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BackgroundEarly diagnosis of sepsis enables timely resuscitation and antibiotics and prevents subsequent morbidity and mortality. Clinical approaches relying on point-in-time analysis of vital signs or lab values are often insensitive, non-specific and late diagnostic markers of sepsis. Exploring otherwise hidden information within intervals-in-time, heart rate variability (HRV) has been documented to be both altered in the presence of sepsis, and correlated with its severity. We hypothesized that by continuously tracking individual patient HRV over time in patients as they develop sepsis, we would demonstrate reduced HRV in association with the onset of sepsis.Methodology/Principal FindingsWe monitored heart rate continuously in adult bone marrow transplant (BMT) patients (n = 21) beginning a day before their BMT and continuing until recovery or withdrawal (12±4 days). We characterized HRV continuously over time with a panel of time, frequency, complexity, and scale-invariant domain techniques. We defined baseline HRV as mean variability for the first 24 h of monitoring and studied individual and population average percentage change (from baseline) over time in diverse HRV metrics, in comparison with the time of clinical diagnosis and treatment of sepsis (defined as systemic inflammatory response syndrome along with clinically suspected infection requiring treatment). Of the 21 patients enrolled, 4 patients withdrew, leaving 17 patients who completed the study. Fourteen patients developed sepsis requiring antibiotic therapy, whereas 3 did not. On average, for 12 out of 14 infected patients, a significant (25%) reduction prior to the clinical diagnosis and treatment of sepsis was observed in standard deviation, root mean square successive difference, sample and multiscale entropy, fast Fourier transform, detrended fluctuation analysis, and wavelet variability metrics. For infected patients (n = 14), wavelet HRV demonstrated a 25% drop from baseline 35 h prior to sepsis on average. For 3 out of 3 non-infected patients, all measures, except root mean square successive difference and entropy, showed no significant reduction. Significant correlation was present amongst these HRV metrics for the entire population.Conclusions/SignificanceContinuous HRV monitoring is feasible in ambulatory patients, demonstrates significant HRV alteration in individual patients in association with, and prior to clinical diagnosis and treatment of sepsis, and merits further investigation as a means of providing early warning of sepsis.

Abstractfections. In the post-antibiotic era this complication of neck infection is much less Background -Descending necrotising mediastinitis is caused by downward common. Estrera et al 2 reported the largest series since 1960 with 10 cases. We have sucspread of neck infection and has a high fatality rate of 31%. The seriousness of cessfully treated seven adult patients with descending necrotising mediastinitis and also this infection is caused by the absence of barriers in the contiguous fascial planes present a child in whom the infection developed and spread rapidly, leading to death. This paper of neck and mediastinum. Methods -The recent successful treatment reviews these cases and presents a meta-analysis of 24 case reports and 12 series of adult desof seven adult patients with descending necrotising mediastinitis emphasises the cending necrotising mediastinitis since 1970. importance of optimal early drainage of both neck and mediastinum and prolonged antibiotic therapy. The case is also pre-Methods sented of a child with descending ne-  1 crotising mediastinitis, demonstrating the A 35 year old male engineer with a past history rapidity with which the infection can de-of hepatitis B was admitted following transfer velop and lead to death. Twenty four case from the intensive care unit of a peripheral reports and 12 series of adult patients with hospital. Five days prior to admission he had descending necrotising mediastinitis pub-sought medical attention for odynophagia, lished since 1970 were reviewed with meta-hoarseness, and mild left otalgia for which he analysis. In each case of confirmed des-was given oral penicillin. Forty eight hours later cending necrotising mediastinitis the he was admitted to the intensive care unit There were bilateral pleural effusions and lower 19% when mediastinal drainage was added lobe consolidation. The pericardial space was

ObjectiveThe authors set out to determine whether immediate enteral feeding minimizes early postoperative decreases in handgrip and respiratory muscle strength. Summary Background DataMuscle strength decreases considerably after major surgical procedures. Enteral feeding has been shown to restore strength rapidly in other clinical settings. MethodsA randomized, controlled, nonblinded clinical trial was conducted in patients undergoing esophagectomy or pancreatoduodenectomy who received immediate postoperative enteral feeding via jejunostomy (fed, n = 13), or no enteral feeding during the first 6 postoperative days (unfed, n = 15). Handgrip strength, vital capacity, forced expiratory volume in one second (FEV1), and maximal inspiratory pressure (MIP) were measured before surgery and on postoperative days 2, 4, and 6. Fatigue and vigor were evaluated before surgery and on postoperative day 6. Mobility was assessed daily after surgery using a standardized descriptive scale. Postoperative urine biochemistry was evaluated in daily 24-hour collections. ResultsPostoperative vital capacity (p < 0.05) and FEV1 (p = 0.07) were consistently lower (18%-29%) in the fed group than in the unfed group, whereas grip strength and maximal inspiratory pressure were not significantly different. Postoperative mobility also was lower in the fed patients (p < 0.05) and tended to recover less rapidly (p = 0.07). Fatigue increased and vigor decreased after surgery (both p < 0.001), but changes were similar in the fed and unfed groups. Intensive care unit and postoperative hospital stay did not differ between groups. ConclusionsImmediate postoperative jejunal feeding was associated with impaired respiratory mechanics and postoperative mobility and did not influence the loss of muscle strength or 369

ContributorsGIW wrote and revised the manuscript in response to co-author comments. He finalized all the figures and tables, performed the literature search, and assisted with data interpretation. HJK critically reviewed the manuscript and made important suggestions to improve it. He assisted with data interpretation. IBA performed the data analysis, constructed the figures and tables, and made important suggestions to improve the manuscript. H-CK assisted with the data analysis and also reviewed the manuscript. GRC critically reviewed the manuscript and made important suggestions to improve it. He assisted with data interpretation. All other authors were given the opportunity to review the manuscript and make suggestions which GIW received, either revising the paper or providing explanations. All who are not deceased were involved with approval of the manuscript.

Degeneration and significant loss of nerve fibres associated with predominant T-cell lymphocytic inflammatory infiltrate around the myenteric plexus support the concept for the inflammatory, probably autoimmune, aetiology of autonomic nervous system injury in primary achalasia.

PAAL leads to longer hospital stays, and approximately 4.8% of patients undergoing pulmonary resection experience PAAL that necessitates placement of additional chest drains, bronchoscopy, reoperation, or life support. Further study is required to assess the cost-effectiveness of measures to reduce PAAL.

Although digital devices decreased tube clamping trials, the impact on duration of chest tube drainage and hospital stay was not statistically significant, even after stratifying by postoperative air leak status.