Enhanced Protein-Energy Provision via the Enteral Route Feeding (PEPuP) protocol in critically ill surgical patients: a multicentre prospective evaluation.

Suboptimal levels of feeding in critically ill patients are associated with poor clinical outcomes. The Enhanced Protein-Energy Provision via the Enteral Route Feeding (PEPuP) protocol was developed to improve nutritional delivery in the critically ill and has been studied in several hospitals. However, the experience with this protocol in surgical patients is limited to date. The objective of this analysis was to describe the experience with this protocol in surgical patients. We analysed observational patient data obtained from the 2013 International Nutrition Survey. We compared nutritional practices and outcomes of patients admitted for surgical and medical reasons to ICUs in sites that implemented the PEPuP protocol. We used surgical ICU patients in non-PEPuP sites as a concurrent control group. In sites that implemented the PEPuP protocol, surgical patients received a smaller proportion of prescribed calories (43% versus 61%, P=0.004) and protein (38% versus 57%, P=0.002) compared to medical patients. When compared to the cohort of surgical patients from control sites, the surgical patients from PEPuP sites received similar amounts of calories and protein. Although surgical PEPuP patients were more likely to receive trophic and volume-based feeds compared to surgical patients in control sites, other aspects of the PEPuP protocol were not adequately implemented. We conclude that nutritional delivery to surgical patients remains inadequate and the PEPuP protocol seems ineffective in improving nutritional intake in this population. Further research to determine methods of optimising PEPuP protocol implementation and adherence in surgery patients is needed.

Intensive care unit family satisfaction survey.

OBJECTIVES: To examine the level of family satisfaction in a local intensive care unit and its performance in comparison with international standards, and to determine the factors independently associated with higher family satisfaction. DESIGN: Questionnaire survey. SETTING: A medical-surgical adult intensive care unit in a regional hospital in Hong Kong. PARTICIPANTS: Adult family members of patients admitted to the intensive care unit for 48 hours or more between 15 June 2012 and 31 January 2014, and who had visited the patient at least once during their stay. RESULTS: Of the 961 eligible families, 736 questionnaires were returned (response rate, 76.6%). The mean (± standard deviation) total satisfaction score, and subscores on satisfaction with overall intensive care unit care and with decision-making were 78.1 ± 14.3, 78.0 ± 16.8, and 78.6 ± 13.6, respectively. When compared with a Canadian multicentre database with respective mean scores of 82.9 ± 14.8, 83.5 ± 15.4, and 82.6 ± 16.0 (P<0.001), there was still room for improvement. Independent factors associated with complete satisfaction with overall care were concern for patients and families, agitation management, frequency of communication by nurses, physician skill and competence, and the intensive care unit environment. A performance-importance plot identified the intensive care unit environment and agitation management as factors that required more urgent attention. CONCLUSIONS: This is the first intensive care unit family satisfaction survey published in Hong Kong. Although comparable with published data from other parts of the world, the results indicate room for improvement when compared with a Canadian multicentre database. Future directions should focus on improving the intensive care unit environment, agitation management, and communication with families.

Carnitine therapy for the treatment of metabolic syndrome and cardiovascular disease: evidence and controversies.

As the incidence of metabolic syndrome increases, there is also a growing interest in finding safe and inexpensive treatments to help lower associated risk factors. L-carntine, a natural dietary supplement with the potential to ameliorate atherosclerosis, has been the subject of recent investigation and controversy. A majority of studies have shown benefit of L-C supplementation in the metabolic syndrome or cardiovascular risk factors. However, recent work has suggested that dietary L-C may accelerate atherosclerosis via gut microbiota metabolites, complicating the role of L-C supplementation in health.

Mind the gap: Opportunities for improving end-of-life care for patients with advanced heart failure.

BACKGROUND: Patients with advanced heart failure (HF) experience progressive symptoms, decreased quality of life, and more frequent hospitalizations as they approach the end of life (EOL). Understanding patient perspectives and preferences regarding EOL issues is necessary to identify key opportunities for improving care. OBJECTIVE: To identify, from the patient's perspective, the major opportunities for improving EOL care for patients hospitalized because of advanced HF. METHODS: A cross-sectional survey of patient perspectives regarding EOL care was administered via interview of 106 hospitalized patients who had advanced HF in five tertiary care centres across Canada. The study compared which aspects of EOL care patients rated as 'extremely important' and their level of satisfaction with these aspects of EOL care to identify key opportunities for improvement of care. RESULTS: The greatest opportunities for improvement in EOL care were reducing the emotional and physical burden on family, having an adequate plan of care following discharge, effective symptom relief and opportunities for honest communication. The three most important issues ranked by patients were avoidance of life support if there was no hope for a meaningful recovery, communication of information by the doctor and avoidance of burden for the family. CONCLUSIONS: Advanced care planning that seamlessly bridges hospital and home must be standard care for patients who have advanced HF. Components must include coordination of care, caregiver support, comprehensive symptom management, and effective communication regarding HF and EOL issues.

Immune-modulatory actions of arginine in the critically ill.

Current trials of immune-enhancing diets suggest several beneficial clinical effects. These products are associated with a reduction in infectious risk, ventilator days, ICU and hospital stay. However, methodological weaknesses limit the inferences we can make from these studies. Furthermore, improvements in outcomes were largely seen in surgical patients and in patients who tolerated critical amounts of formula. We propose that the beneficial findings cannot easily be extrapolated to other patient populations since there is suggestion from clinical trials that the sickest patients, especially those with severest appearances of sepsis, shock and organ failure may not benefit or may even be harmed. In these conditions we hypothesize that systemic inflammation might be undesirably intensified by immune-enhancing nutrients like arginine in critically ill patients. In this paper, we review the purported effects of arginine on the immune system and organ function to understand the scientific rationale for its inclusion into enteral feeding products. We conclude that patients with the most severe appearances of the systemic inflammatory response syndrome should not receive immune-enhancing substrates which may aggravate systemic inflammation and worsen clinical outcomes.

The attributable mortality and length of intensive care unit stay of clinically important gastrointestinal bleeding in critically ill patients.

OBJECTIVE: To estimate the mortality and length of stay in the intensive care unit (ICU) attributable to clinically important gastrointestinal bleeding in mechanically ventilated critically ill patients. DESIGN: Three strategies were used to estimate the mortality attributable to bleeding in two multicentre databases. The first method matched patients who bled with those who did not (matched cohort), using duration of ICU stay prior to the bleed, each of six domains of the Multiple Organ Dysfunction Score (MODS) measured 3 days prior to the bleed, APACHE II score, age, admitting diagnosis, and duration of mechanical ventilation. The second approach employed Cox proportional hazards regression to match bleeding and non-bleeding patients (model-based matched cohort). The third method, instead of matching, derived estimates based on regression modelling using the entire population (regression method). Three parallel analyses were conducted for the length of ICU stay attributable to clinically important bleeding. SETTING: Sixteen Canadian university-affiliated ICUs. PATIENTS: A total of 1666 critically ill patients receiving mechanical ventilation for at least 48 hours. MEASUREMENTS: We prospectively collected data on patient demographics, APACHE II score, admitting diagnosis, daily MODS, clinically important bleeding, length of ICU stay, and mortality. Independent adjudicators determined the occurrence of clinically important gastrointestinal bleeding, defined as overt bleeding in association with haemodynamic compromise or blood transfusion. RESULTS: Of 1666 patients, 59 developed clinically important gastrointestinal bleeding. The mean APACHE II score was 22.9 +/- 8.6 among bleeding patients and 23.3 +/- 7.7 among non-bleeding patients. The risk of death was increased in patients with bleeding using all three analytic approaches (matched cohort method: relative risk [RR]= 2.9, 95% confidence interval (CI)= 1.6-5.5; model-based matched cohort method: RR = 1.8, 95% CI = 1.1-2.9; and the regression method: RR = 4.1, 95% CI = 2.6-6.5). However, this was not significant for the adjusted regression method (RR = 1.0, 95% CI = 0.6-1.7). The median length of ICU stay attributable to clinically important bleeding for these three methods, respectively, was 3.8 days (95% CI = -0.01 to 7.6 days), 6.7 days (95% CI = 2.7-10.7 days), and 7.9 days (95% CI = 1.4-14.4 days). CONCLUSIONS: Clinically important upper gastrointestinal bleeding has an important attributable morbidity and mortality, associated with a RR of death of 1-4 and an excess length of ICU stay of approximately 4-8 days.

In search of the magic nutraceutical: problems with current approaches.

Over the last few decades, substrates with immune-modulating properties have been identified in all groups of micro- and macronutrients. Numerous experimental studies have focused on evaluating these substances, either alone or in combination. After hundreds of experiments, no clear, consistent signal exists that any of these agents result in significant treatment benefits in critically ill patients. The current approach to establishing the efficacy of nutritional interventions suffers from several limitations. First, the majority of studies focus on surrogate or substitute end points rather than clinically important end points. Second, the majority of clinical studies are small, and as such are underpowered to detect a significant treatment effect on clinically important end points. Third, the methodological quality of individual randomized trials varies. Methodological limitations, prevalent in nutrition studies, limit the strength of clinical inference that can be made from study results. High quality studies have been shown to differ significantly from low quality studies in their estimation of treatment effect. Fourth, the generalizability of single-site studies is limited. Finally, studies sponsored solely by industry are considered to be less believable than studies conducted under the auspices of peer-review agencies. Future evaluations must be done in the context of large, multicenter, well-designed, randomized trials focusing on clinically important end points that are sponsored from a variety of sources (including peer-reviewed agencies). Although such trials are costly, they are feasible and are much more likely to be believable and generalizable than the current approach.

Effect of postpyloric feeding on gastroesophageal regurgitation and pulmonary microaspiration: results of a randomized controlled trial.

OBJECTIVE: To determine the extent to which postpyloric feeding reduces gastroesophageal regurgitation and pulmonary microaspiration in critically ill patients. DESIGN: Randomized trial. SETTING: A medical/surgical intensive care unit at a tertiary care hospital. PARTICIPANTS: Intensive care unit patients were expected to remain ventilated >72 hrs. We excluded patients with esophageal, gastric, or small bowel surgery in the last week and patients with overt or clinically significant gastrointestinal bleeding. We studied 33 patients; 42.4% were female, mean age (sd) was 59.2 (+/- 16.8) yrs, and mean Acute Physiology and Chronic Health Evaluation II score was 22.5 (7.8). INTERVENTIONS: Patients were randomized to gastric or postpyloric enteral feeds. Technetium 99-sulphur colloid was added to the feeds for 6 hrs of each of the first 3 days on study. MEASUREMENTS AND RESULTS: We sampled the oropharynx and trachea hourly for the 6 hrs per day that patients received radioisotope-labeled enteral feeds, and the level of radioactivity in these specimens was measured. We defined an episode of gastroesophageal regurgitation and microaspiration as an increase in radioactivity >100 counts per minute/g. Patients fed into the stomach had more episodes of gastroesophageal regurgitation (39.8% vs. 24.9%, p =.04) and trended toward more microaspiration (7.5% vs. 3.9%, p =.22) compared with patients fed beyond the pylorus. When the logarithmic mean of the radioactivity count was compared across groups, there was a trend toward an increase in gastroesophageal regurgitation (3.7 vs. 2.9 counts/g, p =.22) and a trend toward increased microaspiration (1.9 vs. 1.4 counts/g, p =.09) in patients fed into the stomach. Patients who had gastroesophageal regurgitation were much more likely to aspirate than patients who did not have gastroesophageal regurgitation (odds ratio: 3.2; 95% confidence interval: 1.36, 7.77). CONCLUSIONS: Feeding beyond the pylorus is associated with a significant reduction in gastroesophageal regurgitation and a trend toward less microaspiration.

Capnography confirms correct feeding tube placement in intensive care unit patients.

PURPOSE: To test the accuracy and potential time savings of capnography as compared with a two-step radiographic method in placing feeding tubes in critically ill patients. METHODS: One hundred feeding tube placements were studied in our tertiary care intensive care unit. All placements utilized a two-step radiographic method, but capnography was added to the procedure. The procedure was then completed or abandoned depending on radiographic interpretation. RESULTS: Radiography showed 11 feeding tubes projecting within the tracheobronchial tree. In all 11 of these placements, the capnography unit displayed a normal capnogram. Radiography revealed 86 tube placements in the midesophageal region. In all 86 of these placements, capnography displayed a "purging warning". In three placements, radiography indicated that the tube was coiled in the oropharynx. In these cases, the capnograph displayed one "no purging/no capnogram" result, and two "purging" warnings. If using capnography alone, an average of 72.5 min would be required to complete a feeding tube placement (which includes time for requisite "pre-feed radiograph"). The two-step radiological approach took an average of 169.4 min, a difference of 96.9 min (P <0.0001) between the two methods. CONCLUSIONS: Capnography accurately identified all intratracheal feeding tube placements in this study. This study also shows that the use of capnography would significantly shorten the time needed for tube placement compared with a two-step radiologic method. Capnography should be considered for routine use when placing feeding tubes since it adds little time to the procedure and may improve patient safety.

Should immunonutrition become routine in critically ill patients? A systematic review of the evidence.

CONTEXT: Several nutrients have been shown to influence immunologic and inflammatory responses in humans. Whether these effects translate into an improvement in clinical outcomes in critically ill patients remains unclear. OBJECTIVE: To examine the relationship between enteral nutrition supplemented with immune-enhancing nutrients and infectious complications and mortality rates in critically ill patients. DATA SOURCES: The databases of MEDLINE, EMBASE, Biosis, and CINAHL were searched for articles published from 1990 to 2000. Additional data sources included the Cochrane Controlled Trials Register from 1990 to 2000, personal files, abstract proceedings, and relevant reference lists of articles identified by database review. STUDY SELECTION: A total of 326 titles, abstracts, and articles were reviewed. Primary studies were included if they were randomized trials of critically ill or surgical patients that evaluated the effect of enteral nutrition supplemented with some combination of arginine, glutamine, nucleotides, and omega-3 fatty acids on infectious complication and mortality rates compared with standard enteral nutrition, and included clinically important outcomes, such as mortality. DATA EXTRACTION: Methodological quality of individual studies was scored and necessary data were abstracted in duplicate and independently. DATA SYNTHESIS: Twenty-two randomized trials with a total of 2419 patients compared the use of immunonutrition with standard enteral nutrition in surgical and critically ill patients. With respect to mortality, immunonutrition was associated with a pooled risk ratio (RR) of 1.10 (95% confidence interval [CI], 0.93-1.31). Immunonutrition was associated with lower infectious complications (RR, 0.66; 95% CI, 0.54-0.80). Since there was significant heterogeneity across studies, we examined several a priori subgroup analyses. We found that studies using commercial formulas with high arginine content were associated with a significant reduction in infectious complications and a trend toward a lower mortality rate compared with other immune-enhancing diets. Studies of surgical patients were associated with a significant reduction in infectious complication rates compared with studies of critically ill patients. In studies of critically ill patients, studies with a high-quality score were associated with increased mortality and a significant reduction in infectious complication rates compared with studies with a low-quality score. CONCLUSION: Immunonutrition may decrease infectious complication rates but it is not associated with an overall mortality advantage. However, the treatment effect varies depending on the intervention, the patient population, and the methodological quality of the study.

Total parenteral nutrition in the surgical patient: a meta-analysis.

OBJECTIVE: To examine the relationship between total parenteral nutrition(TPN) and complication and death rates in surgical patients. DATA SOURCES: A computer search of published research on MEDLINE, personal files and a review of relevant reference lists. STUDY SELECTION: A review of 237 titles, abstracts or papers. Primary studies were included if they were randomized clinical trials of surgical patients that evaluated the effect of TPN (compared to no TPN or standard care) on complication and death rates. Studies comparing TPN to enteral nutrition (EN) were excluded. DATA EXTRACTION: Relevant data were abstracted on the methodology and outcomes of primary studies. Data were independently abstracted in duplicate. DATA SYNTHESIS: There were 27 randomized trials in surgical patients that compared the use of TPN to standard care (usual oral diet plus intravenous dextrose). When the results of these trials were aggregated, there was no effect on mortality (risk ratio = 0.97, 95% confidence intervals, 0.76 to 1.24). There were fewer major complications in patients who received TPN, although there was significant heterogeneity in the overall estimate (risk ratio = 0.81, 95% CI, 0.65 to 1.01). Because of this significant heterogeneity, several a priori hypotheses were examined. Studies that included only malnourished patients demonstrated a trend to a reduction in complication rates but no difference in death rate when compared with studies of patients who were not malnourished. Studies published in 1988 or earlier and studies with a lower methods score were associated with a significant reduction in complication rates and a trend to a reduction in death rate when compared with studies published after 1988 and studies with a higher methods score. There was no difference in studies that provided lipids as a component of TPN when compared with studies that did not. Studies that initiated TPN preoperatively demonstrated a trend to a reduction in complication rates but no difference in death rate when compared with studies that initiated TPN postoperatively. CONCLUSIONS: TPN does not influence the death rate of surgical patients. It may reduce the complication rate, especially in malnourished patients, but study results are influenced by methodologic quality and year of publication.

Measuring family satisfaction with care in the intensive care unit: the development of a questionnaire and preliminary results.

PURPOSE: To develop and test the feasibility of administering a questionnaire to measure family members' level of satisfaction with care provided to them and their critically ill relative. MATERIALS AND METHODS: To develop the questionnaire, existing conceptual frameworks of patient satisfaction, decision making, and quality of end-of-life care were used to identify important domains and items. We pretested the questionnaire for readability, clarity, and sensibility in 21 family members and 16 professionals. To assess validity, we measured the correlation between satisfaction with overall care and satisfaction with decision making. To assess the reliability of the questionnaire, we administered the questionnaire to next of kin of surviving patients on discharge and 7 to 10 days later. RESULTS: Questionnaires were mailed out to 33 family members of nonsurvivors; 24 were returned completed but only 22 (66%) were usable.Twenty-five family members of eligible surviving critically ill patients participated in the test-retest part of this study. Of the 47 respondents, 84% were very satisfied with overall care and 77% were very satisfied with their role in the decision making. There was good correlation between satisfaction with overall care and satisfaction with decision making (correlation coefficient =.64). The assessment of overall satisfaction with care was shown to be reliable (correlation coefficient =.85). CONCLUSIONS: This questionnaire has some measure of reliability and validity and is feasible to administer to next of kin of critically ill patients.

Long-term health-related quality of life in survivors of sepsis. Short Form 36: a valid and reliable measure of health-related quality of life.

OBJECTIVE: To describe the long-term health-related quality of life (HRQL) of survivors of sepsis and to evaluate the reliability and validity of the medical outcomes study Short Form-36 (SF-36) in this population. STUDY DESIGN: Cross-sectional survey. SETTING: University intensive care unit. PATIENTS: Surviving patients over the age of 17 yrs who met the criteria for the Society of Critical Care Medicine/American College of Chest Physicians definition of sepsis identified through a review of patients admitted to the intensive care unit from 1994 to 1998. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Baseline demographics and clinical characteristics were abstracted from the medical chart. After hospital discharge, the SF-36 and Patrick's Perceived Quality of Life scale were administered by telephone. The SF-36 was readministered 2 wks later. We screened the charts of 109 patients; 78 had a diagnosis of sepsis. Of these, 31 had died, 3 had severe communication problems, 9 refused to participate, and 5 patients could not be located. A total of 30 patients completed the first interview; 26 completed the second. Compared with established norms for the U.S. general population, survivors of sepsis scored significantly lower on the physical functioning, role physical, general health, vitality, and social functioning domains, as well as on the Physical Health Summary Scale. Mean scores on the Mental Health Summary Scale were very similar between the survivors of sepsis and U.S. norms. The SF-36 demonstrated high internal consistency (Cronbach's alpha ranged from 0.65 to 0.94) and excellent test-retest stability (intraclass correlation coefficient ranged from 0.75 to 0.97). Both the Physical Health Summary Scale and the Mental Health Summary Scale correlated well with overall Perceived Quality of Life scores (Pearson correlation coefficients 0.45 and 0.56, respectively). CONCLUSIONS: The long-term HRQL of survivors of sepsis is significantly lower than that of the general U.S. population. The SF-36 demonstrated good reliability and validity when used to measure HRQL in survivors of sepsis.

Dying in Canada: is it an institutionalized, technologically supported experience?

Although preliminary evidence shows that people generally prefer to die at home, very little is known about where Canadians die. Understanding the epidemiology of dying in Canada may illuminate opportunities to improve quality of end-of-life care and related health policy. We conducted a cross-sectional analysis of death records in Canada to determine the proportions of deaths occurring in hospitals and special care units. Our analysis found that deaths in Canada occur in hospitals with provincial and territorial proportions ranging from 87% in Quebec to 52% in the Northwest Territories. In hospitals recording deaths in special care units, 18.64% of all deaths occurred in special care units. The proportion of deaths in special care units ranged from 25% in Manitoba to 7% in the Northwest Territories. The proportion of deaths in special care units varied by size and nature (teaching vs. non-teaching) of hospitals. It increased with the size of the hospital from 8% in hospitals with 1-49 beds, to 23% for hospitals with 400 or more beds. In teaching hospitals, 27% of deaths occurred in special care units, and in non-teaching hospitals the proportion was 15%. In conclusion, the majority of deaths in Canada occur in hospitals and a substantial proportion occur in special care units, raising questions about the appropriateness and quality of current end-of-life care practices in Canada.

End-of-life decision making in the seriously ill hospitalized patient: an organizing framework and results of a preliminary study.

Recent studies of patient/family satisfaction with end-of-life care suggest that improvements in communication and decision making are likely to have the greatest impact on improving the quality of end-of-life care. The apparent failure of recent studies specifically designed to improve decision making strongly suggest that there are powerful determinants of the decision making process that are not completely understood. In this paper, we present an organizing framework that describes the decision making process and breaks it into three analytic steps: information exchange, deliberation, and making the decision. In addition, we report the results of a preliminary study of end-of-life decision making that incorporates aspects of this organizing framework. Thirty-seven seriously ill hospitalized patients were interviewed. The majority wanted to share decisional responsibility with physicians. We demonstrated the feasibility of measuring certain aspects of the decision making process in such patients. By providing and using a framework related to end-of-life decision making, we hope to better understand the complex interaction and processes between dying patients, caregivers, and physicians.

Parenteral nutrition in the critically-ill patient: more harm than good?

While many studies have reported that providing parenteral nutrition (PN) can change nutritional outcomes, there are limited data that demonstrate that PN influences clinically-important end points in critically-ill patients. The purpose of the present paper is to systematically review and critically appraise the literature to examine the relationship between PN and morbidity and mortality in the critically-ill patient. Studies comparing enteral nutrition (EN) with PN and studies comparing PN with no PN were reviewed. The results suggest that EN is associated with reduced infectious complications in some critically-ill subgroups. PN, on the other hand, is associated with increased morbidity and mortality in critically-ill patients. When nutritional support is indicated, EN should be used preferentially over PN. Further studies are needed to define the optimal timing and composition of PN in patients not tolerating sufficient EN. Strategies to optimize EN delivery and minimize PN utilization in critically-ill patients are indicated.

Do potential patients prefer tissue plasminogen activator (TPA) over streptokinase (SK)? An evaluation of the risks and benefits of TPA from the patient's perspective.

BACKGROUND: In patients with acute myocardial infarction, TPA (compared to SK), has been shown to reduce the 30-day mortality rate at the expense of an increased rate of stroke. The assumption in the literature is that were it not for cost issues, all patients presenting with a myocardial infarction would choose TPA. Our hypothesis is that, for many informed individuals, regardless of cost, the increased risk of stroke may deter them from selecting TPA over SK. OBJECTIVE: To assess which thrombolytic drug informed patients would prefer and to explore the clinical and economic implications of such preferences. DESIGN: Prospective survey. SETTING: Tertiary care hospital. PATIENTS: 120 hospitalized patients with cardiac disease who would be "at risk" for a myocardial infarction. INTERVENTIONS: Face-to-face interviews utilizing a decision instrument. MEASUREMENTS: To minimize bias in soliciting patients' preferences and to standardize the presentation of information we developed a decision instrument which portrays a case scenario of a myocardial infarction, describes treatment outcomes (survival and stroke rate), and displays the likelihood of these outcomes with SK and TPA using three scenarios: a base stroke risk (all patients data), a lower stroke risk (<75 years old data), a higher stroke risk (>75 years old data). Outcome data were derived from the published literature (GUSTO study). RESULTS: When presented the overall results of the GUSTO study, 60/120 (50%) expressed a preference for SK. When presented the outcome data for the subgroups of patients <75 years old (lower stroke rate), 37/120 (31%) preferred SK. When presented the subgroup data for patients >75 years old (higher stroke risk), 67/120 (56%) preferred SK. CONCLUSIONS: Regardless of the scenario that individuals were presented with, a substantial proportion of individuals (31-56%) who could potentially require thrombolytic therapy chose SK over TPA. This study should be repeated in other settings to establish the generalizability of our results. Assuming that these results will be consistent, considering the patient's perspective has significant implications on clinical decision making as well as from an economic perspective.

Enteral and parenteral nutrition in the seriously ill, hospitalized patient: a critical review of the evidence.

Providing nutritional support has become a standard component of managing seriously ill patients. While many studies have documented that providing nutrition support can change nutritional outcomes (amino acid profile, weight gain, nitrogen balance, etc.), there are limited da ta that demonstrate that nutrition support actually influences clinicall y important endpoints. The purpose of this paper is to systematically r eview and critically appraise the literature to examine the relationship between nutritional support and morbidity and mortality in the seriously ill patient. As a product of this critical appraisal of the evidence, clinical recommendations based on rules of evidence are put forward.