Abdominal Ecchymosis: Emergency, or Urgen-C?

Scurvy is a multisystem disease caused by vitamin C deficiency, historically associated with lethargy, gingivitis, ecchymosis, edema, and death if left untreated. Contemporary socioeconomic risk factors for scurvy include smoking, alcohol abuse, fad diets, mental health conditions, social isolation, and economic marginalization. Food insecurity is also a risk factor. This report describes a case of a man in his 70s who presented with unexplained dyspnea, abdominal pain, and abdominal ecchymosis. His plasma vitamin C level was undetectable, and he improved with vitamin C supplementation. This case highlights the significance of awareness of these risk factors and emphasizes the need for a comprehensive social and dietary history to enable the timely treatment of this rare but potentially fatal disease.

The Effects of a Pass-Fail Curriculum on a Physician Assistant Program.

PURPOSE: The grading scale for students in a physician assistant program of study is not standardized. Students may be evaluated on a traditional 5-tiered A to F scale or a pass-fail system. The decision to change from ordered grading to pass-fail at an established program in the southeast was done following a change in the affiliated School of Medicine. The purpose of this study was to review effects on student scores following such a change. METHODS: The Physician Assistant National Certifying Exam (PANCE) and PACKRAT 2 exam scores for the last 2 cohorts of students scored in the 5-tiered system (2016, N = 60 and 2017, N = 59) were compared against the same for the first 2 cohorts (2018, N = 59 and 2019, N = 58) of the pass-fail system. Nonrandom sampling of all students in each cohort year was evaluated using 2-tailed t-testing. RESULTS: A total of 236 student scores were evaluated using a 95% confidence interval. The traditionally scored classes outperformed all pass-fail cohorts (means 460.67/491.86 versus 503.34/493.92). P values were found to be significant at all values between the 5-tier scored classes and the pass-fail cohorts in PANCE scoring, resulting in failure to reject the null hypothesis. This was also true for the PACKRAT 2 with the exception of the 2019 cohort, which was significant only for outperformance of the other pass-fail cohort. For the purpose of this study, the only analysis performed was scoring. CONCLUSION: For cohorts undergoing curricular change, unforeseen impacts on initial standardized exam scores may occur. In this study, PANCE scores for the first year of the 2 pass-fail cohorts decreased while the overall program scores remained at or above the national average. The pass-fail cohort did show an upward trend in the second year of the curriculum, suggesting that as programs become more familiar with the pass-fail system, steady improvements occur. This suggests that while an anticipated drop in initial scores may be expected, further studies are needed to evaluate the impact on stress reduction, long retention, and intraclass competition.

Long-term facilitation of ventilation in humans with chronic spinal cord injury.

RATIONALE: Intermittent stimulation of the respiratory system with hypoxia causes persistent increases in respiratory motor output (i.e., long-term facilitation) in animals with spinal cord injury. This paradigm, therefore, has been touted as a potential respiratory rehabilitation strategy. OBJECTIVES: To determine whether acute (daily) exposure to intermittent hypoxia can also evoke long-term facilitation of ventilation after chronic spinal cord injury in humans, and whether repeated daily exposure to intermittent hypoxia enhances the magnitude of this response. METHODS: Eight individuals with incomplete spinal cord injury (>1 yr; cervical [n = 6], thoracic [n = 2]) were exposed to intermittent hypoxia (eight 2-min intervals of 8% oxygen) for 10 days. During all exposures, end-tidal carbon dioxide levels were maintained, on average, 2 mm Hg above resting values. Minute ventilation, tidal volume, and breathing frequency were measured before (baseline), during, and 30 minutes after intermittent hypoxia. Sham protocols consisted of exposure to room air and were administered to a subset of the participants (n = 4). MEASUREMENTS AND MAIN RESULTS: Minute ventilation increased significantly for 30 minutes after acute exposure to intermittent hypoxia (P < 0.001), but not after sham exposure. However, the magnitude of ventilatory long-term facilitation was not enhanced over 10 days of intermittent hypoxia exposures. CONCLUSIONS: Ventilatory long-term facilitation can be evoked by brief periods of hypoxia in humans with chronic spinal cord injury. Thus, intermittent hypoxia may represent a strategy for inducing respiratory neuroplasticity after declines in respiratory function that are related to neurological impairment. Clinical trial registered with www.clinicaltrials.gov (NCT01272011).

Drug reaction with eosinophilia and systemic symptoms syndrome in a patient taking phenytoin and levetiracetam: a case report.

INTRODUCTION: Drug reaction with eosinophilia and systemic symptoms syndrome is a potentially life-threatening hypersensitivity reaction with rash, fever, and internal organ involvement, often hepatitis, occurring most commonly two to eight weeks after initiation of a medication. The present case is an example of severe and potentially life-threatening hepatitis as a manifestation of drug reaction with eosinophilia and systemic symptoms syndrome. CASE PRESENTATION: We report a case of anti-epileptic-induced drug reaction with eosinophilia and systemic symptoms syndrome in an 18-year-old African-American man who presented with a five-day history of rash, periorbital and upper extremity edema, hepatitis and fever. Laboratory findings revealed an atypical lymphocytosis, eosinophilia, and elevated serum transaminases. No drug allergies were reported at the time of presentation, but phenytoin and levetiracetam therapy had been initiated five weeks prior to hospital admission for new-onset seizures. Both medications were discontinued on hospital admission, and after three days of high-dose corticosteroid therapy the patient experienced resolution of both his symptoms and laboratory markers of inflammation. CONCLUSION: Given the significant mortality attributed to drug reaction with eosinophilia and systemic symptoms syndrome, medical personnel should be aware of the potential for this severe hypersensitivity reaction and should ensure close follow-up and offer anticipatory guidance when beginning any new medication, particularly anti-epileptic therapy. Early recognition of drug reaction with eosinophilia and systemic symptoms syndrome and initiation of appropriate therapy are imperative in limiting morbidity.