BACKGROUND:Tecovirimat (TPOXX) is an antiviral authorized for the treatment of mpox infections in Canada, but recent clinical trials found it has no impact on symptom duration. METHODS:We conducted a prospective cohort study of individuals diagnosed with mpox in Toronto, Canada. Skin lesion swabs were collected weekly to quantify infectious monkeypox virus (MPXV) shedding through cell culture. The presence of antiviral resistance mutations was assessed by PCR and sequencing the F13L gene. RESULTS:Among 17 participants, 9 received tecovirimat, with a median initiation time of 14 days post-symptom onset. Infectious MPXV was detected in 31% (17/55) of lesion swabs from tecovirimat-treated participants and 32% (20/62) from untreated individuals. Shedding kinetics were similar between groups, with persistent infectious virus detected in several participants beyond 2 weeks of symptoms. Despite more than 7 days after tecovirimat initiation, 4 treated participants still shed viable virus in at least 1 sampled lesion, including up to 15 days after tecovirimat initiation. No known resistance mutations were identified in viral sequences from a subset of lesion swabs from both treated and untreated individuals, suggesting that tecovirimat resistance mutations were not widely circulating in Toronto during the 2022 outbreak. CONCLUSIONS:Our findings suggest that tecovirimat does not significantly impact the duration of infectious MPXV shedding from skin lesions, aligning with recent randomized trial results. These findings highlight the need for alternative antiviral strategies and continued genomic surveillance to monitor resistance emergence.

BACKGROUND:Tecovirimat is an antiviral drug that was used compassionately for treating mpox in high-income settings during the 2022 global outbreak. Randomized controlled trials of its efficacy have not yet been completed. OBJECTIVES:To describe medication adherence, tolerability and clinical outcomes of adults receiving open-label tecovirimat for mpox infection. METHODS:We conducted a prospective observational study and a retrospective case series of adults with mpox cared for at three academic hospitals in Toronto, Canada, between May and August 2022. We present a descriptive analysis of those prescribed oral tecovirimat 600 mg twice daily for 14 days for the management of severe manifestations. RESULTS:Of 69 consenting participants, all were cisgender men, of whom 60 (87%) identified as gay, and 6 (9%) as bisexual. Nearly half (46%) were living with HIV, with a median (IQR) CD4 count of 468 (328-678) cells/mm3, among whom plasma HIV RNA was <20 copies/mL in 29 (91%) participants. One-third (33%) of participants received tecovirimat during the course of their illness. All participants experienced a decline in number of symptoms over time, but three treated participants initially experienced worsening symptoms despite therapy. Self-reported adherence to tecovirimat was excellent and tolerability was good. CONCLUSIONS:Our experience prescribing tecovirimat for mpox suggests it is safe and well tolerated, but the evolution of symptoms in some tecovirimat-treated patients underscores the ongoing uncertainty regarding its efficacy. In the context of considerable community demand for the drug, efforts should be made to connect mpox patients to rigorous randomized controlled trials, given this ongoing clinical equipoise.

Background: Pre-exposure prophylaxis (PrEP) for HIV is underutilized. We aimed to identify barriers to use of PrEP and strategies that may facilitate its uptake. Methods: Gay, bisexual and other men who have sex with men, aged 19 years or older and living in Ontario and British Columbia, Canada, completed a cross-sectional survey in 2019–2020. Participants who met Canadian PrEP guideline criteria and were not already using PrEP identified relevant barriers and which strategies would make them more likely to start PrEP. We described the barriers and strategies separately for Ontario and BC. Results: Of 1527 survey responses, 260 respondents who never used PrEP and met criteria for PrEP were included. In Ontario, the most common barriers were affordability (43%) and concern about adverse effects (42%). In BC, the most common reasons were concern about adverse effects (41%) and not feeling at high enough risk (36%). In Ontario, preferred strategies were short waiting time (63%), the health care provider informing about their HIV risk being higher than perceived (62%), and a written step-by-step guide (60%). In BC, strategies were short waiting time (68%), people speaking publicly about PrEP (68%), and the health care provider counselling about their HIV risk being higher than perceived (64%), adverse effects of PrEP (65%) and how well PrEP works (62%). Interpretation: Concern about adverse effects and not self-identifying as having high risk for HIV were common barriers, and shorter waiting times may increase PrEP uptake. In Ontario, the findings suggested lack of affordability, whereas in BC, strategies involving health care providers were valued.

BackgroundSelf-perceived and clinically assessed HIV risk do not always align. We compared self-perceived and clinically assessed risk of HIV and the reasons for self-perceived low risk of HIV among gay, bisexual, and other men who have sex with men (GBM) from large urban centers in Ontario and British Columbia, Canada.MethodsNever PrEP users recruited from sexual health clinics or online, completed a cross-sectional survey between July/2019 and August/2020. We contrasted self-perceived HIV risk against criteria from the Canadian PrEP guidelines and participants were categorized as concordant or discordant. We used content analysis to categorize participants' free-text explanations for perceived low HIV risk. These were compared with answers to quantitative responses about condomless sex acts and number of partners.ResultsOf 315 GBM who self-perceived low risk of HIV, 146 (46%) were considered at high risk according to the guidelines. Participants with discordant assessment were younger, had less years of formal education, were more often in an open relationship and were more likely to self-identify as gay. Reasons for self-perceived low HIV risk in the discordant group were condom use (27%), being in a committed relationship/having one main partner (15%), having no or infrequent anal sex (12%) and having few partners (10%).ConclusionsThere is a disjuncture between self-perceived and clinically assessed risk of HIV. Some GBM may underestimate their HIV risk and clinical criteria may overestimate risk. Bridging these gaps requires efforts to increase HIV risk awareness in the community, and refinement of clinical assessments based on individualized discussions between the provider and the user.

Abstract Background We aimed to explore the association between PrEP-related stereotypes and perceived disapproval (hereafter PrEP-related stigma), and PrEP use. Methods We used data from a cross-sectional online survey among adult gay, bisexual, other men who have sex with men in Ontario and British Columbia, Canada. Participants were recruited 2019–2020 in-person from sexual health clinics and outreach programs, and online through dating mobile applications and websites. We used logistic regression models to explore the relationship between PrEP-related stigma and: 1-being a ‘never’ versus ‘current’ PrEP user, and 2-being a ‘former’ versus ‘current’ user. Results The median age of the sample was 32 (Q1-Q3 = 27–40), most were white born in Canada (48%), 45% had never used PrEP, 16% were former PrEP users and 39% were current PrEP users. Of 1527 individuals who started the survey, 1190 participants answered questions about PrEP-related stigma: 254 (21.3%) were classified as having low level of PrEP-related stigma, 776 (65.2%) intermediate, and 160 (13.5%) high. No significant association was found when never PrEP users and current PrEP users were compared: adjusted OR = 1.44 (95%-CI: 0.8–2.5). High PrEP-related stigma was positively associated with being a former PrEP user compared to being a current PrEP user: adjusted OR = 2.5 (95%-CI: 1.3–4.9). Conclusion PrEP-related stigma is associated with not using PrEP, particularly with PrEP discontinuation. Our findings indicate that stigma persists as a barrier to PrEP use.

Objective This review investigated the effectiveness of clinical interventions on depressive symptoms in people with all types of chronic pain. Methods We searched seven electronic databases and reference lists on September 15, 2020, and included English-language, systematic reviews and meta-analyses of trials that examined the effects of clinical interventions on depressive outcomes in chronic pain. Two independent reviewers screened, extracted, and assessed the risk of bias. PROSPERO registration: CRD42019131871. Results Eighty-three reviews were selected and included 182 meta-analyses. Data were summarized visually and narratively using standardized mean differences with 95% confidence intervals as the primary outcome of interest. A large proportion of meta-analyses investigated fibromyalgia or mixed chronic pain, and psychological interventions were most commonly evaluated. Acceptance and commitment therapy for general chronic pain, and fluoxetine and web-based psychotherapy for fibromyalgia showed the most robust effects and can be prioritized for implementation in clinical practice. Exercise for arthritis, pharmacotherapy for neuropathic pain, self-regulatory psychotherapy for axial pain, and music therapy for general chronic pain showed large, significant effects, but estimates were derived from low- or critically low-quality reviews. Conclusions No single intervention type demonstrated substantial superiority across multiple pain populations. Other dimensions beyond efficacy, such as accessibility, safety, cost, patient preference, and efficacy for non-depressive outcomes should also be weighed when considering treatment options. Further effectiveness research is required for common pain types such as arthritis and axial pain, and common interventions such as opioids, anti-inflammatories and acupuncture.

Abstract:HIV pre-exposure prophylaxis (PrEP) should be free across Canada for all those who meet evidence-based guidelines. PrEP is a highly effective tool for preventing HIV acquisition that has been approved for use in Canada since 2016. However, without public drug plans or private insurance, generic PrEP costs approximately $200 to $250 CAD monthly. Current PrEP programs across Canada are a confusing patchwork system with variability in coverage and prohibitive co-payments, making PrEP too expensive for many equity-deserving groups. However, publicly funded PrEP programs are demonstrated to be cost-effective and even cost-saving by reducing the long-term healthcare expenditures associated with managing HIV. PrEP is not just an individual-level clinical tool. It is a public health intervention. Alongside “treatment as prevention,” PrEP is an important population-level strategy for eliminating new HIV infections in Canada and can play a role in helping to address complex health inequities affecting communities highly affected by HIV. Navigating drug coverage for patients consumes time and resources among healthcare providers that could be spent helping to improve other social determinants of health. Affordability will remain the foremost barrier to PrEP access until PrEP is made free to all those who meet evidence-based guidelines.

HIV pre-exposure prophylaxis (PrEP) should be free across Canada for all those who meet evidence-based guidelines. PrEP is a highly effective tool for preventing HIV acquisition that has been approved for use in Canada since 2016. However, without public drug plans or private insurance, generic PrEP costs approximately $200 to $250 CAD monthly. Current PrEP programs across Canada are a confusing patchwork system with variability in coverage and prohibitive co-payments, making PrEP too expensive for many equity-deserving groups. However, publicly funded PrEP programs are demonstrated to be cost-effective and even cost-saving by reducing the long-term healthcare expenditures associated with managing HIV. PrEP is not just an individual-level clinical tool. It is a public health intervention. Alongside "treatment as prevention," PrEP is an important population-level strategy for eliminating new HIV infections in Canada and can play a role in helping to address complex health inequities affecting communities highly affected by HIV. Navigating drug coverage for patients consumes time and resources among healthcare providers that could be spent helping to improve other social determinants of health. Affordability will remain the foremost barrier to PrEP access until PrEP is made free to all those who meet evidence-based guidelines.

The purpose of this review was to investigate the association between publication performance and the organizational and psychosocial work environment of academics in a university setting. In 2018 we conducted database searches in Web of Science, Medline and other key journals (hand-searched) from 1990 to 2017 based on population, exposure and outcome framework. We examined reference lists, and after a title and abstract scan and full-text reading we identified studies that were original research and fulfilled our inclusion criteria. Articles were evaluated as having a low, moderate or high risk of bias using a quality assessment form. From the studies ( n = 32) identified and synthesized, work-environment characteristics could explain the quality and quantity aspects of publication performance of academics. Management practices, leadership and psychosocial characteristics are influential factors that affect academics’ publication productivity. Most of the reviewed studies were judged to be of moderate quality because of issues of bias, related to the measuring of publication outcome. The findings in the studies reviewed suggest that highly productive research academics and departments significantly tend to be influenced by the organizational and psychosocial characteristics of their working environment. The practical relevance of this review is that it highlights where academics’ performance needs support and how the work environment can be improved to bolster publication productivity.

Abstract Background HIV Pre-exposure prophylaxis (PrEP) is an underutilized intervention to prevent HIV infection in Canada. Known barriers to PrEP uptake include lack of awareness, low HIV risk perception, side effects, PrEP not being publicly funded (which is the case in Ontario) and stigma. We aimed to identify barriers to PrEP use and actions that may facilitate PrEP uptake in Ontario and British Columbia. Methods Gay, bisexual and other men who have sex with men 19 years or older living in Ontario and British Columbia, Canada, answered a survey between July 2019 and August 2020. Participants who met Canadian PrEP guideline criteria for PrEP and not already using PrEP indicated which barriers were relevant to them and which actions would make them more likely to start PrEP. We used descriptive statistics and tested differences between Ontario and British Columbia using Chi-square tests for proportions and t-tests or Wilcoxon rank-sum tests for continuous variables. Results Of 1527 survey responses, 260 (184 in Ontario and 76 in British Columbia) who were never PrEP users and met criteria for PrEP were included. In Ontario, the most common barriers were affordability (43%) and concern about side effects (42%). In British Columbia, the most common reasons were concern about side effects (41%) and not feeling at high enough risk (36%). In Ontario, the actions that would most likely encourage the respondent to start PrEP were short waiting time (63%), the healthcare provider informing about their HIV risk being higher than perceived (62%) and a written step-by-step guide (60%). In British Columbia, the actions that would most likely encourage the respondent to start PrEP were short waiting time (68%), people speaking publicly about PrEP (68%) and their healthcare provider counselling about: their HIV risk being higher than perceived (64%), side effects of PrEP (64%) and about how PrEP works (62%). Table. Top reasons for not using PrEP and top actions that might influence the decision to start PrEP stratified by province. (n= 184 in Ontario, n= 76 in British Columbia). Conclusion Concern about side effects and not feeling at high enough risk were common barriers. Short waiting times may increase PrEP uptake. In Ontario, the findings suggested lack of affordability. In British Columbia, actions involving healthcare providers were valued. Disclosures Kevin Woodward, MD FRCPC, Gilead (Independent Contractor) Darrell Tan, MD PhD, Abbvie (Grant/Research Support)Gilead (Grant/Research Support)GlaxoSmithKline (Scientific Research Study Investigator)ViiV Healthcare (Grant/Research Support)

Objective: To evaluate the cost-effectiveness of deep tissue massage ('massage'), strengthening and stretching exercises ('exercises') or a combination of both ('combined therapy') in comparison with advice to stay active ('advice') for subacute and persistent neck pain, from a societal perspective. Methods: We conducted a cost-effectiveness analysis alongside a four-arm randomized controlled trial of 619 participants followed-up for one year. Health-related quality of life was measured using EQ 5D 3L and costs were calculated from baseline to one year. The interventions were ranked according to quality adjusted life years (QALYs) in a cost-consequence analysis. Thereafter, an incremental cost per QALY was calculated. Results: In the cost-consequence analysis, in comparison with advice, exercises resulted in higher QALY gains, and massage and the combined therapy were more costly and less beneficial. Exercises may be a cost-effective treatment compared with advice to stay active if society is willing to pay 17 640 EUR per QALY. However, differences in QALY gains were minimal; on average, participants in the massage group, spent a year in a state of health valued at 0.88, exercises: 0.89, combined therapy: 0.88 and, advice: 0.88. Conclusions: Exercises are cost-effective compared to advice given that the societal willingness to pay is above 17 640 EUR per year in full health gained. Massage and a combined therapy are not cost-effective. While exercise appeared to have the best cost/benefit profile, even this treatment had only a modest benefit and treatment innovation is needed. Advice to stay active remains as a good therapeutic alternative from an economical perspective.

OBJECTIVE:To compare the effectiveness of deep tissue massage, supervised strengthening and stretching exercises, and a combined therapy (exercise followed by massage) (index groups), with advice to stay active (control group). METHODS:Randomized controlled trial of 619 adults with subacute or persistent neck pain allocated to massage (n = 145), exercise (n = 160), combined therapy (n = 169) or advice (n = 147). Primary outcomes were minimal clinically important improvements in neck pain intensity and pain-related disability based on adapted questions from the Chronic Pain Questionnaire. Secondary outcomes were perceived recovery and sickness absence. Outcomes were measured at seven, 12, 26 and 52 weeks. RESULTS:We found improvement in pain intensity favouring massage and combined therapy compared to advice; at seven weeks (RR = 1.36; 95%CI:1.04-1.77) and 26 weeks (RR = 1.23; 95%CI:0.97-1.56); and seven (RR = 1.39; 95%CI:1.08-1.81) and 12 weeks (RR = 1.28; 95%CI:1.02-1.60) respectively, but not at later follow-ups. Exercise showed higher improvement of pain intensity at 26 weeks (RR = 1.31; 95%CI:1.04-1.65). Perceived recovery was higher in the index groups than in the advice group at all follow-ups. We found no consistent differences in pain related disability or sickness absence. CONCLUSIONS:In this study, at 12-months follow-up, none of the index therapies were more effective than advice in terms of pain intensity in the long term or in terms of pain-related disability in the short or long term. However, the index therapies led to higher incidence of improvement in pain intensity in the short term, and higher incidence of favorable perceived recovery in the short and in the long term than advice. TRIAL REGISTRATION:ISRCTN01453590. Registered 3 July 2014.

Objectives: The objectives of this study were to describe the 1-year trajectories of disabling subacute or persistent neck pain and to investigate whether baseline age, sex, pain characteristics, and depressive symptoms are associated with such trajectories. Study Design and Setting: Participants (n=617) included in a randomized controlled trial provided weekly pain intensity ratings by responding to text messages over 1 year. We used latent class mixed model analyses to identify clusters of individual trajectories. Thereafter, we used logistic regression to determine the association between baseline age, sex, pain characteristics, depressive symptoms and treatment, and trajectories of neck pain. Results: Six different clusters of trajectories were identified. Most participants (73%) followed a trajectory of decreasing pain throughout follow-up. The remaining experienced unfavorable trajectories: persistent pain of high intensity (22%) and slightly (3%) or highly (2%) fluctuating levels of pain reaching high levels of pain intensity. Pain intensity at baseline: odds ratio (OR): 3.76 (95% confidence interval [CI]: 2.49-5.68), depressive symptoms: OR: 3.46 (95% CI: 2.01-5.95), younger age: OR: 2.29 (95% CI: 1.48-3.54), female sex: OR: 1.51 (95% CI: 1.01-2.26), and sudden onset of pain: OR: 1.74 (95% CI: 1.13-2.69) were associated with unfavorable trajectories. Conclusions: Most individuals with disabling subacute or chronic neck pain show improvement in pain intensity over a year. However, a quarter present unfavorable trajectories. High pain intensity at baseline, depressive symptoms, younger age, female sex, and sudden onset of pain are factors associated with unfavorable trajectories.

ObjectivesThe effect of a healthy lifestyle on the prognosis of neck pain is unknown. This study aimed to investigate if a healthy lifestyle behaviour influences the risk of long-duration troublesome neck pain among men and women with occasional neck pain.DesignLongitudinal cohort study.SettingsGeneral population, and a subsample of the working population, in Stockholm County, Sweden.ParticipantsThis study involved 5342 men and 7298 women, age 18 to 84, from the Stockholm Public Health Cohort, reporting occasional neck pain at baseline in 2006.MeasuresBaseline information about leisure physical activity, smoking, alcohol consumption and consumption of fruits and vegetables were dichotomised into recommendations for healthy/not healthy behaviour. The exposure, a healthy lifestyle behaviour, was categorised into four levels according to the number of healthy behaviours (HB) met. Generalised linear models were applied to assess the exposure on the outcome long-duration troublesome neck pain (activity-limiting neck pain ≥2 days/week during the past 6 months), at follow-up in 2010.ResultsThe adjusted risk of long-duration troublesome neck pain decreased with increasing adherence to a healthy lifestyle behaviour among both men and women (trend test: p<0.05). Compared with the reference category, none or one HB, the risk decreased by 24% (risk ratio 0.76, 95% CI 0.58 to 0.98) among men and by 34% (0.66, 0.54 to 0.81) among women, with three or four HBs. The same comparison showed an absolute reduction of the outcome by 3% in men (risk difference −0.03, 95% CI −0.05 to −0.01) and 5% in women (-0.05,–0.08 to −0.03). Similar results were found in the working population subsample.ConclusionAdhering to a healthy lifestyle behaviour decreased the risk of long-duration troublesome neck pain among men and women with occasional neck pain. The results add to previous research and supports the importance of promoting a healthy lifestyle behaviour.

Objetivo Determinar la calidad de vida relacionada con la salud (CVRS) en población general del área urbana de Bucaramanga.Metodología Encuesta transversal, realizada entre septiembre y noviembre de 2013, donde se aplicó el cuestionario SF-36 para medir CVRS en población general residentes en cuatro barrios seleccionados por conveniencia. La información fue sistematizada en el programa Excel, se calcularon puntajes por cada dominio y se compararon por edad, sexo, ocupación, escolaridad y estrato socioeconómico de los participantes.Resultados Se entrevistaron 1 098 personas entre 15 y 99 años, 732 (66,7%) mujeres, con edad promedio de 46 años, mediana de escolaridad de 11 años, residentes en estratos socioeconómicos 1 a 4, dedicados principalmente a actividades de comercio/servicios y hogar. Los puntajes en todos los dominios fueron superiores a 60%, considerados indicadores de buena CVRS. Sin embargo, hay un decline de la CVRS con el aumento de la edad, en contraste, los hombres mostraron mejores puntajes de CVRS que las mujeres en todos los dominios, además los estudiantes y personas con mayor escolaridad presentaron niveles más altos de CVRS.Discusión La CVRS en ésta población fue reportada como buena, sin embargo, se identificaron diferencias por edad, sexo, escolaridad y ocupación; que pueden sugerir inequidades en el acceso y uso de los servicios de salud. Estos hallazgos orientan acciones de promoción de la salud tendientes a mejorar la CVRS en éstos grupos vulnerables, como parte de las estrategias del Plan Decenal de Salud Pública en la ciudad.

•Hyperlipidaemia may be associated with the risk of back, neck and/or shoulder pain.•Diabetes may be a risk factor for back, neck and/or shoulder pain among men.•Metabolic conditions may be associated with the risk of musculoskeletal pain.

RESUMEN La necrolisis epidermica toxica es una patologia de escasa ocurrencia, que se acompana de mortalidad elevada y se caracteriza por lesiones cutaneas vesiculo ampollosas que con frecuencia afecta la mucosa respiratoria, digestiva y ocular. Se presenta un caso de la enfermedad atendido en el Hospital Universitario de Santander en octubre del ano 2007 desencadenado por el tratamiento con fenitoina - acido valproico como terapia anticonvulsiva, con desenlace fatal y al cual se le practico autopsia medico cientifca. Se pretende con este trabajo presentar una revision del tema y analizar los factores relacionados con esta grave condicion clinica. Palabras clave: Necrolisis epidermica toxica. Sindrome de Stevens - Johnson. Fenitoina. Esclerosis hipocampal. Autopsia. SUMMARY Toxic epidermal necrolysis is an infrequent pathology, accompanied of high mortality risk in concordance with extension of comprised skin characterized for blisters. Frequently these are present in respiratory, digestive and ocular mucous. An autopsy case is presented occurred in Hospital Universitario de Santander in october 2007 of toxic epidermal necrolysis secondary to treatment with phenytoin associated with valproic acid as anticonvulsivant therapy for messial hippocampal sclerosis. It pretends with this work show a review and to analyze related factors with this condition. Key words: Toxic epidermal necrolysis. Stevens Johnson Syndrome. Phenytoin. Hippocampal sclerosis. Autopsy.