Recent evidence suggests that vitamin D insufficiency is associated with an increased risk of stress fracture, total body inflammation, infectious illness and impaired muscle function (1,2) and is thus likely to impair the training ability of athletes in addition to affecting their overall health. Though not widely studied, vitamin D deficiency and insufficiency have been reported among athletes, irrespective of geographic location (3) . The aim of the current study was to assess vitamin D status in two groups of elite Irish athletes sampled in different months of the year.Non-fasting blood samples were taken from consenting volunteers (n 66) and total serum 25-hydroxyvitamin D (25(OH)D) was quantified by enzymeimmunoassay (IDS Limited, Boldon, UK). Serum calcium and plasma parathyroid hormone (PTH) concentration were also assessed (using the I-lab 650 Clinical Chemistry analyser and ARCHITECT i1000SR integrated system, respectively). *Significant difference between athletic groups (P < 0.05, independent t-test). Significance remained after controlling for age and gender (P < 0.001, ANCOVA); †mean daily intakes estimated from a validated food frequency questionnaire . Among the paralympians, the serum 25(OH)D and calcium concentrations of wheelchair-bound athletes were significantly lower compared to that of their able-bodied counterparts (P = 0.013 and P = 0.001, respectively), without significantly affecting PTH concentrations (P = 0.676). There were no significant differences in mean daily vitamin D (P = 0.903) or calcium (P = 0.210) intakes between the two groups of paralympians. Mean daily vitamin D and calcium intake were significantly correlated after controlling for age and gender (r = 0.464, P = 0.030), however were not associated with circulating 25(OH)D, PTH or calcium concentrations.This study highlights a high prevalence of vitamin D deficiency among elite Irish athletes, particularly at the end of winter. Inadequate sun exposure, rather than diet, is the likely cause of lower 25(OH)D concentrations observed in the wheelchair athletes. A serum 25(OH)D concentration ‡ 80 nmol/L has recently been postulated as desirable for athletes (2) however, the majority of athletes sampled in this study failed to reach this level. Vitamin D supplementation should therefore be considered for these athletic groups.

For physicians, diagnosing hematologic malignancies in children can often be challenging. The clinical signs and symptoms can often be non-specific or mimic other disease processes. We present the case of a previously healthy pediatric patient with persistent back and abdominal pain whose ultimate diagnosis of Hodgkin Lymphoma mimicked the osteomyelitis. As this case illustrates, it is imperative to be persistent and maintain a broad differential diagnosis in children during their evaluation and treatment stages in order to make the correct diagnosis.Keywords: Hematologic malignancies; Hodgkin lymphoma; Osteomyelitis; Abdominal pain Case ReportA previously healthy 12-year-old male presented to the emergency department where he was evaluated for 6-7 weeks of low back pain and one week of diffuse, cramping right lower quadrant abdominal pain. The patient was an active 7 th grader who played tennis and basketball and thus thought that his back pain may be musculoskeletal in nature. He had noticed slight improvement of his back pain with Advil; however, his abdominal pain had been worsening over the past week. His parents reported that he "hadn't looked right" for a few weeks. His review of systems was negative for fever, urologic complaints, cough, shortness of breath, chest pain, testicular pain, trauma, recent travel or exposure to homeless or prison populations. The patient has no significant past medical or surgical history, medications, or allergies. He was not sexually active and denied the use of drugs or alcohol. He lived with his mom, dad, and sister. Family history revealed MRSA skin infections in sister associated with school sports.Physical examination revealed stable vital signs without fever, and was significant for a diffusely tender abdomen with increased tenderness in the right and left upper quadrants. There was no rebound, guarding, masses, or organomegaly. The patient also had mild tenderness to palpation over the right lumbar paraspinal muscles but no midline tenderness to palpation. There was no notable lymphadenopathy. Overall he appeared to be a healthy pre-teen in no acute distress.Emergency department evaluation included the following tests. A complete blood count (CBC) revealed a WBC of 11.1 k/ cumm with a normal differential; hemoglobin of 11.2 gm/dL; hematocrit of 34.3%; and platelets of 350 k/cumm. A basic metabolic panel (BMP) and liver function tests were normal. An erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were elevated at 76 mm/hr and 3.4 mg/dL, respectively.A Chest X-ray revealed bilateral hilar lymphadenopathy ( Figure 1) with no parenchymal lesions. An abdomen/pelvis with IV contrast showed no signs of acute appendicitis but revealed a destructive lesion of the first lumbar vertebral body (L1) with paraspinal swelling of the adjacent right psoas muscle in addition to multiple microabscesses in the spleen with likely lymphadenopathy near the portal hepatitis.

A 67-year-old male presented to the emergency department with a chief complaint of weakness and abdominal pain. The patient was a resident of an extended care facility where he had lived for the past four months after extensive resection of an abdominal sarcoma complicated by wound dehiscence and an enterocutaneous fistula. Additional past medical history included type II diabetes mellitus, hypercalcemia, hypertension and chronic kidney disease stage II (CKD). On initial presentation the patient was afebrile, diaphoretic, tachycardic (heart rate 120-170's) with a labile systolic blood pressure (down to 60 mmHg).He was awake, alert, and cachectic, in moderate distress, with extremely dry mucus membranes, cracked lips, and no urine output. His abdomen showed a healing surgical wound with wet to dry dressings and a small fistula. An emergent electrocardiogram (EKG) was obtained ( Image 1 ) and labs were sent. His EKG showed a wide complex tachycardia (QRS 150, QTc 551) at a rate of 162. Due to these EKG findings and low blood pressure, the patient was deemed an unstable wide-complex tachycardia and preparation for cardioversion was initiated. However, while the patient was being placed on the cardioversion monitor with electrode pads, additional causes of his EKG findings were considered, including hyperkalemia. With his history of CKD, no urine output and hypercalcemia, immediate treatment with IV sodium bicarbonate was initiated. His rhythm strip narrowed in response and a second dose was given. A repeat EKG ( Image 2 ) revealed a narrow-complex junctional tachycardia (QRS 106, QTc 464) at a rate of 105. His blood pressure improved to systolics in the 120's.

Visual case discussionA 24-year-old female medical student presented after standing for two hours in a cold operating room observing surgery with digits 2-5 on both bands pale and cool to touch ( Fig. 1 ). She described parasthesias and stiffness in those digits, and denied any other symptoms. Her other hand appeared similar. Roughly thirty minutes after exiting the operating room and treating her hands with external passive rewarming, the parasthesias diminished and the color began to return to her digits ( Fig. 2 ). Her past medical history is significant for extreme cold (or hypothermia) exposure and frostbite to her hands at the age of fourteen with residual hypersensitivity of her hands (or fingers) to cold temperature. Conflict of interest and authorship confirmationAll authors have participated in (a) conception and design, or analysis and interpretation of the data; (b) drafting the article or revising it critically for important intellectual content; and (c) approval of the final version.The article I have submitted to the journal for review is original, has been written by the stated authors, and has not been published elsewhere.The image(s) that I have submitted to the journal for review are original, was (were) taken by the stated authors, and has not been published elsewhere.

A 72-year-old female presented to the Emergency Department (ED) reporting one week of increasing abdominal pain, distension, and discoloration over her mid abdomen. She had an abdominal ventral hernia repair with mesh 6 months prior. The incision had healed well after surgery but began swelling and draining a small amount of greenish fluid the week prior. She went to her primary care physician and was placed on antibiotics for concerns of cellulitis; however she did not fill the prescription. Associated symptoms included fatigue, nausea, and shortness of breath. She denied fevers or vomiting. Pertinent past medical history included coronary artery disease, hypertension, hyperlipidemia, methacillin resistant staphalococcus aureus (MRSA) skin abscesses, and an abdominal wall reconstruction with bilateral component separations and implantation of mesh 6 months ago. Physical examination revealed an afebrile, obese female in no distress with a tender 6×8 cm area of erythema with central greenish discoloration over her mid abdomen (Image 1, black arrow). An abdominal/pelvic computed tomography (CT) scan with intravenous (IV) contrast was obtained (Image 2, red arrow) revealing a large anterior abdominal wall abscess centered predominantly in the musculature with superficial extension into the subcutaneous fat, all above the mesh. The patient was started on IV vancomycin and piperacillin/tazobactam due to her history of MRSA and admitted to general surgery. She was taken to the operating room for open drainage of the abscess,