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Sufficient nutrients are needed for critically ill patients to meet metabolic needs. Previous studies have shown that appropriate nutritional feeding during critical illness improves the success in weaning patients from mechanical ventilation and in reducing the length of hospitalization [1][2][3][4][5] Correspondence: Yi-Chia Huang, ych@csmu.edu.tw AF = appropriate feeding; APACHE = Acute Physiology and Chronic Health Evaluation; ICU = intensive care unit; MAC = mid-arm circumference; MEE = measured energy expenditure; MI = Maastricht Index; NRI = Nutritional Risk Index; OF = overfeeding; RQ = respiratory quotient; TLC = total lymphocyte count; TSF = triceps skinfold thickness; UF = underfeeding; UUN = urine urea nitrogen. AbstractBackground There is very little information on what is considered an adequate energy intake for mechanically ventilated, critically ill patients. The purpose of the present study was to determine this energy requirement by making use of patients' nutritional status. Methods The study was conducted in a multidisciplinary intensive care unit of Taichung Veterans General Hospital, Taiwan. Patients were hemodynamically stable and not comatose, and were requiring at least 7 days of mechanical ventilation. Fifty-four patients successfully completed this study. The resting energy expenditure was measured using indirect calorimetry. The total energy requirement was considered 120% of the measured energy expenditure. The daily nutrient intake was recorded. Nutritional status was assessed using single and multiple parameters, nitrogen balance, and medical records, and was performed within 24 hours of admission and after 7 days in the intensive care unit. Results Fifteen patients were being underfed (< 90% of total energy requirement), 20 patients were in the appropriate feeding (AF) group (within ± 10% of total energy requirement), and 19 patients received overfeeding (> 110% of total energy requirement). Patients in the underfeeding group received only 68.3% of their energy requirement, while the overfeeding group patients received up to 136.5% of their required calories. Only patients in the AF group had a positive nitrogen balance (0.04 ± 5.1) on day 7. AF group patients had a significantly higher Nutritional Risk Index value at day 7 than at day 1. Conclusion AF patients had more improvement in nutritional status than patients in the other feeding groups. To provide at least 120% of the resting energy expenditure seemed adequate to meet the caloric energy needs of hemodynamically stable, mechanically ventilated, critically ill patients.

The potentiating and blocking effects of U50,488H and naloxone, respectively, suggest that endogenous opioid peptides are involved in the pathophysiology of myocardial ischaemia and play an important role in ischaemic heart disease.

Paravalvular leakage is a major complication of prosthetic valve dysfunction. Sixty-one subjects with valvular heart disease who had received prosthetic mitral valve replacement 5 months to 5 years before (43 received a porcine prosthesis and 18 received Bjork-Shiley valve prostheses) were evaluated for this complication. Careful auscultation was performed by two experienced cardiologists followed by transthoracic and transesophageal echocardiography. Physiologic leaks were detected in all Bjork-Shiley valves, but in only 30% of porcine valves using transesophageal echocardiography. These regurgitant jets were flame-like, with mean low velocities of 50 +/- 12.3 cm/sec and 48 +/- 18.2 cm/sec in the two types of valves. Neither transthoracic echocardiography nor auscultation could detect physiological regurgitant jets. Ten cases with paravalvular leak were detected by transesophageal echocardiography and subsequently demonstrated by left ventriculography (7 porcine, 3 Bjork-Shiley valves). Pathologic regurgitant jets were seen as high-velocity, systolic-retrograde turbulent flow across the prosthesis. However, only 6 cases of prosthetic valve dysfunction were detected by transthoracic echocardiography, 4 cases of mild paravalvular leakage went undetected. Thirteen of the 61 subjects had an apical systolic murmur and suspected prosthetic valve leakage; in 10 of the 13 cases the findings corresponded to those obtained by transesophageal echocardiography. In 3 cases of double valve replacement with Bjork-Shiley valves the magnitude of the leakage was overestimated by auscultation.

The effects of the stereoisomers of naloxone during myocardial ischemia were studied. (-)-Naloxone (but not the (+)-isomer naloxone) attenuated the ischemia-induced cardiac arrhythmias, hypotension, and bradycardia that result from coronary artery occlusion in anesthetized rats. From these findings, it may be inferred that endogenous opioid peptides may play a role in the pathophysiology of myocardial ischemia. It is also suggested that naloxone may have therapeutic value in the prevention and treatment of ischemic heart disease.

A large congenital aneurysm, arising from the first diagonal branch of the left anterior descending artery in a 52 year old woman was diagnosed by transoesophageal echocardiography, computed tomography, and magnetic resonance imaging. Surgical closure of the aneurysm was successful. (Br HeartJ7 1993;70:274-275) Large congenital aneurysms of the coronary arteries are rare.'-5 Most of the reported aneurysms were diagnosed at necropsy, and rarely by non-invasive methods before coronary angiography.6 We report a patient in whom a large coronary arterial aneurysm was diagnosed by transoeosophageal echocardiogram, computed tomography, and magnetic resonance imaging before operation.Case report A 52 year old woman was admitted to hospital with a five month history of chest tightness and cough. She had episodes of non-exertional chest tightness lasting five minutes. This was generally followed by coughing that produced mucoid sputum. She was a nonsmoker. Her (fig 3).The other branches of the coronary artery were all normal. The aneurysm was partially filled by thrombus. The patient underwent marsupialisation of the aneurysm. She has remained symptom free since surgery.