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Either your web browser doesn't support Javascript or it is currently turned off. In the latter case, please turn on Javascript support in your web browser and reload this page. The effect of early enteral nutrition EN in patients with acute pancreatitis AP has been confirmed. In recent years, some researchers provided new strategy that immediate EN adobe acrobat dc pro standard free download offered after admission.
The effect and safety of immediate EN xownload unclear because of the different results among studies. The study aimed to implement the xin key endnote x7 free download analysis of randomized controlled trials RCT to xun the effect and safety between the immediate EN group and the early refeeding group.
Endnote X7. Then data extraction and evaluation of risk of bias for included studies were performed after initial selection and full-text selection. All statistical analyses were performed by Review Manager 5. Acute pancreatitis AP is a common gastrointestinal condition involving hospitalization worldwide [ 1 ].
When patients suffer from AP, premature activation of digestive enzymes leads to auto-digestion of the pancreatic gland, followed by an increased risk xin key endnote x7 free download developing systematic inflammatory response and multi-organ endnoye [ 345 ]. Patients in this group often develop the symptoms of pancreatic edema, without local or systemic complications or transient organ failure.
And they can usually recover within 1—2 weeks without incident [ 6 ]. With the aim of minimizing stimulation of pancreatic secretion and thus putting inflamed pancreas at rest, the initial treatment of mild AP traditionally was consist of three basic elements: initial fasting for 3—7 days, xin key endnote x7 free download of parenteral fluids and analgesia [ 89 xin key endnote x7 free download, 10 ]. While the rational for pancreatic rest is questioned by emerging evidence which suggests that the secretion of pancreatic juice and trypsin may not increase over the first days of AP [ 1112 ].
Besides, it has been reported that fasting may induce intestinal mucosal atrophy and bacterial translocation which are the risk factors of AP complications kwy 1314 ]. For initial management of AP, the American Gastroenterological Association AGA released a guideline in and recommended that oral feeding within 24 h should be used as soon as possible if the patients are tolerant of oral feeding [ 7 ]. And if not, enteral nutrition EN is to be given preference.
Early EN is a more downlozd approach to provide nutrients to the intestinal tract. What's more, it has a dowmload effect on maintenance of intestinal mucosal integrity and promotion of normal bowel function [ 1516xin key endnote x7 free download18 ]. A recent meta-analysis evaluating 6 studies demonstrated that EN within 48 h, compared with delayed enteral feeding, lowered the risks of multiple organ failure.
This review also suggested читать далее tendency for decreased systematic inflammatory syndrome SIRS with early initiation of EN [ 19 ]. To date, the optimal timing for recommencing EN was unclear. The traditional opinion considers that whether EN oral or enteral tube can be restarted according to resolution of abdominal pain, recovery of gastrointestinal function and normalization of pancreatic enzymes [ 1020 ].
Contrary to this, some recent studies xin key endnote x7 free download that immediate EN seems to be a safe approach. Two RCTs demonstrated this way may accelerate recovery without increasing adverse gastrointestinal events [ 1521 ]. However, this result was not observed in others [ 2223 ]. We therefore conducted a vownload review and meta-analysis to assess the efficacy and feasibility fre immediate EN in patients with mild AP.
We also tried to define the optimum time to start EN after disease onset. In order to obtain endnotf eligible studies, the manual searching was conducted by reviewing the dowhload of all included studies and related все comic book collector free думаю. The language of published studies was not restricted.
Finally, all the relevant literatures were imported to Endnote X7. Before completing the meta analysis, we designed the selecting criteria according to the five aspects including patients, intervention, comparison, outcome measures and study designs PICOS [ 25 ]. The studies which met the following the inclusion читать полностью would be included. P : Ensnote the patients were aged 16 and above, and the gender was not limited. C : Enteral nutrition after pain relief or bowel sound after admission or parenteral nutrition.
O : Length of hospital stay, pain xin key endnote x7 free download time, adverse effects, local complications, mortality, and gastrointestinal symptoms including nausea, vomiting and diarrhea. If the studies couldn't offer sufficient data, they would be excluded. Two investigators YLQ and XTH were independently asked to finish reviewing the title and abstract of all the relevant literatures to judge whether literatures met inclusion xin key endnote x7 free download.
If a study met the selection criteria based on the title and abstract, full-text was obtained to further judge its eligibility. After ensuring the eligibility of included studies, two investigators QHG and XYT independently extracted the basic information including the first author, publication year, country, age and sex of xin key endnote x7 free download, random method, the number of dropout, intervention regimes and outcome measures. If there was any disagreements between the two investigators, the third investigator WHW would make the ultimate decision.
The Cochrane risk of bias assessment tool including seven domains was used to evaluate the risk of bias of all the included studies by two investigators YLQ and XTH. The seven domains were randomization sequence generation, allocation concealment, blinding of participants and study personnel, blinding of outcome assessors, incomplete outcome data, selective reporting, and other biases frree 26 ]. After judging the risk of bias of each eligible study, we finally graded the overall quality moderate xin key endnote x7 free download most of the eligible study was evaluated as unclear or low risk downlooad bias.
The third investigator WHW would deal with the discrepancy between the two investigators. Random-effect model was chosen to perform statistical analysis of each outcome measure downloar the present study, which simultaneously considering the heterogeneity within and across trials [ 27 ]. The qualitative description x7 2016 endnote update free word chi-square test and the quantitative description by I 2 statistic were used to xin key endnote x7 free download the heterogeneity [ 28 ].
While the number of included studies for each outcome measure was less than 10, we didn't draw the funnel plot to analyze the publication bias [ 29 ].
A total of 99 articles were captured xin key endnote x7 free download four electronic databases and one article was found by manual searching of references of all the included studies and ksy reviews. After initial selection and free selection, 5 studies involving patients were included in the present study [ 15212223downloac ]. The flow diagram of searching and selecting of articles was displayed in Figure 1.
We concluded the basic characteristics of 5 included studies, which presented in Table 1. For the 5 included studies in the meta analysis, the sample size of each study ranged from 26 to and all patients were diagnosed with mild acute pancreatitis. The country of publication of each study was different. The publication language included English, Chinese and Spanish.
The article published in Spanish was translated into English by two native speakers who had a high level of competence in English [ 30 ]. The experiment group of each study performed the immediate enteral nutrition downoad admission, but the time and method of enteral nutrition вот ссылка the control group of each study was slightly different.
The 5 included studies all reported randomization and only one study didn't mention the method of randomization sequence generation adequately [ 23 ]. Three studies dree the use of allocation concealment [ 152122 ]. Because the ссылка and method of enteral nutrition were different between the experiment group and the control group, it was impossible to blind the participants and study personnel.
Therefore, all the included studies were evaluated as a high risk of bias in the domain of the blinding of participants and study personnel. Catalina audirvana free download were three studies performed the blinding of outcome assessment [ 152130 ]. In all, the overall methodological quality of five included studies could be rated as moderate level.
More details of results of risk of bias were presented in Figure 2. The five included studies reported LOHS but only four studies involving patients offered the specific data [ 15212223 ]. Only two studies involving patients offered the specific information concerning readmission [ 15 xin key endnote x7 free download, 30 ]. The included three studies reported the assessment of pain before and after refeeding [ 152230 ].
But only one studies offered the specific data, and thus qualitative description was performed [ 30 ]. The included three studies all showed no significant differences between two groups concerning abdominal pain. There were three studies providing the specific information about progression to severe pancreatitis [ 152123 ].
The intolerance of feeding included vomiting, nausea and other gastrointestinal symptoms. Only two studies involving patients displayed the number of complications [ 1523 ]. Only three studies involving patients offered the specific data concerning difference of the values of C-reactive protein CRP before and after EN [ 212230 ]. Because Eckerwall et al. Only two studies involving patients reported the specific data concerning difference of the d7 counts before and after EN [ 2230 ].
Eckerwall et al. Nutritional support seems to play a pivotal role in the course of recovery in patients with mild type. The AGA for clinical practice guidelines for the nutritional support of mild AP recommends initiation of early EN oral or enteral tube instead of parenteral nutrition [ 7 ]. However, it is unclear how early the EN could be offered. Hence, in recent years, some researchers explored the effect and safety of immediate EN after admission compared with the early EN after bowel sounds existing or pain stopping [ 1521222330 ].
But the conclusion couldn't be confirmed owing to inconsistent results among studies. The present study is the first meta analysis to clarify the effect and safety of immediate EN after admission in patients with mild AP. According to the traditional views, fasting and PN were performed in patients with AP xin key endnote x7 free download fasting and PN were believed to decrease auto-digestion xin key endnote x7 free download the pancreas and tissue damage by reducing pancreatic secretion of enzymes and minimizing the impact on the pancreatic gland [ 3132 ].
But several clinical studies and animal experiments found that EN could prevent the damage of integrity and function of the intestinal barrier by affecting the intestinal permeability, immunocompetent cells rndnote bacteria translocation, which promoting recovery and decreasing the mortality of AP [ 132022 ]. During the period of AP, the gut function damage could occur as xin key endnote x7 free download as 28—72 h after the development of AP [ 5 ].
Earlier EN and shorter fasting time were associated with accelerated recovery, shorter LOHS and decreased intolerance of feeding. Immediate oral feeding may suppress the progression of severe AP but the present meta analysis did not show meaningful result due to a low number of events and participants which was consistent with the three original studies [ 152123 ].
At present, some published meta-analyses explored the optimal time of EN in AP [ 1933343536 ]. However, only one of five published meta-analysis performed subgroup analysis to explore the effect of immediate EN on LOHS [ 36 ]. But the subgroup analysis only included two xin key endnote x7 free download.
The other meta analyses included all the studies which EN was offered within 24 h or 48 h, and so they couldn't analyze the effect of immediate EN separately. Meanwhile, the patients included in the other meta analyses were mild to moderate AP or severe AP. Therefore, these limitations destroyed the robustness and reliability of the results of the effect of immediate EN in patients with mild AP. More importantly, more recent published studies were searched and included in this meta analysis.
Thus, more reliable and rigorous findings could be obtained in the present study compared with published meta-analysis. For other secondary outcome measures including readmission after discharging, progression to severe pancreatitis, complications and et al, the results of included studies нажмите чтобы прочитать больше meta analysis and published meta-analysis were consistent with the results of the present study, which revealing immediate EN were safe.
We have to acknowledge that there are still some limitations in the meta analysis including 5 studies involving patients. The heterogeneity within and across 5 trials was a little high and we couldn't perform subgroup analysis to explore the reason according to the intervention methods in experiment group or control нажмите чтобы прочитать больше because of the inadequate number of included studies.
- "جهاز المشروعات" ينفذ مشروعات كثيفة العمالة للمساهمة في تطوير المناطق العشوائية - موقع متناهي
Some have arranged a program to improve crop quality as they are top agricultural production. Therefore, these Southeast Asia countries contribute to the highest agricultural production globally. Here is an overview of the leading agricultural product of Southeast Asia countries. Southeast Asia countries with their prominent agricultural product Vietnam Southeast Asia accounts for about half of global rice exports. It produces one-fifth to one-fourth of global output.
The Vietnam news predicts that the country will be the second-largest rice exporter in Vietnam outsourced 6. Vietnam outsourced almost 1. Thailand became the most competitive year for Thailand and Vietnam. The two countries competed to title as the first runner up of world rice exporter. Yet, Thailand only got third place as a rice exporter after India and Vietnam.
Rice is one of the most crucial agricultural products. Rice is also a food source in Thailand, with each person consuming nearly kilograms per year on average. As a vital economic crop, rice naturally occupies a central position in the private sector. Rice is Thailand's most planted crop, accounting for 45 percent of all Thai farmland, and Indonesia Indonesia is the nation's largest palm oil producer, with an annual output of more than 30 million tons.
The palm oil industry provides jobs to over 2 million Indonesians, with several obtaining indirect economic advantages. In , Indonesia manufactured Malaysia Per previous data, Malaysia follows Indonesia as the second-largest palm oil manufacturer. Sabah becomes the home of palm oil that can deliver 25 percent palm oil supplier. After it, Sarawak contributed 19 percent to global demand, followed by Johor at 16 percent, Pahang at 14 percent, and Perak at 7 percent.
Lastly, to keep their agricultural production up and stable, each country has programs and strategies. In this digitalization era, technology makes it simpler to develop and improve agricultural products quality. Want to see what are the programs? Stay tuned to our blog and social media. What might you recommend in regards to your put up that you made some days in the past? Any sure? Case Studies Forestry Palm Sugarcane. The overview of leading agricultural product of Southeast Asia: Good for invest.
Southeast Asia has a rich environmental and agricultural diversity. Southeast Asia accounts for about half of global rice exports. The language of published studies was not restricted. Finally, all the relevant literatures were imported to Endnote X7.
Before completing the meta analysis, we designed the selecting criteria according to the five aspects including patients, intervention, comparison, outcome measures and study designs PICOS [ 25 ]. The studies which met the following the inclusion criteria would be included. P : All the patients were aged 16 and above, and the gender was not limited.
C : Enteral nutrition after pain relief or bowel sound after admission or parenteral nutrition. O : Length of hospital stay, pain relief time, adverse effects, local complications, mortality, and gastrointestinal symptoms including nausea, vomiting and diarrhea. If the studies couldn't offer sufficient data, they would be excluded.
Two investigators YLQ and XTH were independently asked to finish reviewing the title and abstract of all the relevant literatures to judge whether literatures met inclusion criteria. If a study met the selection criteria based on the title and abstract, full-text was obtained to further judge its eligibility. After ensuring the eligibility of included studies, two investigators QHG and XYT independently extracted the basic information including the first author, publication year, country, age and sex of patients, random method, the number of dropout, intervention regimes and outcome measures.
If there was any disagreements between the two investigators, the third investigator WHW would make the ultimate decision. The Cochrane risk of bias assessment tool including seven domains was used to evaluate the risk of bias of all the included studies by two investigators YLQ and XTH.
The seven domains were randomization sequence generation, allocation concealment, blinding of participants and study personnel, blinding of outcome assessors, incomplete outcome data, selective reporting, and other biases [ 26 ]. After judging the risk of bias of each eligible study, we finally graded the overall quality moderate if most of the eligible study was evaluated as unclear or low risk of bias.
The third investigator WHW would deal with the discrepancy between the two investigators. Random-effect model was chosen to perform statistical analysis of each outcome measure in the present study, which simultaneously considering the heterogeneity within and across trials [ 27 ]. The qualitative description by chi-square test and the quantitative description by I 2 statistic were used to express the heterogeneity [ 28 ]. While the number of included studies for each outcome measure was less than 10, we didn't draw the funnel plot to analyze the publication bias [ 29 ].
A total of 99 articles were captured from four electronic databases and one article was found by manual searching of references of all the included studies and related reviews. After initial selection and full-text selection, 5 studies involving patients were included in the present study [ 15 , 21 , 22 , 23 , 30 ].
The flow diagram of searching and selecting of articles was displayed in Figure 1. We concluded the basic characteristics of 5 included studies, which presented in Table 1. For the 5 included studies in the meta analysis, the sample size of each study ranged from 26 to and all patients were diagnosed with mild acute pancreatitis. The country of publication of each study was different. The publication language included English, Chinese and Spanish. The article published in Spanish was translated into English by two native speakers who had a high level of competence in English [ 30 ].
The experiment group of each study performed the immediate enteral nutrition after admission, but the time and method of enteral nutrition in the control group of each study was slightly different.
The 5 included studies all reported randomization and only one study didn't mention the method of randomization sequence generation adequately [ 23 ]. Three studies reported the use of allocation concealment [ 15 , 21 , 22 ]. Because the time and method of enteral nutrition were different between the experiment group and the control group, it was impossible to blind the participants and study personnel. Therefore, all the included studies were evaluated as a high risk of bias in the domain of the blinding of participants and study personnel.
There were three studies performed the blinding of outcome assessment [ 15 , 21 , 30 ]. In all, the overall methodological quality of five included studies could be rated as moderate level. More details of results of risk of bias were presented in Figure 2. The five included studies reported LOHS but only four studies involving patients offered the specific data [ 15 , 21 , 22 , 23 ]. Only two studies involving patients offered the specific information concerning readmission [ 15 , 30 ].
The included three studies reported the assessment of pain before and after refeeding [ 15 , 22 , 30 ]. But only one studies offered the specific data, and thus qualitative description was performed [ 30 ]. The included three studies all showed no significant differences between two groups concerning abdominal pain. There were three studies providing the specific information about progression to severe pancreatitis [ 15 , 21 , 23 ].
The intolerance of feeding included vomiting, nausea and other gastrointestinal symptoms. Only two studies involving patients displayed the number of complications [ 15 , 23 ]. Only three studies involving patients offered the specific data concerning difference of the values of C-reactive protein CRP before and after EN [ 21 , 22 , 30 ]. Because Eckerwall et al. Only two studies involving patients reported the specific data concerning difference of the leukocyte counts before and after EN [ 22 , 30 ].
Eckerwall et al. Nutritional support seems to play a pivotal role in the course of recovery in patients with mild type. The AGA for clinical practice guidelines for the nutritional support of mild AP recommends initiation of early EN oral or enteral tube instead of parenteral nutrition [ 7 ].
However, it is unclear how early the EN could be offered. Hence, in recent years, some researchers explored the effect and safety of immediate EN after admission compared with the early EN after bowel sounds existing or pain stopping [ 15 , 21 , 22 , 23 , 30 ]. But the conclusion couldn't be confirmed owing to inconsistent results among studies. The present study is the first meta analysis to clarify the effect and safety of immediate EN after admission in patients with mild AP.
According to the traditional views, fasting and PN were performed in patients with AP because fasting and PN were believed to decrease auto-digestion of the pancreas and tissue damage by reducing pancreatic secretion of enzymes and minimizing the impact on the pancreatic gland [ 31 , 32 ]. But several clinical studies and animal experiments found that EN could prevent the damage of integrity and function of the intestinal barrier by affecting the intestinal permeability, immunocompetent cells and bacteria translocation, which promoting recovery and decreasing the mortality of AP [ 13 , 20 , 22 ].
During the period of AP, the gut function damage could occur as early as 28—72 h after the development of AP [ 5 ]. Earlier EN and shorter fasting time were associated with accelerated recovery, shorter LOHS and decreased intolerance of feeding. Immediate oral feeding may suppress the progression of severe AP but the present meta analysis did not show meaningful result due to a low number of events and participants which was consistent with the three original studies [ 15 , 21 , 23 ].
At present, some published meta-analyses explored the optimal time of EN in AP [ 19 , 33 , 34 , 35 , 36 ]. However, only one of five published meta-analysis performed subgroup analysis to explore the effect of immediate EN on LOHS [ 36 ]. But the subgroup analysis only included two studies. The other meta analyses included all the studies which EN was offered within 24 h or 48 h, and so they couldn't analyze the effect of immediate EN separately.
Meanwhile, the patients included in the other meta analyses were mild to moderate AP or severe AP. Therefore, these limitations destroyed the robustness and reliability of the results of the effect of immediate EN in patients with mild AP. More importantly, more recent published studies were searched and included in this meta analysis. Thus, more reliable and rigorous findings could be obtained in the present study compared with published meta-analysis. For other secondary outcome measures including readmission after discharging, progression to severe pancreatitis, complications and et al, the results of included studies in meta analysis and published meta-analysis were consistent with the results of the present study, which revealing immediate EN were safe.
We have to acknowledge that there are still some limitations in the meta analysis including 5 studies involving patients. The heterogeneity within and across 5 trials was a little high and we couldn't perform subgroup analysis to explore the reason according to the intervention methods in experiment group or control group because of the inadequate number of included studies.
Moreover, the sample size is not adequately large, which limited its wider clinical application. A large multi-center clinical trial is still required. With the present findings, immediate EN after admission could safely reduce LOHS and intolerance of feeding in patients with mild AP, compared with early refeeding. However, large multi-center studies with more rigorous methodology are required to improve the quality of evidence before determining clinical decisions owing to the presence of limitations.
Qing Hua Guo: Conceived and designed the experiments; Performed the experiments; Analyzed and interpreted the data; Wrote the paper. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The following is the supplementary data related to this article:.
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By using the site you are agreeing to this as outlined in our privacy notice and cookie policy. Recent Activity. The snippet could not be located in the article text. This may be because the snippet appears in a figure legend, contains special characters or spans different sections of the article. Published online Feb 1. PMID: Author information Article notes Copyright and License information Disclaimer.
Weihong Wang: moc. Corresponding author. Published by Elsevier Ltd. This article has been cited by other articles in PMC. Abstract Objectives The effect of early enteral nutrition EN in patients with acute pancreatitis AP has been confirmed.
Results 5 randomized controlled trials RCT involving patients were included in the present study. Keywords: Immediate, Enteral nutrition, Mild acute pancreatitis, Meta analysis. Introduction Acute pancreatitis AP is a common gastrointestinal condition involving hospitalization worldwide [ 1 ]. Methods 2. Selecting criteria Before completing the meta analysis, we designed the selecting criteria according to the five aspects including patients, intervention, comparison, outcome measures and study designs PICOS [ 25 ].
I : Enteral nutrition initiated immediately after admission. S : Randomized controlled trials RCT. Studies were excluded if they met the exclusion criteria. S : Not RCT, animal experiment. Data extraction Two investigators YLQ and XTH were independently asked to finish reviewing the title and abstract of all the relevant literatures to judge whether literatures met inclusion criteria.
Evaluation of risk of bias of included studies The Cochrane risk of bias assessment tool including seven domains was used to evaluate the risk of bias of all the included studies by two investigators YLQ and XTH. Results 3. Results of searching and selecting A total of 99 articles were captured from four electronic databases and one article was found by manual searching of references of all the included studies and related reviews.
Open in a separate window. Figure 1. The basic characteristics of 5 included studies We concluded the basic characteristics of 5 included studies, which presented in Table 1. Table 1 The basic characteristics of the five trials included into the study. Results of assessment of risk of bias of 5 included studies The 5 included studies all reported randomization and only one study didn't mention the method of randomization sequence generation adequately [ 23 ].
Figure 2. Risk of bias. A risk of bias graph and B risk of bias summary. Length of hospital stay The five included studies reported LOHS but only four studies involving patients offered the specific data [ 15 , 21 , 22 , 23 ]. Figure 3. Readmission after discharging Only two studies involving patients offered the specific information concerning readmission [ 15 , 30 ].
Figure 4. Meta analysis of incidence of readmission after discharging. Abdominal pain The included three studies reported the assessment of pain before and after refeeding [ 15 , 22 , 30 ].
Progression to severe pancreatitis There were three studies providing the specific information about progression to severe pancreatitis [ 15 , 21 , 23 ]. Figure 5. Meta analysis of incidence of progression to severe pancreatitis. Figure 6. Complications Only two studies involving patients displayed the number of complications [ 15 , 23 ]. Figure 7. Systemic inflammatory response 3. C-reactive protein Only three studies involving patients offered the specific data concerning difference of the values of C-reactive protein CRP before and after EN [ 21 , 22 , 30 ].
Figure 8. Leukocyte counts Only two studies involving patients reported the specific data concerning difference of the leukocyte counts before and after EN [ 22 , 30 ].
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