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Background: People living with HIV have accounted for 38–50% of those affected in the 2022 multicountry mpox outbreak. Most reported cases were in people who had high CD4 cell counts and similar outcomes to those without HIV. Emerging data suggest worse clinical outcomes and higher mortality in people with more advanced HIV. We describe the clinical characteristics and outcomes of mpox in a cohort of people with HIV and low CD4 cell counts (CD4 Methods: A network of clinicians from 19 countries provided data of confirmed mpox cases between May 11, 2022, and Jan 18, 2023, in people with HIV infection. Contributing centres completed deidentified structured case report sheets to include variables of interest relevant to people living with HIV and to capture more severe outcomes. We restricted this series to include only adults older than 18 years living with HIV and with a CD4 cell count of less than 350 cells per mm3 or, in settings where a CD4 count was not always routinely available, an HIV infection clinically classified as US Centers for Disease Control and Prevention stage C. We describe their clinical presentation, complications, and causes of death. Analyses were descriptive. Findings: We included data of 382 cases: 367 cisgender men, four cisgender women, and ten transgender women. The median age of individuals included was 35 (IQR 30–43) years. At mpox diagnosis, 349 (91%) individuals were known to be living with HIV; 228 (65%) of 349 adherent to antiretroviral therapy (ART); 32 (8%) of 382 had a concurrent opportunistic illness. The median CD4 cell count was 211 (IQR 117–291) cells per mm3, with 85 (22%) individuals with CD4 cell counts of less than 100 cells per mm3 and 94 (25%) with 100–200 cells per mm3. Overall, 193 (51%) of 382 had undetectable viral load. Severe complications were more common in people with a CD4 cell count of less than 100 cells per mm3 than in those with more than 300 cells per mm3, including necrotising skin lesions (54% vs 7%), lung involvement (29% vs 0%) occasionally with nodules, and secondary infections and sepsis (44% vs 9%). Overall, 107 (28%) of 382 were hospitalised, of whom 27 (25%) died. All deaths occurred in people with CD4 counts of less than 200 cells per mm3. Among people with CD4 counts of less than 200 cells per mm3, more deaths occurred in those with high HIV viral load. An immune reconstitution inflammatory syndrome to mpox was suspected in 21 (25%) of 85 people initiated or re-initiated on ART, of whom 12 (57%) of 21 died. 62 (16%) of 382 received tecovirimat and seven (2%) received cidofovir or brincidofovir. Three individuals had laboratory confirmation of tecovirimat resistance. Interpretation: A severe necrotising form of mpox in the context of advanced immunosuppression appears to behave like an AIDS-defining condition, with a high prevalence of fulminant dermatological and systemic manifestations and death. Funding: None.

Significance: Cancer is related to redox biology from many points of view, such as initiation and promotion, metabolism and growth, invasion and metastasis, vascularization, or through the interaction with the immune system. In addition, this extremely complex relationship depends on the redox homeostasis of each cellular compartment, which might be used to fight cancer. Recent Advances: New ways of modulating specific and little explored aspects of redox biology have been revealed, as well as new delivery methods or uses of previously known treatments against cancer. Here, we review the latest experimental evidence regarding redox biology in cancer treatment and analyze its potential impact in the development of improved and more effective antineoplastic therapies. Critical Issues: A critical issue that deserves particular attention is the understanding that both extremes of redox biology (i.e., oxidative stress [OS] and reductive stress) might be useful or harmful in relation to cancer prevention and treatment. Future Directions: Additional research is needed to understand how to selectively induce reductive or OS adequately to avoid cancer proliferation or to induce cancer cell death.

Background The 13-item Patient Activation Measure (PAM-13) is an instrument that assesses people's knowledge, skills and confidence for self-management of their health and health care. Scores on the PAM-13 have been shown to predict adherence to health behaviours, health-related outcomes and health care costs. Objectives To develop a European Spanish adaptation of the original PAM-13 and to examine its psychometric properties in a sample of chronic patients. Methods The PAM-13 was forward-backward translated and then completed by chronic patients attending a primary health care centre. Data were analysed with a Rasch model. We assessed the functioning of the rating scale, its reliability, the item goodness-of-fit, differential item functioning (DIF), local dependence, unidimensionality and correlation analysis. Results A total of 208 patients (80%) completed the questionnaire. Data showed a fit to the Rasch model. More than 50% of patients endorsed all the items. Item rank for the Spanish sample was similar to the original, with few differences. We found significant differences (P < 0.05) in PAM-13 measures according to adherence to prescribed medicines and positive correlations with self-efficacy and physical quality of life. Conclusions The European Spanish PAM-13 is a reliable and valid instrument for assessing activation in patients with chronic disease in Spain. We suggest adding new items to the instrument so as to examine patients with higher activation levels in the future. Further studies are needed to evaluate the usefulness of this new Spanish PAM-13 in different settings and populations, as well as to examine the relationship between PAM-13 scores and other health-related outcomes.

ObjectiveIn stroke survivors, atrial fibrillation (AF) is typically evaluated solely by short-term ECG monitoring in the stroke unit. Prolonged continuous ECG monitoring or insertable cardiac monitors require substantial resources. Chest and thumb ECG could provide an alternative means of AF detection, which in turn could allow prompt anticoagulation to prevent recurrent stroke. The objective of this study was to assess the yield of newly diagnosed AF during 28 days of chest and thumb ECG monitoring two times per day in cryptogenic stroke.MethodsThis study, Transient ECG Assessment in Stroke Evaluation, included patients who had a stroke from Region Gävleborg, Sweden, between 2017 and 2019. Patients with a recent ischaemic stroke without documented AF (or other reasons for anticoagulation) before or during ECG evaluation in the stroke unit were evaluated using the Coala Heart Monitor connected to a smartphone application for remote monitoring.ResultsThe prespecified number of 100 patients (mean age 67.6±10.8 years; 60% men) was analysed. In nine patients (9%, number needed to screen 11) AF but no other significant atrial arrhythmias (>30 s) was diagnosed. The mean CHA2DS2-VASc score was similar among patients with AF and no AF (4.9±1.1 vs 4.3±1.3; p=0.224) and patients with AF were older (74.3±9.0 vs 66.9±10.8; p=0.049). Patients performed on average 90.1%±15.0% of scheduled transmissions.ConclusionIn evaluation of cryptogenic stroke, 9% of patients had AF detected using chest and thumb ECG two times per day during 1 month. In many stroke survivors, this is a feasible approach and they will be potentially protected from recurrent stroke by anticoagulation treatment.Trial registration numberNCT03301662.

Rationale aims and objectives The increasing amount of the clinical research conducted in the primary health care has enabled extending research beyond traditional settings, but this transfer has implied some trade-offs. Health care professionals who conduct research with trusted patients require assuming the ethical standards of research and communication skills to enable patients' autonomy and freedom of choice. This study aims to measure the opinions of health professionals and patients on issues of communication in clinical research. Method A cross-sectional study with health care professionals and patients from primary health care centres in Barcelona (Spain). Each group completed a similar self-administered questionnaire. A Rasch model was fitted to data. After examination of goodness-of-fit, differences between groups were compared using analysis of variance, and patients' measures were calibrated to professionals' measures to compare overall mean measures. Results Professionals and patients found the ethical attitudes most difficult to endorse related to trust in clinical researchers and conflicts of interest. Patients' perceptions of professional ethical behaviour were significantly lower than professionals'. Different item functioning between nurses and family doctors was found in the item on seeking ethical collaboration when collaborating in clinical research. Effective knowledge of ethical norms was associated with greater perceived ethical values in clinical research and confidence in health care professionals among patients. Conclusions Differences in the views of the communication process between patients and professionals could alert research boards, health care institutions and researchers to the need for greater transparency, trust and ethical instruction when patients are involved in clinical research.

Background In pregnant women, the use of Mycophenolic acid (MPA) is associated with teratogenicity. Recently, the European Medicines Agency (EMEA) and the Spanish Agency of Medicine and Sanitary Products (AEMPS) warned about the potential teratogenic effects of MPA. These adverse events may occur even in children from males on treatment with MPA. However, evidence of malformations in offsprings of male kidney transplanted patients (KT) exposed to MPA is limited. Thus, the present study aimed to evaluate the incidence of offspring malformations in children of renal transplanted males under MPA. Materials and methods We conducted a retrospective study in which we evaluated the incidence of malformations in descendants from male recipients that were exposed or not to MPA before and at the time of conception. Two groups of patients were evaluated. Those exposed to MPA (MPA group, n = 20) and the non-MPA group (n = 13) that included patients that did not receive AZA (n = 5) and eight that did receive AZA (n = 8) at the time of conception. Results A total of forty-nine post-transplant conceptions were identified from 33 different renal transplanted males. MPA was used as the immunosuppressant in 28 of the conceptions. Males from the non-MPA group fathered the other 21 children. Median time from grafting to conception was 6.1 (IQR 2.4–11.1) years, and it was similar between groups. There were eight miscarriage episodes, 2 in the non-MPA group and 6 in the MPA group although differences were not reached. After that, all patients had children without problems. No malformations were detected in any of the 49 regardless whether they were exposed or not to MPA. Conclusions No evidence of MPA-associated malformations was observed in descendants of kidney transplanted males on treatment with MPA. Further research is warranted to confirm our findings to properly advice transplanted males keen to procreate.

Normative ethics includes ethical behaviour health care professionals should uphold in daily practice. This study assessed the degree to which primary health care (PHC) professionals endorse a set of ethical standards from these norms. Health care professionals from an urban area participated in a cross-sectional study. Data were collected using an anonymous, self-administered questionnaire. We examined the level of ethical endorsement of the items and the ethical performance of health care professionals using a Rasch multidimensional model. We analysed differences in ethical performance between groups according to sex, profession and knowledge of ethical norms. A total of 452 Professionals from 56 PHC centres participated. The level of ethical performance was lower in items related to patient autonomy and respecting patient choices. The item estimate across all dimensions showed that professionals found it most difficult to endorse avoiding interruptions when seeing patients. We found significant differences in two groups: nurses had greater ethical performance than family physicians (p

Resumen Fundamento y objetivo Recientemente se ha desarrollado un nuevo sistema de pH-metria esofagica ambulatoria sin cateter, el sistema Bravo®. El objetivo de este estudio es comprobar la tolerancia, la seguridad y la eficacia del sistema en la medicion del reflujo gastroesofagico, en comparacion con la pH-metria convencional. Pacientes y metodo El estudio se realizo en un grupo control constituido por 10 voluntarios sanos (grupo 1) y en un grupo de 40 pacientes con sintomas de enfermedad por reflujo gastroesofagico (grupos 2 y 3). A todos los pacientes se les realizo endoscopia digestiva alta, manometria esofagica y pH-metria esofagica convencional y/o pH-metria sin cateter con el sistema Bravo®. Todos los pacientes a los que se realizaron ambas pruebas (grupos 1 y 3) rellenaron un cuestionario sobre molestias fisicas y alteraciones de su actividad diaria. Resultados La tolerancia de la prueba fue mejor con el sistema Bravo® en 9 de los 10 parametros estudiados. En el grupo de voluntarios sanos (grupo 1), la mediana (intervalo) del porcentaje total de pH Conclusiones La pH-metria sin sonda (Bravo®) es mejor tolerada y de mayor satisfaccion para los voluntarios sanos y los pacientes que la pH-metria convencional, en ocasiones incluso es mas eficaz para el estudio del reflujo acido por la menor frecuencia de resultados negativos.

The increasing amount of the clinical research conducted in the primary health care has enabled extending research beyond traditional settings, but this transfer has implied some trade-offs. Health care professionals who conduct research with trusted patients require assuming the ethical standards of research and communication skills to enable patients' autonomy and freedom of choice. This study aims to measure the opinions of health professionals and patients on issues of communication in clinical research.A cross-sectional study with health care professionals and patients from primary health care centres in Barcelona (Spain). Each group completed a similar self-administered questionnaire. A Rasch model was fitted to data. After examination of goodness-of-fit, differences between groups were compared using analysis of variance, and patients' measures were calibrated to professionals' measures to compare overall mean measures.Professionals and patients found the ethical attitudes most difficult to endorse related to trust in clinical researchers and conflicts of interest. Patients' perceptions of professional ethical behaviour were significantly lower than professionals'. Different item functioning between nurses and family doctors was found in the item on seeking ethical collaboration when collaborating in clinical research. Effective knowledge of ethical norms was associated with greater perceived ethical values in clinical research and confidence in health care professionals among patients.Differences in the views of the communication process between patients and professionals could alert research boards, health care institutions and researchers to the need for greater transparency, trust and ethical instruction when patients are involved in clinical research.

Over the last few decades, the terminology, diagnostic techniques and treatment of patients with altered levels of consciousness have varied considerably. At the same time, the percentage of patients in this clinical situation has undergone a marked increase.The purpose of this study is to present a historical review of the different terms that have been used in the medical literature to describe patients with altered states of consciousness. The article also includes the different diagnostic criteria utilised by research groups that have focused their attention on this population.The concept of 'vegetative state', a term coined back in the sixties, has since been transformed and replaced by other terms with a less negative connotation, such as 'unresponsive wakefulness syndrome'. In parallel, new clinical categories (minimally conscious state or minimally conscious plus) have appeared since it has been acknowledged that there are patients with a low level of consciousness but who nevertheless show signs that are consistent with interaction with the environment by means of unmistakeably voluntary behaviours in response to orders or gestures.The wide spectrum of signs and symptoms shown by patients with altered levels of consciousness reflects the clinical and neuropathological heterogeneity of these states. The current tendency is to describe the state clinically, adding the aetiology and the date of the event that caused the clinical picture. This article focuses on the context of an effort made by the scientific community to highlight the needs of this growing population.

A new catheter-free outpatient oesophageal pH-meter system (Bravo) has recently been developed. The objective of this study is to test the tolerance, safety and efficacy of the system in the measurement of gastric-oesophageal reflux by comparing it with a conventional pH system.The study was performed on a control group consisting of 10 healthy volunteers (group 1) and in a group of 40 patients with symptoms of gastric-oesophageal reflux disease (groups 2 and 3). An upper digestive system endoscopy, oesophageal manometry and oesophageal pH measurements with a conventional system and/or with the Bravo catheter-free system, was performed on all patients. All patients who had both tests done (groups 1 and 2) filled in a questionnaire on any physical problems and changes in their daily activity.The test tolerance was higher with the Bravo system in the 9 parameters studied. In the group of healthy volunteers (group 1), the median (range) of the total percentage of pH4 was 1.1% (0.5-3.1) with the conventional pH and 1.7% (0-3.4) with the Bravo. When comparing the patients with symptoms of gastric-oesophageal reflux disease (group 2) with those who had only one type of pH measurement made, the acid reflux was significantly higher in patients with Barrett's oesophagus than in the rest of the groups, with conventional pH as well as with the Bravo. If we analyse the patient group with disease due to gastric-oesophageal reflux with those on whom both techniques were used (group 3), 7 of the 10 patients had a pathological reflux that only showed up on measuring pH with the Bravo system.Catheter-free pH measurements (Bravo) is better tolerated and with better satisfaction for the healthy volunteers and patients than with conventional PH, even, on occasions being more efficient for studying acid reflux due to the lower incidence of negative results.

Serum antibody detection tests and a urine antigen detection technique were compared in samples from 116 patients epidemiologically characterized as belonging to a legionellosis outbreak. Sera were tested by enzyme-linked immunosorbent assays (ELISAs) for immunoglobulin M (IgM) and IgG plus IgM and by immunofluorescent assays (IFAs) for IgG, IgM, IgA, and polyimmunoglobulin using commercial kits (Vircell); concentrated urines were tested with the Binax NOW Legionella test. ELISA for IgM, ELISA for IgG plus IgM, antigenuria detection, and IFA for IgM were able to diagnose 72.3%, 60.5%, 53.3%, and 51.4%, respectively, of patients. Antigenuria was present in 53.8% of first samples, ELISA detected IgM in 29.7%, ELISA detected IgG plus IgM in 7.9%, and IFA detected IgM in 3.9%. Ten antigenuria-negative first samples tested serologically positive, 9 of them to IgM by ELISA. Despite the single source of the samples included in the study, detection of IgM using a sensitive technique such as ELISA seems to be a suitable complement to antigenuria detection for the diagnosis of legionellosis.

Noe E, Olaya J, Navarro MD, Noguera P, Colomer C, Garcia-Panach J, Rivero S, Moliner B, Ferri J. Behavioral recovery in disorders of consciousness: a prospective study with the Spanish version of the Coma Recovery Scale–Revised. Objective To describe the clinical characteristics and short-term pattern of evolution of a sample of patients within 1 year after acquiring a brain injury that led to a vegetative state (VS) or a minimally conscious state (MCS). Design Cohort study. Setting Inpatient brain injury rehabilitation program. Participants Patients with acquired brain injury (N=32; 47% traumatic, 37.5% hemorrhagic, 15.5% anoxic) who were in a VS or an MCS according to Coma Recovery Scale–Revised (CRS-R) scores. Intervention Integrative multisensory program comprising daily physical rehabilitation procedures and multimodal sensory stimulation. Main Outcome Measure All patients were assessed with a Spanish version of the CRS-R at admission and then monthly for at least 6 months or until emergence from MCS. Results At the time of admission, 12 patients were diagnosed as being in a VS and 20 as being in an MCS. Eight patients were able to emerge from their MCS during follow-up. Seven of these 8 patients were diagnosed as being in an MCS at inclusion, and only 1 was diagnosed as being in a VS. Emergence from an MCS was mostly associated with improvement in both the communication and motor function scales (n=4). Lesser chronicity ( P =.01) and the presence of more than visual behavioral responses at admission ( P =.05) were both significant predictors of emergence from an MCS. Conclusions The CRS-R seems appropriate for establishing an immediate prognosis in this population. A quick referral of these patients for specialized assessment and rehabilitation facilities is recommended.