There are still high mortality in patients with sepsis and multiple organ dysfunction syndrome in the field of emergency and critical care medicine. Both inflammatory cytokines and anti-inflammatory cytokines play important roles in the pathogenesis of these sepsis and multiple organ dysfunction syndrome. We reviewed the role of the cytokine imbalance in the response against the insult, and the cytokine modulation therapy may be useful for the treatment of such highly-complicated states, from the findings both basic in vivo studies and clinical studies.

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The expression in eukaryotic cells of heat shock proteins (Hsps) is induced by various stresses such as burn, infection, inflammation, and exposure to carcinogens or heavy metals. Hsp70 genes (hsp70) were isolated from human cDNA and were inserted into E. coli. Hsp70 proteins were separated from the inclusion bodies in E. coli expressing Hsp70 and were purified by sonication, detergents (Triton-X and urea) and sequential chromatography on Sephacryl S-200 and Resource Q column. Anti-Hsp70 antibodies in sera of burn patients (burn group) were measured by Western blot and enzyme-linked immunosorbent assey (ELISA) with purified Hsp70 protein as the antigen. Control sera were taken from multiple trauma or hemorrhagic shock patients (stress group) and from normal adults (control group). The results showed that the anti-Hsp70 antibody titers of the IgG class were significantly elevated in both the burn patients (0.71±0.46) and the stress group (0.70±0.42) in comparison with the control group (0.42±0.43). Furthermore, the anti-Hsp70 antibody titers of IgG class in the sera of burn patients tend to negatively correlate with the degree of burn surface area.

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Changes in the brain immediately after cardiopulmonary resuscitation (CPR) from whole brain ischemia due to sudden cardiopulmonary arrest (CPA) were studied by head CT. The subjects were 88 cases of non-traumatic CPA excluding those with primary brain disease. The subjects were divided into 4 groups according to the duration of cardiac arrest: Group A (less than 15 minutes, 2 cases), Group B (15-30 minutes, 11 cases), Group C (more than 30 minutes, 40 cases), Group D (no resuscitation after cardiac arrest, 35 cases). Head CT was performed within 4 hours after restoration of the cardiac rhythm, or within 1 hour after discontinuing resuscitation. All cases in Group A were observed to be clear consciousness after resuscitation. Not only the functional outcome but also the survivals rates were poorer as the duration of cardiac arrest increased in Groups B and C compared to Group A. The mortality rate was 85% or higher for cardiac arrests of 15 minutes or longer. Brain edema after resuscitation was examined by head CT in the basal-ganglia and thalamus regions, and in the corticomedullary junction of the cerebrum. In the cases of short duration of cardiac arrest, the basal-ganglia and thalamus regions, and the corticomedullary junction were clearly visible on CT. On the other hand, these areas were poorly or not visible (marked brain edema) in the cases of longer duration of cardiac arrest. The borders of the basal-ganglia and thalamus regions, and the corticomedullary junction were not obscured in any of the cases in Group A. However, the borders of these regions were poorly visible or not visible more frequently as the duration of cardiac arrest increased. In particular, the corticomedullary junction was not visible more frequently after cardiac arrest of long duration. Brain edema is caused and intensified by prolongation of hypoxia, but it is also reported to be caused by external cardiac massage, which increases the intracranial pressure. This was also suggested by the more notable brain edema in the corticomedullary junction than in the basal-ganglia and thalamus regions. These findings of brain edema appeared on head CT within 4 hours after CPR. Findings suggestive of vascular occlusion were also obtained.

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A case of spontaneous cervical epidural hematoma in an elderly patient was reported. An 82-year-old male was referred to our department because of right hemiparesis. He was diagnosed as cerebral thrombosis and treated conservatively. He complained of neck pain and CT scanning on the second day showed a high dense area at the level of dorsal C2 and C4. MRI revealed iso-low intense area in T1WI and T2WI, and the lesion was diagnosed as spontaneous cervical epidural hematoma. On the third day after the onset, C2-C4 laminectomy and evacuation of the hematoma was performed. No vascular anomaly was recognized in the lesion on histopathological examination. Postoperatively, his hemiparesis alomost fully recovered within one week and he was discharged on the 14th day after the operation. In a review literature, elderly patients whose hematoma was evacuated within 36 hours of the lesion being detected in the thoracic region showed a good prognosis. Especially in elderly patients, prompt diagnosis and treatment are essential for good quality of life.

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Emergency surgical repairs were performed successfully in two cases of blunt traumatic rupture of the thoracic aorta. Case 1 was a 32 year-oldman, and case 2 was a 50 year-old man. Two patients were injured in separate traffic accidents and suffered aortic ruptures just distal to the isthmus. The diagnoses were made only by enhanced helical CT. Aortic repairs were accomplished with the aid of left heart bypass. Intraoperative transesophageal echocardiogrphy, which was done in case 2, was very useful in delineating the site of rupture and coincident aortic dissection. Prosthetic graft interpositions were performed. There were no postoperative paraplegia in either case. Rapid diagnosis and urgent definitive surgical repair are crucial for the successful outcome of blunt traumatic rupture of the thoracic aorta.

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