Cards can trigger the Suicide King effect, pills can activate the Health Down effect, and active items can trigger Plan C. This makes any strategy involving them unreliable and potentially dangerous. All activated collectibles, pills, cards and runes have a random effect upon being used.However, other pickups may provide red hearts when picked up, giving no benefit if health is full. Hearts follow their standard behavior, and cannot be picked up unless Isaac is injured, even though they provide other resources.Lucky Pennies will still provide +1 Luck.This makes it very hard to accumulate coins as they can be gained only from bombs and hearts, at a 1 in 3 rate.Coins and keys give hearts, bombs or keys.Once a pickup is acquired, it is randomly changed to another. Pickups (coins/hearts/bombs/keys), unlike pedestal items, are not displayed incorrectly.All items are still pulled from the correct item pool ( Angels will still drop Key Pieces, Mom will drop The Polaroid and The Negative if they are unlocked).While Curse of the Blind is not active, the fact that all pedestal items are displayed incorrectly means that, like with Curse of the Blind, it is impossible to know what each item is until acquired.All changes mentioned above are designed to make this challenge exceedingly difficult and frustrating.
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