Much evidence has suggested the existence of bidriectional communication between the brain and the immune system. The brain is known to modulate peripheral immunity by the autonomic nervous innervation as well as the neuroendocrine communication. This review focuses particularly on the involvement of the hypothalamo-sympathetic nervous system in the stress-induced immunosuppression. On the other hand, the immune system may signal the brain by means of signal molecules such as cytokines derived from immunological cells. Proinflammatory cytokines (interleukin-1 (IL-1), IL-6 and interferonα) act directly or indirectly on the brain cells to elicit a wide variety of autonomic, neuroendocrine and behavioral responses such as fever, anorexia, sleep, ACTH release, pain modulation and immunosuppression. These acute phase responses are also demonstrated to modulate the immune system. Thus, the brain and the immune system may act together to maintain the body homeostasis through the bidirectional communication in an integrated way.

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The beneficial effect of hypothermia on the treatment of ischemic cerebral damages has been explored since last several decades. However, less attention has been paid then on the application of hypothermia because of hampered complications and lack of basic knowledges. In the 1980s at long last, it was shown in the animal experiments that lowering temperature only by a few degrees could rescue central neurons against ischemic damages; seemingly the dawn of the second generation of hypothermia. In the animal models of transient global ischemia or focal ischemia, mild to moderate intraischemic hypothermia provided aremarkably protective effect on neurons, both histologically and functionally. A therapeutically relevant issue might be whether such hypothermia, even when introduced in the postischemic period, could also be neuroprotective against ischemic cerebral damages. At least in gerbil models, hippocampal CA 1 neurons were definitely rescued by hypothermia for 24hrs following transient forebrain ischemia for 5min and then normothermic reperfusion for couples of hrs. On the other hand, hypothermia on permanent focal cerebral ischemia has been considerably less studied than global ischemia, results obtained being still shaky.
The mechanism underlying the protective effect of postischemic hypothermia are not clear yet. However, a growing body of evidence has indicated that lowering temperature depresses ischemia induced glutamate release, intracellular calcium mobilizaion, and microglial activation along with production of NO and superoxides. It also restores postischemic protein synthesis, permeability of vessels, and the function of blood-brain barrier, and obviously induce transcription factors like AP 1 which may link to synthesis of cytokines. Thus, mode of action of hypothermia is broad and non-specific, which may be greatly of advantage in regard to cerebral protection against ischemic damages.

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Determination was made of the concentrations of ambient NOx (nitric oxide+nitrite oxide), to clarify whether the NO (nitric oxide) inhalation therapy would lead to room air pollution at this ICU. NO (5-10ppm; 800ppm 50-200ml/min) was administered to an infant with pulmonary hypertension in ICU. The exhaust gas was fully scavenged during mechanical ventilation, but not during short period of tracheal suction by manual ventilation. NOx was measured continuously for 11 days with or without NO at the bedside of the patient, and for 9 days at the outdoor of the ICU. During the course of this study, NOx varied from 0.01 to 0.12ppm at these sites, but the relationship between the NO inhalation therapy and the ambient NOx values could not be found. According to a questionnaire, 46% of the staff of ICU experienced mild headache and 28% felt a sense of smell, especially during manual ventilation. During manual ventilation without scavenging exhaust gas, transient increase in NOx (to 0.24ppm) was observed. These results suggest that scavenging and monitoring of NO gas are inevitable for the safe administration of NO.

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Since the use of blood purification methods following coronary artery bypass graft (CABG) surgery in patients with hemodialysis is controversial, we therefore retrospectively compared nine patients with chronic renal failure (CRF group) with 10 patients without renal dysfunction (control group) after CABG surgery. In the CRF group, all patients underwent continuous hemodialysis (CHD) in the early postoperative period, for a mean of 34±11 hours, followed by intermittent HD. The duration of mechanical ventilation was significantly longer in th CRF group than that in the control group, but the findings of arterial blood gas data analysis were similar in the two groups. There were no significant differences in hemodynamics or postoperative blood loss between the two groups. Negative fluid balance was pronounced in the CRF group on the second postoperative day. There were no serious complications in either group. We conclude that CHD is useful for postoperative fluid management following CABG surgery in hemodialysis patients.

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Endothelin (ET)-1 is potent vasoconstrictor peptide mainly synthesized by and secreted from vascular endothelium, which increases in various pathophysiological states. To elucidate the relationship between ET-1 and multiple organ dysfuncition, we measured plasma ET-1 concentrations, APACHE III score, and number of organ dysfunctions in 46 (ages: 63.5±2.0, years old) critically ill patients. Plasma ET-1 concentrations (11.0±1.0pg·ml^-1, mean±SE) in these patients on admission to ICU was significantly (P<0.01) higher than those of healthy subjects (1.5±0.1pg·ml^-1) and showed a significant (P<0.01) positive correlation with APACHE III score. Plasma ET-1 concentrations in patients with 3 dysfunctioning organ (n=10, 15.1±2.6pg·ml^-1) and in patients with 4 dysfunctioning organ (n=7, 14.9±2.4pg·ml^-1) were significantly (P<0.05) higher than those in patients with 1 dysfunctioning orgen (n=16, 7.6±1.3pg·ml^-1) and in patients with 2 dysfunctioning organ (n=13, 8.9±1.1pg·ml^-1). Plasma ET-1 concentrations in survivors (n=30) were significntly (P<0.01) decreased at discharge from ICU. These findings suggest that endogenous ET-1 is increased in proportion to the severity in critically ill patients and sustained increase in ET-1 is related to number of organ dysfunctions in multiple organ dysfunction syndrome.

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We reported two cases of severe acute pulmonary failure who were successfully treated with face (nasal) CPAP mask and the application of postural improving effect on the pulmonary oxygenation (Non-invasive respiratory support), instead of the conventional respiratory therapy including endotracheal intubatin (ETI), mechanical ventilation (CMV) etc.. First case was a 16 year old female who had bronchopneumonia from aplastic anemia, and her PaO₂/F_IO₂ (P/F) ratio was improved from 146 in supine position to 174 in right anterolateral position. Second case was a 21 year old male who had ARDS from acute myelogenous leukemia, and his P/F ratio was improved from 94 in supine position to 183 in left anterolateral position. Subsequently, clinical management was performed keeping these patients in anterolateral position in which their PaO₂ were improved within life saving range (over 60mmHg). And they were put into prone position for short periods (2 hours maximum) several times a day. Their P/F ratio were improved rapidly and exceeded 300 in all positions by the 5th ICU day.
Face (Nasal) CPAP mask is superior to permit patient to drink and eat something, to keep orally contact with others, and breath freely, moreover to avoid the pulmonary injuries associated with ETI, CMV, high PEEP, and high F_IO₂ inhalation.
Thsee cases suggest that if PaO₂ improve over 20mmHg with turning to anterolateral position in acute respiratory failure patient, even severe, respiratory treatments could be performed successfully with face (nasal) CPAP mask, instead of active conventional therapeutic skills.

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Copper deficiency during enteral nutrition is very rare. In this case, we treated a patient who developed leukocytopenia and anemia caused by copper deficiency during long-term enteral nutrition.
A 67-year-old woman was admitted for treatment of brain damage after cardiopulmonary resuscitation. After one month, her condition improved and she started rehabilitation. As she could not eat spontaneously, she received forced enteral feeding (Fiberen YH^(R)). However, She developed leukocytopenia after 15 weeks enteral feeding, and then had anemia for 23 weeks (white blood cell count; WBC 2.5×10³μl^-1, red blood cell count; RBC 2.68×10⁶·μl^-1, hemoglobin; Hb 8.4gdl^-1, hematocrit; Ht 25.1% for 24 weeks). Bone marrow was tapped and found to be normal. The plasma copper level was markedly below normal (9μg·dl^-1). After 4 weeks of intravenous (0.3mg·day^-1) and enteral (6.4mg·day^-1) copper supplementation, the plasma copper level increased to 97μg·dl^-1 and hematologic values improved dramatically (WBC; 9.0×10³μl^-1, RBC; 3.95×10⁶μl^-1, Hb; 12.0g·dl^-1, Ht; 36.0%). In conclusion, the copper deficiency should be considered during not only total parenteral nutrition but also enteral nutrition when hematologic disorder develops.

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Neurological and functional prognoses were studied in 6 patients (2 men, 4 women, age; 21-72yr) with crush syndrome injured in the Kobe Earthquake. Patients were buried under collapsed buildings. Two patients were injured in their unilateral legs, the other 4 patients were in bilateral legs. All the patients were associated with acute renal failure and serum creatine kinase was elevated. Affected limbs were remarkably swollen, muscle power and sensitivity to all modalities were diminished in the area distal to the site of compression. No patients underwent amputations or developed infections in their limbs and all the patients regained renal function. Burning pain and numbness occurred with the recovery of sensitivity 1 to 3 weeks following receiving injury. Muscle weakness and sensory deficits persist in all patients 6 months after the earthquake. There were no correlations between the level of muscle injury and duration of use of analgesics, recovery of motor function. We conclude that pain and functional disorder persists for a long time in patients with crush syndrome and pain control, rehabilitation are required for improving prognosis.

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We treated a patient with congenital defect of activation of pyruvate dehydrogenase complex with respiratory depression. A 10-year-old male patient was alert but had little spontaneous respiration because of the lack of respiratory drive due to remarkable hypocapnemia. His arterial carbon dioxide partial pressure was increased and his acidbase balance was normalized through the use of acetate solutions which patients with this disease can use as a source of TCA cycle. His production of carbon dioxide sufficiently increased with a very-high-fat diet analyzed by metabolic monitor. His spontaneous respiration reappeared after these treatments. Metabolic monitor was useful to estimate the energy sources which were actually used in the body at once.

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A case of crush syndrome with multiple organ failure and massive intestinal necrosis is reported.
A 50-year-old female suffered severe crush injury to abdomen and both thighs in the 1995 Great Hanshin Earthquake, Japan. Her subsequent course was complicated by acute renal failure, disseminated intravascular coagulation, paralytic ileus, lung abscess and hepatic failure. She did not improved regardless of intensive treatment including blood purification, mechanical ventilation. Fasciotomy was not performed.
Paralytic ileus prolonged, but small bowel injury was not identified by CT scanning. Repeated physical examination didn't show absolute indications for surgery. Later intestinal necrosis was recognized by ultrasonography, and massive intestinal resection was performed on 28th hospital. day.
Postoperative course was good. Rehabilitation made her walked again. Conservative local treatment of crush injury bore the good outcome.
In a case of prolonged paralytic ileus after crush injury for abdomen, small bowel injury should be considered regardless of diagnostic tests.

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