Clinical vignette: Ataxia and rash in a patient undergoing Hepatitis C treatment

Case Presentation: A 60-year-old man with hepatitis C and gout presented to our hospital with rash and ataxia. He was on week 10 of treatment for hepatitis C with peginterferon, ribavirin, and telaprevir. One week before admission he developed an ascending erythematous rash starting at his shins. His hepatitis C treatment was discontinued, but his rash progressed superiorly. He also developed fever and altered mentation, with confusion and difficulty walking. On admission he was febrile to 39.8°C and tachycardic. He had a diffuse erythematous rash with papules coalescing into plaques involving the forearms, back, abdomen, all extremities, and face and superficial erosion of the hard palate. Labs showed a white count of 3.2 x 103/mm3, hemoglobin 11.9 g/dL, platelets 101 x 103/mm3, left shift with 82% neutrophils without eosinophils or atypical lymphocytes, AST 88 U/L, ALT 59 U/L, and total bilirubin 2.1 mg/dL. CT head was normal. Drug screen was negative. Lumbar puncture was negative for syphilis, cocciodiodes, varicella, and herpes. Dermatology diagnosed erythema multiforme (EM), possibly secondary to a virus versus drug hypersensitivity. Gastroenterology thought the rash was due to telaprevir. He was started on empiric antibiotics and steroids. The punch biopsy returned showing \u27acute spongiotic dermatitis with lymphohistiocytic infiltrate,\u27 most consistent with drug eruption. On hospital day 5, the patient\u27s rash stopped progressing and began to scale over, with improved mentation. Discussion: Hepatitis C genotype 1 is commonly treated with peginterferon, ribavirin, and 1 of the protease inhibitors — boceprevir or telaprevir. The key side effects of peginterferon/ribavirin include anemia, thrombocytopenia, and neuropsychiatric symptoms like depression and fatigue. The level of cognitive dysfunction noted in the literature does not appear consistent with this particular patient\u27s ambulation difficulties or prior reported seizures. For telaprevir, skin reactions are common: nearly 56% of patients reported rash. The range of skin reactions is broad and includes Stevens—Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and drug reaction with eosinophilia and systemic symptoms (DRESS). The presence of rash, fever, and liver function test abnormalities is most suggestive of DRESS. Treatment includes stopping the offending drug. Topical corticosteroids may be used; systemic corticosteroids are generally not recommended. Conclusions: Because community-based physicians are increasingly managing hepatitis C treatment regimes, it is important for hospitalists to be aware of the regimen. Telaprevir commonly causes a rash, which can be life-threatening in a small minority of cases, and the range of skin reactions includes SJS, TEN, DRESS, and EM. Discontinuation of the offending agent and supportive care are the key treatment interventions, with systemic steroids contraindicated. Symptoms may persist for weeks after the drug is discontinued

STEM Education in the United States and Singapore

One of the hottest topics over the past several years has been science, technology, engineering and mathematics (STEM) education. The United States is lagging behind in the STEM education rankings as compared to its counterparts in Europe and Asia, including Singapore, ranked second overall in math and science based on the Program of International Student Assessment. Even as such a small country, Singapore has one of the best education systems in the world, one of the busiest ports, and is a leader in the science and technology market. One factor of this is the family life and the culture that education should improve one’s quality of life. Parent involvement and the drive of the student help them to become more apt learners and pursue a STEM career. The government also plays a role in creating an environment where students will become innovating minds in the workforce and help sustain the country’s economy and place in the global market. The education system fosters student’s interests in math and science and caters to different levels of students abilities in order to retain them in schools. All these factors contribute to Singapore having a higher percentage of students graduate from universities with STEM degrees than in the United States

Clinical vignette: Trust but verify: When believing the patient leads the doctor astray

Case Presentation: A 27-year-old woman with reported sickle-cell disease, protein C deficiency, pulmonary embolism (PE), and recent methicillin-resistant Staphylococcus aureus (MRSA) bacteremia was admitted for sickle cell crisis. She was flying between the east and west coast to visit family when she experienced chest pain 45 minutes into the flight. It was sharp, 7/10 in intensity, constant, substernal, and non-radiating. She felt the pain was similar to her sickle-cell pain. The pain continued to build despite acetaminophen and the plane was diverted for her hospitalization. She mentioned that during prior hospitalizations for sickle cell pain crisis that she required morphine patient-controlled analgesia (PCA). She also stated that she was hospitalized 1 month prior for MRSA bacteremia initially treated with vancomycin and later transitioned to daptomycin requiring a chest port. The admitting resident started the patient on IV fluids, morphine as needed for pain, and her reported previous medications including hydroxyurea, warfarin and daptomycin. The patients care was subsequently transferred to a hospitalist. Several discrepancies started to appear when the hospitalist tried to confirm the patient\u27s history. Her self-identified hematologist stated that his testing failed to show sickle-cell trait or disease. Testing at our hospital also had a normal peripheral smear without sickle cells and a negative sickle cell screen. Calls and record requests to the outside hospitals and pharmacies the patient identified were unsuccessful. When confronted with these inconsistencies, the patient became tearful and stated, \u27I know what I have.\u27 She then gave a different name and birthdate. The diagnosis of bacteremia one month prior was confirmed, but the organism was methicillin-sensitive (MSSA). Given the inability to corroborate the patient\u27s reported medical history, antibiotics and analgesics were discontinued, and the patient was discharged. She has not reappeared in our medical system. Discussion: This case is one of simulated illness. The differential diagnosis includes factitious disorder, malingering, and delusional disorder. Factitious disorder behaviors are unconscious and motivated by a need to assume the sick role. Malingering behaviors are based on a conscious desire to achieve external gains. Delusional disorder is a psychiatric diagnosis characterized by disordered thinking that results in misinterpretation of events. In this case without a clear external gain identified, factitious disorder is presumed. The confirmation of the patient\u27s history was key in this case in both identifying the incorrect prior diagnoses as well as avoiding further harm in continuing hydroxyurea and daptomycin in a patient who has neither sickle-cell disease or MRSA. Conclusions: Physicians are taught to believe a patient\u27s story, but this case highlights the importance of verification in confirming details in order to exclude factitious disorder or malingering.\u2

Unearthing the Seeds of Oppression and Injustice within Education: Using Intuition, Care, and Virtue to Guide the Educative Process and Cultivate Morality.

The emphasis of the inquiry is on the domain of education and the relationship present between the teacher and student more specifically. Essentially, the first part of the thesis outlines how the larger social-political system impacts the domain of public education, with the predominant issues of adversity becoming manifest at the level of the relationship that exists between teacher and student. The second part of the work utilizes the problems discovered and their impact on human experience to propose a virtue/care based method for approaching the relationship with the student in a way that both aligns more closely with the movement of experience, while also functioning to assist the student in shaping their own moral character. Essentially, the method being proposed is something that is meant to assist the teacher in her attempts to communicate with the student in a more personal sort of way, thus allowing for a higher degree of understanding of the unique personality of each student, with this understanding leading the teacher to form a more flexible approach that takes into account the various personalities of the students. In so doing the teacher is working to bring the experience of the student into the educative process, which should thereby increase student performance through their feeling more involved in the education being received

You\u27re New, Or Else You\u27re Through : How Collaborating with James Lapine Kept Stephen Sondheim Fresh and Youthful in His Fifties and Sixties

Traditionally, musical theatre composers have faded out of relevance around their fiftieth birthday. Stephen Sondheim, the composer-lyricist whose incomparable shows changed the landscape and raised the standards of American musicals, managed to be an exception. How did he do it? By working with James Lapine, a playwright and director nearly 20 years his junior. This thesis examines Lapine and Sondheim\u27s relationship and explores how the young Lapine infused the aging Sondheim and his work with youth, allowing him to stay fresh and avoid running out of steam

AN APPLICATION TO THE TEACHING OF ORTHOGRAPHY BASED ON ELEMENTARY PRINCIPLES OF LINGUISTIC SCIENCE

Over the years, teachers and administrators alike have struggled with teaching orthography, the conventions and rules of spelling. In particular, teachers in Prince William County in Virginia have struggled with how to teach orthography in their junior high schools. In the past, various orthography techniques they’ve used have failed to meet the needs of their students. This thesis analyzes the effect of an in-service program in Marsteller Junior High School to improve the orthography instruction in their schools

Crossing the Line: The Life and Musical Legacy of Friedrich Gulda Through a Study of \u3ci\u3ePlay Piano Play\u3c/i\u3e

In the 1950s, Austrian pianist Friedrich Gulda shocked the classical music community by publicly venturing into the realm of jazz. As one of the leading classical pianists of his generation, Gulda’s decision to explore a different type of music was seen as a scandal, leading many in the classical world to label Gulda as an eccentric who sought to upend centuries of musical tradition. Although Gulda had grown weary of the conventions of classical music, it was his lifelong love of jazz that propelled him to devote time and energy studying the techniques of jazz performance. He gave his first professional performance as a jazz artist at New York City’s Birdland in 1956, beginning a unique and controversial career that forever walked between the world of classical and jazz music. Having gained the respect of many in the jazz community, Gulda became known for his programs and recordings of both classical and jazz music. Many of these featured his own compositions, such as Play Piano Play—a ten-piece cycle in which Gulda presents jazz techniques and styles within classical formal structures. In addition to being effective pieces for the concert stage, Gulda wrote these exercises as a tool to teach the classical pianist how to perform jazz. Through a pedagogical and performance analysis of Play Piano Play, this document will help musicians discover how Gulda’s unique compositional approach of combining notated music with elements of improvisation progressively instills the fundamentals of jazz technique throughout the cycle. A brief consideration of three additional solo-piano works continues to show the important contributions Gulda has made to the classical-jazz genre of the piano repertoire. Friedrich Gulda’s career took him on a journey from the finest concert halls to the darkest smoke-filled jazz clubs. Through it all, he remained uniquely himself—an artist confident in his musical vision. Today, his legacy lives in works such as Play Piano Play, as each note describes the journey of one of the twentieth century’s most rebellious, radical, and revolutionary pianists. Advisor: Mark Clinto