Being denied a wanted abortion may have detrimental health effects in the long term

1. Being denied a wanted abortion may have detrimental health effects in the long term
Abstract: http://annals.org/aim/article/doi/10.7326/M18-1666
Editorial: http://annals.org/aim/article/doi/10.7326/M19-1740
URLs go live when the embargo lifts

Women who sought but were denied an abortion due to being past the gestational age limit report worse health 5 years later compared to those who sought and underwent an abortion. Findings from a prospective cohort study are published in Annals of Internal Medicine.

Research demonstrates worse short-term morbidity and mortality associated with childbirth than with abortion, but little research has compared the long-term health of women with unwanted pregnancies after abortion versus after childbirth.

Researchers from the Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco interviewed women who sought, but did not necessarily receive, an abortion. Data were available for 874 women who presented to one of 30 U.S. abortion facilities between 2008 and 2010 and responded to follow-up surveys. Of these women, 328 had a first-trimester abortion, 383 had a second-trimester abortion, and 163 were denied abortion because they were beyond the facility's gestational limit and went on to childbirth. Across most measures studied, women who underwent a first- or second-trimester abortion reported similar physical health to those that gave birth after being denied a wanted abortion. When differences did emerge, they were in the direction of worse health among those giving birth. For example, whereas women who received abortion reported slight improvement in their overall self-rated health over 5 years, those who carried an unwanted pregnancy to term reported persistent worsening in self-rated health. There were no differences in physical health between women who had a 1st and 2nd-trimester abortion. According to the researchers, these findings suggest that having an abortion is not detrimental to women's physical health, but being denied a wanted abortion could be.

Notes and media contacts: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To speak with the lead author, Lauren Ralph, PhD, please contact Jason Harless at Harless.Jason@ucsf.edu or Elliot Levy at elliot.levy@berlinrosen.com.

2. American College of Physicians releases paper on methods for developing evidence-based clinical policy papers
ACP continues to refine and enhance methodology for guidelines and guidance statements
Notes: HD video soundbites of ACP's president discussing the paper are available to download at http://www.dssimon.com/MM/ACP-CGC/.
Abstract: http://annals.org/aim/article/doi/10.7326/M18-3290
URLs go live when the embargo lifts

Recommendations for the screening, diagnosis, and treatment of various diseases often differ by organization, making it difficult to know which ones to follow. To help doctors and patients understand how high-quality, evidence-based recommendations are developed and inform their decisions, the American College of Physicians (ACP) has released a paper, published in Annals of Internal Medicine, that presents ACP'S methods for developing two types of clinical policy papers relevant to internal medicine: clinical guidelines and guidance statements.

According to the authors from ACP, the hallmark of ACP's methodology is that its clinical guidelines and guidance statements are based on the best available scientific evidence. ACP's methodology meets the standards of the Guidelines International Network and National Academy of Medicine. Recent enhancements include more stringent disclosure of interest and conflict management policies; inclusion of public members (individuals who are not physicians) and their perspective; full adoption of Grading of Recommendations Assessment, Development and Evaluation (GRADE) methods; standardized reporting formats that consider value of care, patients with multiple chronic diseases, patient values and preferences, and costs; and further clarification on guidance statement methods.

Clinical guidelines are developed based on a systematic review of the available evidence. Evidence-to-decision tables following the GRADE framework serve as the roadmap for documenting decisions and evidence behind the final recommendations. ACP considers clinical benefits and harms of an intervention and variations in patient values and preferences in deliberations about recommendations for each guideline. ACP also considers costs and burden of care when assessing health care value and developing recommendations. Guidance statements are developed on topics where several clinical guidelines issued by other organizations are available but are conflicting. The aim of ACP guidance statements is to reconcile clinical guidelines to help physicians provide evidence-based care for their patients.

ACP develops its clinical policy papers through its Clinical Guidelines Committee (CGC), a multidisciplinary group of 14 members, 12 of whom are physicians representing general internal medicine and internal medicine subspecialties (e.g., geriatrics, nephrology, rheumatology, pulmonology, and hospital medicine). The CGC also includes two non-physician public members with equal standing and terms as the physician members, including voting and authorship privileges.

Media Contact: For an embargoed PDF or to speak with someone from ACP, please contact Steve Majewski at smajewski@acponline.org.

3. In-office hypertension associated with more than 100 percent increase in death from cardiovascular disease
Abstract: http://annals.org/aim/article/doi/10.7326/M19-0223
Abstract: http://annals.org/aim/article/doi/10.7326/M19-1134
URLs go live when the embargo lifts

Patients who have normal blood pressure at home but elevated blood pressure in the physician's office (white coat hypertension) and were not on antihypertensive medication had a 36 percent increased risk of cardiovascular events, a 33 percent increased risk for all-cause mortality, and a 109 percent increased risk for cardiovascular mortality. Findings from a systematic review and meta-analysis are published in Annals of Internal Medicine.

Recent hypertension guidelines strongly recommend out-of-office blood pressure monitoring (including 24-hour ambulatory blood pressure monitoring and self-monitoring at home) for the diagnosis and management of hypertension. However, many providers have been slow to recommend out-of-office blood pressure monitoring, in part due to skepticism over its utility.

Researchers from the Perelman School of Medicine, University of Pennsylvania reviewed 27 studies that evaluated the association of white coat hypertension with cardiovascular events and mortality. Compared to people with normal blood pressures both at home and in the office, individuals who had white coat hypertension who were not on an antihypertensive were at elevated risk for cardiovascular events and mortality. This elevated risk associated with white coat hypertension was particularly evident in studies that used ambulatory blood pressure monitoring (not home self-monitoring) and studies with at least 5 years of follow up time. Individual with white coat hypertension who were on antihypertensive medication (known as "white coat effect") experienced no increased risk of cardiovascular events or mortality. According to the researchers, these findings suggest that individuals with isolated office hypertension who are not on an antihypertensive treatment should be closely monitored, while individuals on antihypertensive treatment could be harmed by overly aggressive management.

Notes and media contacts: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To speak with the lead author, Jordana Cohen, MD, MSC, please contact Mike Iorfino at Mike.Iorfino@pennmedicine.upenn.edu.

4. Coffee may ease abnormal movements caused by ADCY5-related dyskinesia
Abstract: http://annals.org/aim/article/doi/10.7326/L19-0038
URLs go live when the embargo lifts

A young patient with ADCY5-related dyskinesia experienced a 90 percent decrease in abnormal movements after consuming two cups of coffee a day. The patient was able to resume normal activities, such as walking home from school, writing without difficulty, and riding a bike, which reportedly had been impossible for him previously. Findings from a case report are published in Annals of Internal Medicine.

Dyskinesia related to the ADCY5 gene is an orphan neurological disease. Children who have it have many abnormal movements that can affect the whole body. These abnormal movements are often exacerbated during crises and can occur day or night. There is currently no known cure for this disease.

A team of researchers from the Department of Neurology of the Pitié-Salpêtrière Hospital AP-HP and the Brain and Spinal Cord Institute (CNRS / Inserm / Sorbonne University) studied the case of an 11-year-old boy who was experiencing approximately 30 episodes of abnormal movement per day and had difficulty riding a bike and performing some activities of daily living that require fine motor skills. The patient was prescribed coffee and started with one cup of espresso in the morning, which produced a quick, dramatic, and long-lasting response. With another cup in the afternoon and a half a cup in the evening, the patient had nearly complete resolution of all dyskinesia episodes.

According to the parents, one day they unwittingly gave the boy decaffeinated coffee and saw complete regression back to the abnormal movements. Resuming with caffeinated coffee remedied the situation. According to the researchers, the patient's family demonstrated the effectiveness in a real-life double-blind placebo-controlled therapeutic test since neither they nor their child knew that they were using decaffeinated pods.

Notes and media contacts: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To speak with the lead authors, Pr Emmanuel Flamand-Roze or Dr Aurélie Méneret, please contact AP-HP press office at service.presse@aphp.fr

5. Lynch syndrome screening substantially less efficient after ages 70 to 75
Abstract: http://annals.org/aim/article/doi/10.7326/M18-3316
URLs go live when the embargo lifts
Screening for Lynch syndrome becomes substantially less efficient after ages 70 to 75, suggesting that stopping screening in patients over the age of 80 could be a reasonable strategy compared with universal screening, particularly in resource-limited settings. Findings from a retrospective cohort study are published in Annals of Internal Medicine.

Current guidelines recommend screening all patients with newly diagnosed colorectal cancer for Lynch syndrome, also known as hereditary nonpolyposis colorectal cancer. Although the universal screening strategy is widely accepted, its diagnostic yield and cost-effectiveness, particularly in those older than 70 years, has not been well investigated.

Researchers from Kaiser Permanente Northern California studied 3,891 patients with newly diagnosed colorectal cancer who underwent Lynch syndrome screening between 2011 and 2016 to compare the performance of age-restricted and universal screening strategies using reflex mismatch repair immunohistochemistry of colorectal cancer tumors. The researchers found that the incremental diagnostic yield (the number of Lynch syndrome cases diagnosed among the number of colorectal cancers screened) decreased substantially after age 70 to 75 years, with minimal incremental gain after age 80 years compared with universal screening strategy. The authors conclude that because Lynch syndrome is rare after the age 80 years and the efficiency of universal screening is very low, stopping reflex screening in these elderly patients may be reasonable, especially in resource-limited settings.

Notes and media contacts: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To speak with the lead author, Dan Li, MD, please contact him directly at Dan.X.Li@kp.org.

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