An Unusual Etiology of Severe Right Heart Failure Deserving of Wider Recognition.

A previously healthy 31-year-old man presented with worsening shortness of breath and a petechial rash. Echocardiography showed severe right-sided heart failure with midsystolic notching of the antegrade right ventricular outflow Doppler envelope suggesting pulmonary hypertension. An extensive work-up revealed scurvy, with a dramatic resolution of symptoms shortly after vitamin C supplementation.

Totally extraperitoneal repair under general anesthesia versus Lichtenstein repair under local anesthesia for unilateral inguinal hernia: a prospective randomized controlled trial.

BACKGROUND: Lichtenstein repair (preferably under local anesthesia) or totally extraperitoneal repair (TEP) are both good options for treating uncomplicated unilateral inguinal hernia. We performed a prospective randomized trial to compare the outcome of TEP repair under general anesthesia versus open Lichtenstein inguinal hernioplasty under local anesthesia. METHODS: Adult men with primary unilateral inguinal hernia without any history of lower abdominal surgery were assessed for inclusion in the study. Of the 194 patients assessed for eligibility for recruitment in the trial, 72 were recruited in the trial and randomized into two groups of 36 patients each. A per-protocol analysis was performed. Patients were followed for a period of 3 months. Pain was assessed by a visual analog scale, and quality of life was assessed by the SF-36 Health Survey Questionnaire, version 2. RESULTS: A total of 59 patients were analyzed at the end of the study, 30 in the Lichtenstein group and 29 in the TEP group. The operating time (75.93 ± 13.68 vs. 64.77 ± 12.66 min, p = 0.002) and total operating room time (102.66 ± 15.676 vs. 72.64 ± 12.25 min, p < 0.001) were significantly longer in the TEP group. Postoperative pain scores in the TEP group were lower than the scores in Lichtenstein group, but the difference was not statistically significant. There was significantly more use of analgesics and higher C-reactive protein levels in the Lichtenstein group. Quality of life and patient satisfaction were similar in both groups. CONCLUSIONS: Lichtenstein repair under local anesthesia is as good as TEP under general anesthesia. The shorter operating room time, smaller mesh size, and lower cost of local anesthetic drugs all contribute to make Lichtenstein repair the better choice for repair of uncomplicated unilateral inguinal hernia, especially in developing nations with scarce resources.