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.
The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.
Wesorick DH, Chopra V. Annals for Hospitalists - 20 June 2017. Ann Intern Med. ;166:HO1. doi: 10.7326/AFHO201706200
Download citation file:
Published: Ann Intern Med. 2017;166(12):HO1.
Copyright © 2018 American College of Physicians. All Rights Reserved.
Print ISSN: 0003-4819 | Online ISSN: 1539-3704
Conditions of Use