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Annals of Internal Medicine Tip Sheet
December 20, 2016

Below is information about articles being published in Annals of Internal Medicine. The information is not intended to substitute for the full article as a source of information. Annals of Internal Medicine attribution is required for all coverage.

1. Study suggests that daily sugar intake guidelines are based on low quality evidence

Accompanying editorial questions motives of study funding source


Nutritional guidelines restricting sugar intake are not based on reliable science, suggests a review published in Annals of Internal Medicine. The quality of available evidence to link sugar with health outcomes is generally rated as low to very low. Public health officials and consumers should be aware of these limitations when considering recommendations on dietary sugar.

The relationship between sugar intake and health is complex and is influenced by many variables. Based on available evidence, several authoritative health organizations, including the World Health Organization, have issued differing public health guidelines on sugar consumption. When respected organizations issue conflicting recommendations, it can result in confusion and raises concern about the quality of the guidelines and underlying evidence.

Researchers conducted a systematic review of nine authoritative guidelines on sugar intake to determine the consistency of recommendations, methodological quality of guidelines, and the quality of evidence supporting each recommendation. Guideline quality was rated using the Appraisal of Guidelines for Research and Evaluation 2nd edition (AGREE II) instrument. To assess evidence quality, articles supporting recommendations were independently reviewed and rated using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methods. The researchers concluded that guidelines on dietary sugar are based on low-quality evidence and, therefore, do not meet criteria for trustworthy recommendations. These findings suggest that the development of trustworthy guidelines on dietary sugar requires improvement.

The authors of an accompanying editorial suggest that the public consider the funding source and methods of the review before accepting the authors’ conclusions. They note that the review was funded by the North American branch of the International Life Sciences Institute, a trade group representing several big companies in the food and beverage industry, including The Coca-Cola Company, The Hershey Company, and Mars, Inc.

2. Insurance expansion under the ACA provides patients with greater hospital choice


During the first year of Medicaid expansion under the Affordable Care Act (ACA), researchers have seen a meaningful shift in the location and type of emergency department services used by patients. These changes suggest that expansion provides patients with a greater choice of hospital facilities. The findings are published in Annals of Internal Medicine.

So far, 31 states have implemented Medicaid expansion to households making less than 138 percent of the federal poverty level. The percentage of uninsured in these states is about half of that in nonexpansion states, which has sparked an ongoing debate over the effect of insurance expansion on low-income populations. Little is known about whether insurance expansion affects the location and type of emergency department use. Understanding these changes can inform state-level decisions about Medicaid expansion under the ACA.

Researchers compared changes in the number of ED visits overall, type of visit, and average travel time to the emergency department from the end of 2013 to the end of 2014 for patients from Medicaid expansion versus nonexpansion states from a large sample of U.S. hospitals. The data showed shifts in insurance status, location of emergency department visited, and type of services associated with emergency department visits with the first year of full implementation of the ACA’s coverage expansion. In addition, the number of uninsured emergency visits in Medicaid expansion states decreased across all visit types. According to the authors, these findings provide an important new context for the ongoing debate over the ACA’s effect on access to hospital care.

3. No association found between length of storage for transfused red blood cells and patient mortality


A large binational study found no association between the length of storage of transfused red blood cells and patient mortality. The findings are published in Annals of Internal Medicine.

Red blood cells undergo various physiologic changes during storage, but whether these changes are associated with mortality in the recipient are up for debate. Despite many studies, including four randomized trials, no consensus exists.

Using data from a large binational database, researchers assessed 1 month and 1 year mortality for adult patients who received blood transfusions in Denmark and Sweden between 2003 and 2012 to determine if length of storage was associated with an increased risk for death. Transfusion services in Sweden and Denmark are part of the public health care system. The national guidelines for component preparation and transfusion practice are similar, except the maximum storage time is 42 days in Sweden and 35 days in Denmark. Based on the data, the researchers found no association between length of storage and death.


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