Increased intakes of energy and protein appear to be associated with improved clinical outcomes in critically ill patients, particularly when BMI is <25 or > or =35.

This review provides insights into why the current paradigm of immunonutrition has failed to consistently demonstrate a beneficial effect of key immunomodulating nutrients, and offers a timely solution through the new paradigm of pharmaconutrition.

These data suggest a trend towards long-term benefit in patients surviving high-risk surgery for LVFWR repair. Considering the high lethality of LVFWR, the urgency and complexity of the primary surgical intervention early diagnosis and prompt surgery play a key role in the management of this complication.

The purpose of the present paper is to provide a rationale for zinc supplementation as a potential therapeutic agent in critically ill patients by describing its role in health and disease, conducting a systematic review of current randomized trials in critical care, considering optimum route and dose of administration, and making recommendations for future research. Normal zinc homeostasis is required for a functional immune system, adequate antioxidant capacity, glucose homeostasis, and wound healing. In addition, zinc is a required cofactor for many enzymes, transcription factors, and replication factors. In non-critically ill patients, zinc supplementation has been associated with an improvement in markers of immune function. In critically ill patients, only 4 randomized trials have examined the effect of zinc supplementation on clinical outcomes. When all 4 studies were aggregated, zinc supplementation was associated with a nonsignificant reduction in mortality (relative risk = 0.63, 95% confidence intervals 0.25-1.59, P = .33) and length of stay in intensive care (-0.35 days, -0.85 to 0.15; P = .17). Thus, because of the paucity of clinical data, there is inadequate evidence to recommend the routine use of high-dose zinc supplementation in the critically ill. A first step would be to determine the optimal dose that has a maximal positive effect on underlying inflammatory, immunologic, and metabolic processes yet is safe and tolerated by critically ill patients. Subsequently, large, rigorously designed, randomized trials are required to elucidate the efficacy of such doses of zinc supplementation in this patient population.

Research has shown a close correlation between the decline of the UK Skylark Alauda arvensis population and the replacement of spring-sown cereals with winter-sown varieties, in which advanced sward development prevents successful multiple nesting attempts and reduces access for foraging. Widescale reversal of sowing times is unlikely for commercial reasons, so research has recently focused on ways of manipulating the sward structure of winter wheat to prolong access to nest-sites and food. An RSPB pilot study investigated leaving small 'undrilled patches' in otherwise conventionally managed winter wheat crops. This option was later incorporated into a fully replicated experimental design, as part of the Sustainable Arable Farming For an Improved Environment (SAFFIE) project. This large consortium-led project aims to test solutions for improving biodiversity within wintercereal-dominated rotations. The experiment described here ran over 2002-3, with three field-scale 'treatments' on 15 sites in the first year. The treatments compare (1) conventional winter wheat, (2) winter wheat sown in double-normal width (25 cm) wide-spaced rows (WSR) and (3) winter wheat with two 4-m by 4-m undrilled patches per hectare (UP). Results from the 2002 breeding season showed that undrilled patch treatments supported more breeding Skylarks for longer, most likely by aiding accessibility of food. WSR rows were little used by Skylarks and did not improve the abundance of favoured seed and invertebrate food items over conventional crops. Nesting performance and foraging patterns are discussed with reference to invertebrate food abundance and its accessibility, as determined by sward structure.

Hypermetabolism and malnourishment are common in the intensive care unit. Malnutrition is associated with increased morbidity and mortality, and most intensive care unit patients receive specialized nutrition therapy to attenuate the effects of malnourishment. However, the optimal amount of energy to deliver is unknown, with some studies suggesting that full calorie feeding improves clinical outcomes but other studies concluding that caloric intake may not be important in determining outcome. In this narrative review, we discuss the studies of critically ill patients that examine the relationship between dose of nutrition and clinically important outcomes. Observational studies suggest that achieving targeted caloric intake might not be necessary since provision of approximately 25% to 66% of goal calories may be sufficient. Randomized controlled trials comparing early aggressive use of enteral nutrition compared with delayed, less aggressive use of enteral nutrition suggest that providing increased calories with early, aggressive enteral nutrition is associated with improved clinical outcomes. However, energy provision with parenteral nutrition, either instead of or supplemental to enteral nutrition, does not offer additional benefits. In summary, the optimal amount of calories to provide critically ill patients is unclear given the limitations of the existing data. However, evidence suggests that improving adequacy of enteral nutrition by moving intake closer to goal calories might be associated with a clinical benefit. There is no role for supplemental parenteral nutrition to increase caloric delivery in the early phase of critical illness. Further high-quality evidence from randomized trials investigating the optimal amount of energy intake in intensive care unit patients is needed.

control mechanism which may automatically prevent excessive FSH stimulation of the ovaries. It should also be possible to produce synthetic LH-RH fairly cheaply. Nevertheless, many more clinical studies must be performed before we can define the proper place for LH-RH in the treatment of anovulatory infertility. Our studies in patients with anorexia nervosa prove that LH-RH can be used alone or in combination with HCG to induce follicular growth and maturation, ovulation, and pregnancy in such amenorrhoeic women, who have no evidence of endogenous ovarian activity. It remains to be seen if LH-RH is equally effective in other women with amenorrhoea.

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