Key Points Question How did expenditures for statins change after market exclusivity ended and generic statins became available? Findings Using 17 years of the Medical Expenditure Panel Study data, this survey study of generic competition among statins found that the end of market exclusivity was associated with $925.60 of annual savings per individual and $11.9 billion in savings for the US. Meaning Full generic competition of statins was associated with significant cost savings across all major payers within the US health care system.

Multisystem inflammatory syndrome in children (MIS‐C) is considered a late manifestation of COVID-19 infection, and it is a diagnosis of exclusion after ruling out other causes of systemic inflammations. We present a case of MIS-C to highlight the importance of cardiac workup in MIS-C due to frequent cardiac involvement and discuss the possible association between retropharyngeal edema and MIS-C. The case patient is a 10-year-old previously healthy boy who presented with persistent fever, right-side neck pain, and a new rash. The rash was attributed to recent amoxicillin use by his parents. Pertinent workups included elevated inflammatory markers, a benign electrocardiogram test, a negative urine analysis, blood culture, and retropharyngeal edema by computerized tomography. On day four of hospitalization, the patient failed to improve with broad-spectrum antibiotics and became tachycardic. A repeat echocardiogram revealed a decreased ejection fraction with mitral valve regurgitation. The cardiac finding, the skin finding, the persistent fever, and the initial negative workups fulfilled the case criteria for MIS-C. A positive test for anti-SARS-CoV-2 spike protein receptor-binding domain antibodies confirmed the diagnosis, and the patient improved with intravenous immune globulin (IVIG) and steroids. The retropharyngeal edema was thought to be coincidental; however, there seem to be frequent associations between MIS-C and retropharyngeal edema, suggesting that the retropharyngeal edema could be one of the initial manifestations of MIS-C. More study is needed to study the association between retropharyngeal edema and MIS-C and shed light on the diagnosis and medical management of MIS-C.

Patient: Male, 77-year-old Final Diagnosis: Hepatic portal venous gas Symptoms: Abdominal pain • constipation • sepsis Medication: — Clinical Procedure: Exploratory laparotomy Specialty: Surgery Objective: Rare disease Background: Hepatic portal venous gas is a rare and concerning finding occasionally seen on computed tomography (CT) scans, and must be emergently managed, often in the operating room. This condition can present in conjunction with bowel distension, pneumatosis intestinalis, and intestinal ischemia, so care must be taken to examine the imaging closely so as not to miss this dire condition. This report summarizes our experience with a patient who had this problem and how urgent management prevented a lethal outcome. Case Report: The patient was a 77-year-old morbidly obese man whose complicated hospital course began with admission for abdominal pain evaluation. This led to a flexible sigmoidoscopy for concerning CT findings suggestive of colitis or malignancy, leading to a perforation at the anterior wall of the sigmoid-rectal junction. Urgent sigmoid colectomy and Hartmann’s procedure were performed along with pelvic drainage. Blood cultures returned positive for Klebsiella . After 10 days, the patient decompensated, and a CT scan showed pneumatosis intestinalis, hepatic portal venous gas, and diffuse small bowel distension. Rectal stump dehiscence had occurred; therefore, 2 repeat abdominal wash-outs were performed with aggressive intensive care. The patient eventually stabilized and was ultimately discharged to a skilled nursing facility 32 days later. Conclusions: This case illustrates the importance of prompt imaging, medical management, and, if necessary, surgical exploration in the patient with bowel distension and hepatic portal venous gas on a CT scan. Although uncommon, this finding indicates a potentially poor prognosis and must be addressed emergently to prevent bowel ischemia from progressing in patients with underlying abdominal pathology.

Patient: Female, 43-year-old Final Diagnosis: Rocky Mountain spotted fever Symptoms: Acute kidney injury • hyponatremia • rash Medication: — Clinical Procedure: — Specialty: General and Internal Medicine Objective: Rare disease Background: Rocky Mountain spotted fever (RMSF) is a potentially fatal infectious disease caused by the gram-negative intracellular bacterium Rickettsia rickettsii . The classic triad includes fever, rash, and history of tick exposure; however, the triad presents in only 3% to 18% of cases at the initial visit, and the tick bite is often painless and overlooked. RMSF can present with other manifestations, including hyponatremia, lymphopenia, thrombocytopenia, and coagulopathy. Some of these manifestations can be overlooked if they overlap with manifestations of a patient’s pre-existing conditions. Case Report: A 43-year-old woman with RMSF presented with fever and treatment-resistant hyponatremia before developing a rash. Initially, the cause of her hyponatremia was attributed to adrenal insufficiency and dehydration. After appropriate treatments with hormone replacement therapy and intravenous hydration, her laboratory values remained relatively unchanged. A rash later appeared with an atypical RMSF pattern, warranting a detailed integumentary examination, which uncovered the culprit tick in an unusual location. After starting doxycycline, the patient’s signs and symptoms, including her sodium level, improved. Conclusions: We conclude that the diagnosis of RMSF is an empiric diagnosis based on clinical signs, symptoms, and appropriate epidemiologic settings for tick exposures. However, typical clinical signs do not always display at presentation. Other manifestations that a patient’s pre-existing conditions can simultaneously cause should not be overlooked and should be examined holistically with other signs, symptoms, laboratory values, and physical examinations. Early treatment with doxycycline is encouraged as evidence strongly suggests that early treatment is correlated with lower mortality.

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