) adverse effects are a known cause of preventable harm. A medication safety audit was incentivised for community pharmacies in England in 2 successive years as part of the Pharmacy Quality Scheme (PQS) to address GI safety of NSAIDs., Aims: To evaluate community pharmacy's contributions to NSAID safety and determine any change between audit 1 (2018-2019) and audit 2 (2019-2020)., Method: Patients aged 65 years or over prescribed an NSAID were included in both audits. The audit tool assessed compliance with national standards relating to co-prescribed gastroprotection, referrals to the prescriber and patient advice on long-term NSAID use and effects, with responses submitted via an online portal. Descriptive analyses were performed to explore differences between the years and tested for significance using Χ 2 tests. Qualitative data were analysed using an inductive thematic approach., Key Findings: Data from 91 252 patients in audit 1 and 73 992 in audit 2 were analysed. More patients were prescribed gastroprotection in audit 2 (85.0%) than audit 1 (80.7%, p<0.001). More patients without gastroprotection in audit 2 had a current or recent referral (67.5%) than in audit 1 (58.8%, p<0.001). Verbal or other communications between pharmacists and patients about their NSAID medication were reported more frequently in audit 2 (76.0% vs 63.5%, p<0.001)., Conclusion: During two audits, community pharmacists in England reported referring more than 15 000 patients at risk of preventable harm from NSAIDs to prescribers for review. The audits demonstrated significant potential for year-on-year improvement in GI safety for a large cohort of older patients prescribed NSAIDs. This evaluation provides evidence of how the PQS can effectively address a specific aspect of medicines safety and the place of community pharmacy more broadly in improving medicines safety., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Commercial determinants of health (CDoH) represent a critical frame for exploring undue corporate and commercial influence over health. Power lenses are integral to understanding CDoH. Impacts of food, alcohol, and gambling industries are observable CDoH outcomes. This study aims to inform understanding of the systems and institutions of commercial and/or corporate forces working within the Australian food, alcohol, and gambling industries that influence health and well-being, including broader discourses materialised via these systems and institutions., Methods: Twenty semi-structured interviews were conducted with key-informants on Australian public policy processes. Interviewees were current and former politicians, political staff members, regulators and other public servants, industry representatives, lobbyists, journalists, and researchers with expertise and experience of the Australian food, alcohol, and/ or gambling industries. Interviews sought participants' perceptions of Australian food, alcohol, and gambling industries' similarities and differences, power and influence, relationships, and intervention opportunities and needs., Results: Strategies and tactics used by Australian food, alcohol and gambling industries are similar, and similar to those of the tobacco industry. They wield considerable soft (eg, persuasive, preference-shaping) and hard (eg, coercive, political, and legal/economic) power. Perceptions of this power differed considerably according to participants' backgrounds. Participants framed their understanding of necessary interventions using orthodox neoliberal discourses, including limiting the role of government, emphasising education, consumer freedom, and personal choice., Conclusion: Food, alcohol, and gambling industries exercise powerful influences in Australian public policy processes, affecting population health and well-being. Per Wood and colleagues' framework, these manifest corporate, social, and ecological outcomes, and represent considerable instrumental, structural, and discursive power. We identify power as arising from discourse and material resources alike, along with relationships and complex industry networks. Addressing power is essential for reducing CDoH harms. Disrupting orthodox discourses and ideologies underpinning this should be a core focus of public health (PH) advocates and researchers alike., (© 2023 The Author(s); Published by Kerman University of Medical Sciences This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Five patients, comprising nine treatment courses of sargramostim use in pulmonary alveolar proteinosis, are described. The prevailing standard of treatment, whole lung lavage (WLL), is highly invasive, resource intensive and carries some procedural risk. Nebulised recombinant human GM-CSF (sargramostim) offers a pharmacological treatment option, allowing patients to be treated at home, possessing potential advantages in patient experience and wider health resourcing. The majority of reported patients described subjective improvement in symptoms along with radiographical improvement, although this did not translate into significant improvement in pulmonary function testing. Drug scarcity and high drug cost remain potential barriers to accessing this treatment, and so careful patient selection and treatment outcome assessment remain as challenging needs. Incorporating the routine assessment of validated patient symptom scores with objective physiological measures will allow prediction of response to treatment and help guide management. This report describes the largest published experience of sargramostim use in Australia., (© 2022 British Pharmacological Society.)

Background and Aims: Homelessness is one of the most significant harms associated with gambling and appears to affect older adults disproportionately, but the relationship has received little research attention. This exploratory study investigated how gambling and homelessness is linked in older adults., Methods: Using qualitative research methods, we undertook in-depth semi structured face-to-face individual and group interviews to gather data from a purposive sample (n = 48) of key informants working in service provision for older adults (aged 50+ years) experiencing gambling-related harm and/or homelessness in Victoria, Australia. Thematic analysis of data focused on evaluating mechanisms and identifying contextual conditions that activate pathways between gambling and homelessness., Results: The relationship between gambling and homelessness in older adults is often indirect and non-linear, and can represent a reflexive cycle. Experiencing periods of homelessness into older age can contribute to gambling, often because the adverse impacts of homelessness on older adults' mental and material wellbeing increase the appeal of gambling. Additionally, comorbidities (e.g. substance use, mental illness, past trauma) and structural conditions (e.g. gambling accessibility, poverty, housing insecurity) can activate gambling. Furthermore, because gambling in the older homeless adult population is frequently hidden and regularly overlooked by service providers, it often continues unabated. Gambling in older adults can also contribute to the onset of first-time homelessness. Large and rapid losses from high-intensity gambling frequently characterize this route to homelessness. Such gambling is often triggered by major life events and changes (e.g. bereavement, job loss, relationship difficulties), and the outcomes are often worsened by the conduct of gambling operators and creditors., Conclusions: The link between gambling and homelessness in older adults is complex, with connecting mechanisms often contingent upon individual, interpersonal and structural conditions and contexts. There is potential for preventative and ameliorative action given many of the underlying conditions appear modifiable through policy intervention., (© 2021 Society for the Study of Addiction.)

Introduction: There is growing concern internationally about co-occurring gambling and homelessness. We systematically review prevalence estimates in help-seeking and community samples., Methods: Adopting PRISMA guidelines, we searched CINAHL Plus, Cochrane Library, Embase, Ovid MEDLINE, PsychINFO, Proquest Central, PubMed, Scopus, Web of Science, and Google Scholar for relevant peer-reviewed articles in English. Primary outcomes examined in narrative and quantitative syntheses included prevalence of: (i) gambling in persons experiencing homelessness; (ii) harmful gambling in persons experiencing homelessness; and, (iii) homelessness in persons experiencing harmful gambling., Results: Searches identified 917 records after removing duplicates. After screening, 45 articles providing 54 prevalence estimates across 12 countries were included, with help-seeking (k = 37) and community based sample (k = 8) estimates pooled separately. Gambling prevalence (all timeframes) in help-seeking samples of persons experiencing homelessness is low (28.7%, 95% CI: 17.3-41.7, k = 14) compared to the general population (approximately 60-80%). However, harmful gambling prevalence (including problem, pathological, and disordered gambling) in help-seeking samples of persons experiencing homelessness is high (16.5%, 95% CI: 10.2-24.2, k = 20) compared to the general population (approximately 1-7%). Additionally, homelessness prevalence is high in help-seeking samples of persons experiencing harmful gambling (23.6%, 95% CI: 18.4-29.2, k = 4) compared to the general population (<1%). Meta-analysis found high between-study heterogeneity and risk of bias from small samples sizes., Conclusions: There are high rates of harmful gambling in persons experiencing homelessness and, concurrently, high rates of homelessness in persons experiencing harmful gambling. Improvements in sampling and measurement are needed to strengthen robustness and generalizability of prevalence estimates, which can potentially inform the scale and targeting of clinical interventions, support services, and policy responses., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Stigma is a social process that impedes access to support for mental health conditions and alcohol and other drug (AOD) use, particularly for people from migrant and ethnic minority backgrounds. There is limited understanding, however, of people's experiences of stigma, the underlying drivers, intersections with ethnicity, gender, and citizenship status, and how powerful discourses and social institutions create and perpetuate systems of stigma. This review aims to synthesise and critically analyse qualitative evidence to understand how stigma associated with mental health conditions and AOD use operates among people from migrant and ethnic minority groups., Methods: Qualitative evidence will be identified using MEDLINE, Embase, PsycINFO, CINAHL, Applied Social Sciences Index and Sociological Abstracts. Two reviewers will screen the titles, abstracts and full-text articles. Eligible studies will include original, empirical, peer-reviewed qualitative evidence, published in English since 1990. Studies must examine stigma in relation to mental health conditions, illicit drug use or alcohol consumption among participants who are from migrant and ethnic minority backgrounds. Studies will be critically appraised using the Joanna Briggs Institute Critical Appraisal Checklist for qualitative studies and the level of confidence in the findings will be assessed using Confidence in the Evidence from Reviews of Qualitative research. Data will be analysed using the 'best fit' framework synthesis approach, drawing on the Health Stigma and Discrimination Framework., Discussion: This review will provide an in-depth understanding of the stigma associated with mental health conditions and AOD use among people from migrant and ethnic minority backgrounds. The findings will inform culturally responsive interventions that aim to reduce the negative impact of stigma on individuals, families and communities., Systematic Review Registration: PROSPERO CRD42021204057., (© 2022. The Author(s).)

Purpose: Comprehensive primary health care (PHC) models are seldom implemented in high income countries, in part due to their contested legitimacy in neoliberal policy environments. This article explores how merging affected the perceived legitimacy of independent community health organisations in Victoria, Australia, in providing comprehensive PHC services., Design/methodology/approach: A longitudinal follow-up study (2-3 years post-merger) of two amalgamations among independent community health organisations from the state of Victoria, Australia, was conducted. This article explores the perceived effects of merging on (1) the pragmatic, normative and cognitive legitimacy of studied organisations and (2) the collective legitimacy of these organisations in Victoria's health care system. Data were collected through 19 semi-structured interviews with key informants and subjected to template and thematic analyses., Findings: Merging enabled individual organisations to gain greater overall legitimacy as regional providers of comprehensive PHC services and thus retain some capacity to operationalise a social model of health. Normative legitimacy was most enhanced by merging, through acquisition of a large organisational size and adoption of business practices favoured by neoliberal norms. However, mergers may have destabilised the already contested cognitive legitimacy of community health services as a group of organisations and as a comprehensible state-wide platform of service delivery., Practical Implications: Over-reliance on individual organisational behaviour to maintain the legitimacy of comprehensive PHC as a model of organising health and social care could lead to inequities in access to such models across communities., Originality/value: This study shows that organisations can manage their perceived legitimacy in order to ensure the survival of their preferred model of service delivery., (© Emerald Publishing Limited.)

Objective: To analyse a 'socioecological' health promotion discourse and its relationship to orthodox 'economistic' discourse in Australia., Method: In research on health promotion addressing equity and environmental sustainability, we identified a socioecological discourse, based on an ethic of care for people and ecosystems. Using Foucault's concept of discourse as a regime that produces and legitimises certain kinds of knowledge, and ecofeminist historical analysis, we analysed this discourse and its relationship to economism., Results: The socioecological discourse takes social and ecological wellbeing as primary values, while economism takes production and trade of goods and services, measured by money, as primary. Following British invasion, property-owning white men in Australia had the right to control and profit from land, trade, and the work of women and subordinate peoples. A knowledge regime using money as a primary measure reflects this history. In contrast, a First Nations' primary value expressed in the study was 'look after the land and the children'. Conclusion and implications for public health: Public health often attempts to express value through economism, using monetary measures. However, socioecological discourse, expressed for example through direct measures of social and ecological wellbeing, appears more fit for purpose in promoting a fair and sustainable society., (© 2021 The Authors.)

Background Anticoagulants continue to pose high risk of harm to patients despite the discovery of novel direct-acting oral anticoagulant agents that require less monitoring than warfarin. Objective To evaluate patients' knowledge about their oral anticoagulants and the potential role for community pharmacists in optimising safety. Setting Community pharmacies in England. Methods An online survey-based evaluation conducted over a 5-month period to ascertain patients' knowledge, use of anticoagulant alert cards, compliance with national monitoring requirements for warfarin, and frequency and nature of community pharmacist involvement in optimisation. Differences between patients on direct-acting oral anticoagulant agents and warfarin were assessed using Chi squared tests. Main outcome measure Patients' knowledge and use of anticoagulant alert cards. Results A total of 1515 pharmacies participated. Of 22,624 patients, 97% knew that they were taking anticoagulants; 20% had alert cards with them at time of dispensing; 17% had no card and 10% refuted their usefulness. Patients on warfarin were more aware of interactions with over-the-counter or herbal medicines than those on direct-acting oral anticoagulant agents. Of the patients on warfarin, 82% confirmed monitoring in the previous 12 weeks in accordance with national standards, with the international normalised ratio value known for 76%. Pharmacists intervened in a fifth of the patients to issue an alert card, contact the general practitioner for a change in the prescription or due to interacting medicines. Conclusion Patients had reasonable knowledge of their anticoagulation therapy, but areas for improvement were identified. Community pharmacists are well placed to optimise the safe use of anticoagulants.

The gambling industry has grown into a global business in the 21st century. This has created the need for a new emphasis on problem prevention. This article highlights the core themes of the book Setting Limits: Gambling, Science and Public Policy, taking a broad view of the consequences of gambling for society as a burden on health, well-being and equality. The book covers the extent of gambling and gambling-related problems in different societies and presents a critical review of research on industry practices, policy objectives and preventive approaches, including services to people suffering from gambling and its consequences. It discusses the developments in game characteristics and gambling environments and provides evidence on how regulation can affect those. Effective measures to minimize gambling harm exist and many are well supported by scientific evidence. They include restrictions on general availability as well as selective measures to prevent gamblers from overspending. The revenue generated from gambling for the industry, governments, and providers of public services funded from gambling returns presents an obstacle to developing policies to implement harm-reduction measures. A public interest approach must weigh these interests against the suffering and losses of the victims of gambling., (© 2020 Society for the Study of Addiction.)

Time-limited prevention initiatives are frequently used to address complex and persisting public health issues, such as non-communicable diseases. This often creates issues in terms of achieving sustainable change. In this study, we use a system dynamic perspective to explore the effects of stop-start funding over system behaviour in two community-based initiatives designed to prevent chronic diseases and obesity. We conducted a qualitative exploratory study using complexity theory as an analytical lens of two Healthy Together Communities (HTCs) initiatives in Victoria, Australia. Data were generated from 20 semi-structured interviews with health promotion practitioners and managers, from community health and local government organizations. Template analysis based on properties of complex systems informed the inductive identification of system behaviour narratives across the stop-start life-course of HTCs. A central narrative of system behaviour emerged around relationships. Within it, we identified pre-existing contextual conditions and intervention design elements that influenced non-linearity of system self-organization and adaptation, and emergence of outcomes. Examples include cynicism, personal relationships and trust, and history of collaboration. Feedback loops operated between HTCs and these conditions, in a way that could influence long-term system behaviour. Taking a dynamic life-course view of system behaviour helps understand the pre-existing contextual factors, design and implementation influences, and feedback loops which shape the long-term legacy of short-lived interventions aimed at solving complex issues. In turn, greater awareness of such interactions can inform better design and implementation of community-based interventions., (© The Author(s) 2019. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Complexity and systems science are increasingly used to devise interventions to address health and social problems. Boundaries are important in systems thinking, as they bring attention to the power dynamics that guide decision-making around the framing of a situation, and how it is subsequently tackled. Using complexity theory as an analytical frame, this qualitative exploratory study examined boundary interactions between local government and community health organizations during the operationalization of a systems-based initiative to prevent obesity and chronic diseases (Healthy Together Communities-HTCs) in Victoria, Australia. Across two HTC sites, data was generated through semi-structured interviews with 20 key informants, in mid-2015. Template analysis based on properties of complex systems was applied to the data. The dynamics of boundary work are explored using three case illustrations: alignment, boundary spanning and boundary permeability. Alignment was both a process and an outcome of boundary work, and occurred at strategic, operational and individual levels. Boundary spanning was an important mechanism to develop a unified collaborative approach, and ensure that mainstream initiatives reached disadvantaged groups. Finally, some boundaries exhibited different levels of permeability for local government and community health organizations. This influenced how each organization could contribute to HTC interventions in unique, yet complementary ways. The study of boundary work offers potential for understanding the mechanisms that contribute to the nonlinear behaviour of complex systems. The complementarity of partnering organizations, and boundary dynamics should be considered when designing and operationalizing multilevel, complex systems-informed prevention initiatives., (© The Author(s) 2019. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Objectives: To address the current status of responsible gambling (RG) as the dominant discourse for reducing gambling harm., Study Design: The article is a narrative review of relevant literature analysed discursively., Methods: We identified significant texts describing the discourse of RG and analysed these to extract major characteristics and themes of the discourse. These were then subjected to a critique, using the public health discourses as an alternative system for addressing gambling harm., Results: The discourse of RG is inadequate for preventing or minimising gambling harm. A public health-focused approach to prevent and minimise gambling harm is likely to be far more effective but will be opposed by vested interests., Conclusions: It is timely to consider abandoning the discourse of RG. This discourse has been discredited because of its complicity with vested interests and a lack of evidence to demonstrate its efficacy in preventing or reducing harm. A public health response to the prevention of gambling harm is feasible and practical and can and should be further developed and implemented rapidly., (Copyright © 2020 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.)

Background: Despite increasing attention to the social determinants of health in recent decades, globally there is an unprecedented burden from non-communicable diseases (NCDs). Recently, the corporate and commercial conditions associated with these, commercial determinants of health (CDoH), have also begun to receive attention. This research aims to articulate the CDoH as described in the literature, summarize substantive findings, and assess strengths and limitations of current literature., Methods: Systematic review of formal (Medline, EMBASE, Scopus, Global Health) and grey literature (database, Google Advanced, targeted website, citation searching). Searching identified 125 texts for full-text review, with 33 included for final review. Data extracted were analyzed thematically., Results: The dynamics constituting CDoH include broad facilitators such as globalization of trade, corporate structures, and regulatory systems, articulation of social and economic power, neoliberal and capitalist ideologies; additional elements include corporate activities such as marketing, corporate political activities, corporate social responsibility, extensive supply chains, harmful products and production, and issues of accessibility. These contribute significantly to worsened global health outcomes., Conclusions: Literature describing effects of macro conditions and corporate activities on health could usefully utilize CDoH terminology. Facilitation via revised, consistent and operational definition of CDoH would assist. Social, political, commercial and economic structures and relations of CDoH are under-theorized. Systematic approaches to identifying, describing, and disrupting these are required to improve global health.

Background: Electronic gambling machines (EGMs) are in casinos and community venues (hotels and clubs) in all jurisdictions in Australia, except Western Australia (only in casino). EGMs have a range of features that can affect how people gamble, which can influence losses incurred by users. The Northern Territory Government recently changed two EGM policies - the introduction of note acceptors on EGMs in community venues, and an increase in the cap from 10 to 20 EGMs in hotels and 45 to 55 in clubs. This study evaluates two changes in EGM policy on user losses in community venues, and tracks changes in user losses per adult, EGM gambler, and EGM problem/moderate risk gambler between 2005 and 2015., Methods: Trends in venue numbers, EGM numbers, user losses and user losses per EGM by venue type and size are presented to determine if EGM policy changes affected user losses. Data from the 2005 and 2015 NT gambling surveys are used to determine EGM user losses per adult, per EGM gambler, and per EGM problem and/or moderate risk gambler, with several assumptions applied., Results: From 2010 (post smoking ban) to 2013 real user losses were stagnant, but from 2013 to 2017, real user losses in community venues increased 19, 9, 8 and 5% per annum, with increases higher in clubs and hotels with the maximum allowable number of EGMs. Over the same period user losses in the two casinos declined by 13%. Between 2005 and 2015, estimated user losses per EGM problem/moderate risk and problem gambler increased by 5 and 34% respectively., Conclusions: The analysis demonstrates that reductions in how much money gamblers can insert into an EGM (load-up limit), and/or the abolition of note acceptors, and reductions in the number of EGMs in venues is likely to reduce harm from EGM use. Given the demonstrated inability for Australian jurisdictions to identify and implement effective harm prevention and minimisation interventions, a national approach to gambling regulation in Australia may be desirable. Similarly, national co-ordination of research, particularly on EGMs and online betting is required to better understand changes in gambling policy on related harms.

Comprehensive theories of health justice can supplement rights-based approaches like primary health care, by conceptualizing key terms, and systematizing knowledge about structural factors that influence health. Our aim was to use "health capability" as a theoretical lens for understanding how primary health care approaches might address structural factors impeding health in a rural Swazi community. We conducted abductive, interpretive, analysis of a mixed-method (QUAL+quan) data set about "health capability deprivations," generated through participatory action research. Four themes are discussed: illness and disease, unhealthy daily living environments, inability to move freely, and gendered expectations and norms. The analysis demonstrates that there were complex interrelationships between health capability deprivations, material and ideological deprivation prevented community members from aspiring to or securing their right to health, health capability theory can augment primary health care approaches and vice versa, and qualitatively driven, mixed-method research can generate unique insights about structural factors that influence health.