A Closer Look at Racism and Heterosexism in Medical Students’ Clinical Decision-Making Related to HIV Pre-Exposure Prophylaxis (PrEP): Implications for PrEP Education

Social biases among healthcare providers could limit PrEP access. In this survey study of 115 US medical students, we examined associations between biases (racism and heterosexism) and PrEP clinical decision-making and explored prior PrEP education as a potential buffer. After viewing a vignette about a PrEP-seeking MSM patient, participants reported anticipated patient behavior (condomless sex, extra-relational sex, and adherence), intention to prescribe PrEP to the patient, biases, and background characteristics. Minimal evidence for racism affecting clinical decision-making emerged. In unadjusted analyses, heterosexism indirectly affected prescribing intention via all anticipated behaviors, tested as parallel mediators. Participants expressing greater heterosexism more strongly anticipated increased risk behavior and adherence problems, which were associated with lower prescribing intention. The indirect effect via condomless sex remained significant adjusting for background characteristics. Prior PrEP education did not buffer any indirect effects. Heterosexism may compromise PrEP provision to MSM and should be addressed in PrEP-related medical education.     

FRAX and mandibular sparse trabeculation as fracture predictors: a longitudinal study from 1980 to 2002

The fracture assessment tool (FRAX) is widely used for predicting fractures, but better methods are needed. The aim of this study was to determine whether visual assessments of mandibular trabecular bone could improve FRAX predictions. Three age‐cohorts of women were examined twice – 499 women in 1980/1981 and 412 women in 1992/1993; 397 participated in both examinations. Information on 10‐yr fracture events was available, and bone trabeculation was assessed in radiographs as ‘dense’, ‘mixed’, or ‘sparse’. Fracture assessment tool values, without bone mineral density (BMD), were calculated twice. Both sparse trabeculation and FRAX >15% were associated with a twofold higher risk for future fracture in the younger group and with a three‐ to fourfold higher risk for future fracture in the older group. For those with both FRAX >15% and sparse trabeculation, the relative risk (RR) for a fracture in the next 10 yr was 5.9 (95% CI: 3.5–9.8) in the younger group and 22.7 (95% CI: 5.6–92) in the older group. If either FRAX >15% or sparse trabeculation was present, the RR was 2.6 (95% CI: 1.7–4.1) in the younger group and 15.7 (95% CI: 3.9–6.4) in the older group. We concluded that FRAX >15%, without BMD measurements, was an effective fracture predictor, and mandibular sparse trabeculation had a substantial additive effect. Together, FRAX plus mandibular sparse trabeculation predicts major osteoporotic fractures to approximately the same extent as does FRAX with BMD measurements.     

High acquisition rate and internal validity in the Scandinavian Obesity Surgery Registry

BackgroundThe Scandinavian Obesity Surgery Registry (SOReg) is a national quality register that has collected data on bariatric surgery in Sweden since 2007.ObjectiveEvaluate the acquisition rate and internal validity of entered data in SOReg as well as completeness.SettingsNational quality register, Sweden.MethodThe acquisition rate during 2012–2018 was compared with Swedish national databases, while registered data in 89 selected variables (67 mandatory) was compared with medical records of 1860 randomly selected patients from all bariatric centers (n = 39–43) reporting to SOReg. The evaluation was done by 1 independent observer. Completeness of data in the entire registry for the same time period was studied.ResultsThe acquisition rate was 97.4%, because 33,716 of 34,628 patients recorded in the National Inpatient Registry were registered in SOReg. Exact agreement of reabstracted data was seen in 99.0% of 100,200 unique entries. All studied variables had an almost perfect agreement with Cohen’s kappa ranging from .87–1, that is, >.81 according to Landis and Koch criteria. In addition, .3% (n = 301) missing data entries were discovered, mostly in administrative variables. In the mandatory variables, overall completeness was high; however, declining with time in parallel with reduced follow-up rate, 50% at 5 years.ConclusionThe high acquisition rate and internal validity implies that SOReg reflects Swedish bariatric surgery on a nationwide basis. Hence, SOReg data can be used to monitor quality of care and in research. The overall completeness could be improved by a higher registration rate during long-term follow-up.     

Congenital thrombotic thrombocytopenic purpura caused by new compound heterozygous mutations of the ADAMTS13 gene

Upshaw–Schulman syndrome (USS) is due to severe congenital deficiency of von Willebrand factor (VWF)‐cleaving protease ADAMTS13 (a disintegrin and metalloprotease with thrombospondin type 1 domains, nr 13) activity resulting in the presence of unusually large forms of VWF in the circulation, causing intravascular platelet clumping and thrombotic microangiopathy. Our patient, a 26‐year‐old man, had attacks of thrombotic thrombocytopenic purpura (TTP) with thrombocytopenia and a urine dipstick positive for hemoglobin (4+), often as the only sign of hemolytic activity. He had ADAMTS13 activity of <1% of normal plasma without the presence of inhibitors of ADAMTS13. ADAMTS13 deficiency was caused by two new mutations of the ADAMTS13 gene: a deletion of a single nucleotide in exon17 (c. 2042 delA) leading to a frameshift (K681C fs X16), and a missense mutation in exon 25 (c.3368G>A) leading to p.R1123H. This case report confirms the importance of the analysis of the ADAMTS13 activity and its inhibitor in patients who have episodes of TTP, with a very low platelet count and sometimes without the classic biochemical signs of hemolysis.     

A fast screening method for the detection of CERA in dried blood spots

Continuous erythropoietin receptor activator (CERA) is a third-generation erythropoiesis-stimulating agent that was developed for the treatment of anemia. However, misuse of CERA for doping in endurance sports has been reported. Previous studies have shown blood as the matrix of choice for the detection of CERA, due to its high molecular weight. The use of dried blood spots (DBSs) for anti-doping purposes constitutes a complementary approach to the standard urine and venous blood matrices and could facilitate sample collection and increase the number of blood samples available for analysis due to reduced costs of sample collection and transport. Here, we investigated whether CERA could be indirectly detected in extracts of single DBSs using an erythropoietin-specific immunoassay that is capable of providing results within approximately 2 h. Reconstituted DBS samples were prepared from mixtures of red blood cell pellets and serum samples. The samples were collected in a previous clinical study in which six healthy volunteers were injected with a single, 200 μg dose of CERA. Using a commercially available ELISA kit, CERA was detected in the DBSs with a detection window of up to 20 days post-injection. Furthermore, in order to demonstrate the fitness-for-purpose, three authentic doping control serum samples, which were identified as containing CERA, were analyzed by the presented methodological approach on DBS. The testing procedure described here could be used as a fast and cost-effective method for the detection of CERA abuse in sport.