Open living donor hepatectomy (OLDH) is an intensely painful procedure, with moderate-to-severe pain during the first 2 days after surgery; furthermore, 31% and 27% of donors have developed persistent pain by 6 and 12 months after OLDH, respectively. 1 Inadequate control of perioperative pain will affect the overall quality of life and may contribute to chronic pain. Therefore, advanced strategies should be used to enhance perioperative analgesia and postoperative recovery in patients undergoing OLDH.Enhanced recovery after surgery (ERAS) is an evidence-based, multidisciplinary, and multimodal approach to patient care during the perioperative period. The ERAS pathways seek to blunt surgical stress and maintain endocrine and metabolic homeostasis, thereby

Rationale:Adult-onset Still disease (AOSD) is a rare systemic inflammatory disease of unknown etiology characterized by evanescent salmon-pink rash, spiking fever, arthralgia/ arthritis, and lymphadenopathy. AOSD sometimes was fatal when it is complicated by macrophage activation syndrome (MAS) or hemophagocytic lymphohistiocytosis (HLH). Nonetheless, the literature provides no recommendations for treatment of AOSD patients with severe sepsis.Patient concerns:A previously healthy 65-year-old man with history of AOSD was referred to our hospital for persistent right lower quadrant abdominal pain for 2 days. One week later, an abdominal wall abscess and hematoma developed by extravasation from the inferior epigastric vessels, complicated by necrotizing fasciitis of the right thigh and groin region. To our best knowledge, this case was the first reported case of a perforated appendix complicated with necrotizing fasciitis in a patient with AOSD.Diagnoses:The patient was diagnosed as acute appendicitis complicated with necrotizing fasciitis and abdominal wall abscess.Interventions:This case received intravenous tigecycline injection and daily 10 mg prednisolone initially, and shifted to daily intravenous hydrocortisone 200 mg for suspected MAS or HLH. This patient underwent surgical intervention and debridement for necrotizing fasciitis.Outcomes:The patient's symptoms progressed worse rapidly. He died from cytomegalovirus viremia and bacterial necrotizing fasciitis complicated by septic shock.Lessons:(1) The steroid dose was difficult to titrate when AOSD complicated by sepsis. The differential diagnosis from MAS/HLH with bacterial/viral infection related severe sepsis was difficult but critical for decision making from clinicians and rheumatologists. (2) The conservative treatment with antibiotics for perforated appendix is safe but has a higher failure rate in immunocomprised patients such as systemic lupus erythematosus and AOSD. Early surgical intervention might contribute to better outcome. (3) The abdominal wall abscess can be spread from intra-abdominal lesion through the inferior epigastric vessels which were as weak points of abdominal wall. Imaging examinations contribute to acute diagnosis and help surgeons perform surgical interventions to prevent morbidity and mortality.

Ultrasound during cardiopulmonary resuscitation (CPR) is the latest 14 development in advanced cardiac life support. 1 Transthoracic 15 echocardiography (TTE) became the primary sonographic tool for 16 evaluating patients under cardiac arrest. It can be initiated at the time 17 of resuscitation. It evaluates cardiac lesions and the airway, lung, 18 abdomen, and great vessels. 2 However, recent evidence claimed 19 that performing TTE during resuscitation prolonged the pauses of 20 chest compressions. 3 Transesophageal echocardiography (TEE) 21 has been used to decrease CPR interruptions. 4 It is more reliable 22 than TTE in providing continuous imaging of the heart, aorta, and 23 coronary arteries without occupying the anterior chest space. TEE 24 also guides the operator's hands when repositioning to achieve a 25 higher CPR quality and aids intra-aortic/caval device placement. 5,6

IntroductionThe shorter the time between the onset of symptoms and reperfusion using endovascular thrombectomy, the better the functional outcome of patients. A training program was designed for emergency medical technicians (EMTs) to learn the gaze-face-arm-speech-time test (G-FAST) score for initiating a prehospital bypass strategy in an urban city. This study aimed to evaluate the effect of the training program on EMTs.MethodsAll EMTs in the city were invited to join the training program. The program consisted of a 30 min lecture and a 20 min video which demonstrated the G-FAST evaluation. The participants underwent tests before and after the program. The tests included (1) a questionnaire of knowledge, attitudes, confidence, and behaviors towards stroke care; and (2) watching 10 different scenarios in a video and answering questions, including eight sub-questions of G-FAST parameters, and choosing a suitable receiving hospital.ResultsIn total, 1058 EMTs completed the training program. After the program, significant improvement was noted in knowledge, attitudes, and confidence, as well as scenario judgement. The performance of the EMTs in evaluating G-FAST criteria in comatose patients was relatively poor in the pre-test and improved significantly after the training course. Although the participants answered the G-FAST items correctly, they tended to overtriage the patients and refer them to higher-level hospitals.ConclusionsA short training program can improve the ability to identify stroke patients and choose a suitable receiving hospital. A future training program could put further emphasis on how to evaluate comatose patients and choose a suitable receiving hospital.