David H. Wesorick, MD; Vineet Chopra, MD, MSc
Disclosures: Dr. Chopra reports grants from the Agency for Healthcare Research and Quality. Dr. Wesorick has disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-1400.
Although unable to identify the optimal time to initiate feeding in patients with acute pancreatitis, this review challenges the long-held belief that prolonged fasting is required to treat pancreatitis, and reassures clinicians that feeding in the first 48 hours after admission is not unsafe.
Although none of the 4 studies of patients with severe pancreatitis showed an increase in adverse events with early feeding, only 1 methodologically flawed study showed a benefit (reduced LOS). Noting this, the authors refrain from drawing conclusions about early feeding in this population.
An editorial notes that 7 of 11 included studies had high (or uncertain) risk of bias, and that 3 of 11 studies allowed the use of total parenteral nutrition, which can be associated with longer LOS. The editorialists suggest that additional clinical trials would help to more clearly define the benefits of early enteral nutrition in acute pancreatitis.
The authors conclude that a strategy based on early coronary angiography gives patients with unstable angina a survival advantage, but they do not offer a clear hypothesis of how angiography itself (without revascularization) would influence mortality in this way.
An editorial judges the findings to be implausible and offers other explanations for the results, including the high degree of bias that results from nonrandomized assignment to the study groups and the potentially unreliable diagnosis of unstable angina that results from the use of discharge billing data.
The editorial also notes that the group of patients diagnosed with unstable angina is getting smaller with the rise of high-sensitivity troponin testing, and suggests that new studies will be needed to reevaluate the role of early angiography in this population.
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David H. Wesorick, Vineet Chopra. Annals for Hospitalists - 20 June 2017. Ann Intern Med. 2017;166:HO1. doi: 10.7326/AFHO201706200
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Published: Ann Intern Med. 2017;166(12):HO1.
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