Background: The importance of presenting options for organ/tissue donation to families of patients with irreversible brain damage has been recognized by medical staff; however, it remains difficult for attending doctors and medical teams because it is very distressful for them both physically and emotionally.
Objective: To develope and introduce a clinical pathway (CP) to make it easier to present options for organ/tissue donation.
Method: CP to present options for donation consisted of a cover letter (page 1), medical history and neurological evaluations (page 2), summary (page 3), and questionnaires about donation for the family (page 4, submission optional). We established it not to recommend donation, but to provide information about the patients' status and option of organ/tissue donation as an outcome of CP.
Results: There were 10 cases in which CP was appropriately applied from December 2008 to July 2010. It took about 30 minutes for each case. The presentation of options for organ/tissue donation was improved. CP was applied in 4.9±2.0 (2-9) hospital days. Page 4, the questionnaires about donation for the family, was returned to us in 7 of 10 cases in 0-2 days after applying CP. Families met coordinators for organ/tissue donation in 5 cases, and, finally, organ and/or tissue donation was conducted in 4 cases.
Discussion: Medical teams mostly make efforts to be respectful when presenting the limits of treatment, followed by medical organ donation options. Our developed CP seemed to be helpful to remain on the side of the family, and to provide information about the patients' status and options for organ/tissue donation for the family members.

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Background: Tsutsugamushi disease (Scrub Typhus), a vector-borne zoonosis is caused by Orientia tsutsugamushi (O.tsutsugamushi). This organism is transmitted by infected mites, especially Leptotrombidium scutellare, L.pallidum, and L.akamushi in Japan. The vector of tsutsugamusi disease in Chiba was estimated to be L.scutellare, however there were a few reports of serotypes of O.tsutsugamushi in some cases.
Objective: A retrospective chart review methodology was designed to clarify the epidemiological characteristics of tsutsugamushi disease in the medical care zone of Kameda Medical Center, in the southern part of Chiba Prefecture, including the incidence of infections by season, clinical presentation, and the serotypes of O.tsutsugamushi.
Methods: The study was conducted at Kameda Medical Center in Chiba Prefecture. A chart review for all suspected scrub typhus patients who visited the hospital between 2000 and 2009 was performed. For each suspected case, the serum was assayed by indirect immunofluorescence assay (IFA) for detecting the IgM and IgG antibodies against pooled Gilliam, Karp, and Kato strains of O.tsutsugamushi antigen.
Results: From 2000 to 2009, the results obtained were positive in 90 cases. Of the cases, 52 (58%) were males and 43 (47.8%) were admitted. 76 (84.4%) had eschar, 88 (97.8%) had erythematous lesions, 89 (98.9%) had fever, and 29 (32.2%) had headache. Hyponatremia was found in 37 (44.1%) cases, liver dysfunction was found in 61 (67.8%) cases, thrombopenia was found in 21 (23.3%) cases, and hematuria was found in 47 (78.3%) cases. In the hospitalized group, 25 cases met the criteria of SIRS, average SOFA score was 1.3 and average duration of hospital stays was 8.3 days. The serotypes Gilliam 55 (61%) cases, Karp 14 (15%) cases, Kato 17 (19%) cases were detected by IFA. Most cases occurred between October and December with a peak occurrence in November. Gilliam and Karp types are known to be transmitted by L.pallidum, and the existence of cross-immunoreaction between Gilliam and Kawasaki strain which is transmitted by L.scutellare is also known. However, Karp type is considered to be specific to the antigen transmitted by L.pallidum.
Conclusion: Our results suggest that L.pallidum transmits the causative rickettsia in some municipalities in the south of Chiba Prefecture.

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Although open abdomen management (OAM) is sometimes necessary after emergency surgery for trauma or acute abdomen, abdominal closure is difficult during prolonged OAM. We report a case in which delayed primary closure was achieved using the Wittmann patch. A 58-year-old woman was taken to the hospital with hemodynamic instability after injury from a fall. Transarterial embolization was performed for pelvic fracture. Subsequently, the patient developed abdominal distension. Emergency laparotomy revealed a massive retroperitoneal hematoma. Because of intraoperative coagulopathy and hypothermia, gauze packing and vacuum pack closure (VPC) was performed. On postoperative day (POD) 2, because of oozing of blood and intestinal edema repacking and VPC was performed. On POD 3, the patient developed uncontrollable septic shock. We reopened the packing and found panperitonitis with pus on the omentum and small intestine despite the absence of perforation. Daily intraperitoneal lavage was performed. When the inflammation settled on POD 12, we sutured the Wittmann patch to each fascia and tightened it daily at the bedside. Both fascias reached the midline on POD 16, and we completed definitive closure. There was no evidence of complications at the 6-month follow-up. The Wittmann patch has the ability to complete delayed abdominal closure in prolonged OAM.

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Acute aortic dissection can lead to sudden death. We present the clinical course of a 16-year-old male whose mother had been surgically treated for acute aortic dissection. He experienced sudden back pain and was examined at a clinic. Three days later, he developed sudden convulsive seizures while taking a bath and lapsed into cardio-pulmonary arrest. He was transported to our hospital by ambulance. Chest roentogenography revealed a massive right-sided hemothorax and chest drainage was thus initiated. We continued aggressive resuscitation, but there was no return of spontaneous circulation. The same day, we performed autopsy imaging and pathological anatomic evaluations. We found an aortic dissection, approximately 20 cm in length, on the tail side from the bifurcation of the left subclavian artery, and massive hemothorax was confirmed in the right cavumthoracis. The tunica media of the aorta showed cystic medial necrosis on histological examination. Acute aortic dissection at a young age is often associated with congenital diseases such as Marfan's syndrome. However, no sign of any congenital disease was detected in this case. When an aortic dissection develops in one family member, periodic follow-up of blood relatives is considered to be very important.

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A 59-year-old male with excruciating abdominal pain was transported to the emergency room of local hospital. In spite of an intramuscular injection of 20 mg of scopolamine, his abdominal pain was not improved. Thereafter, the patient was transferred to another hospital and was found to have a dissection of the superior mesenteric artery. To obtain a more detailed diagnosis and select further treatments, he was again transported, this time to our emergency department. On arrival, his vital signs were stable except for high blood pressure. A detailed CT examination revealed a superior mesenteric artery dissection associated with thrombus formation, however, the blood flow to the distal organs was preserved. Based on these findings, we selected conservative treatments with cilostazol and cilnidipine. Follow-up CT examinations performed on the 3rd and 6th hospital days showed no changes in the dissection in comparison with the images observed on his admission CT. Based on these follow-up CTs, and the stable physical symptoms of the patient, we allowed him to start oral intake and to be discharged from the hospital on the 11th hospital day. A CT examination performed two months after the incident showed that the false lumen was almost completely thrombosed, but that the size of the true lumen was narrower. A CT examination performed on six months after the incident showed that the false lumen was completely thrombosed, and the size of the false lumen was smaller, while the size of the true lumen was larger. The dissection of the superior mesenteric artery did not recur in this case. Idiopathic superior mesenteric artery dissection is very rare, but should be kept in mind when a patient presents with acute abdominal pain.

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