Unveiling Multiple Myeloma: Actively Bleeding Extramedullary Gastric Myelomas Lead to Diagnosis.

Multiple myeloma (MM) is a disease of plasma cell replication, leading to a disruption of hematopoiesis, which commonly presents clinically with anemia and fatigue. Extramedullary myelomas are plasma cell collections in bone or soft tissue associated with MM and most often occur later in the disease process. We present a case of a patient with symptomatic anemia with actively bleeding gastric nodules, which were later found to be extramedullary gastric myelomas when pathology demonstrated kappa-restricted plasma cell neoplasms. To confirm the overall diagnosis, a bone marrow biopsy verified the patient had MM.

Dogs Licks Are Not Benign: Pasturella Multocida Bacteremia From Household Dog.

Pasturella (P.) multocida is a gram-negative coccobacilli commonly colonized in the oral, nasopharyngeal, and upper respiratory tracts of animals. Infections due to P. multocida range in severity, and symptoms largely depend on underlying immune status and co-morbid conditions. Widely known, the transmission of P. multocida is commonly thought to occur through biting and skin breakage alone. However, multiple studies have highlighted instances of severe complications secondary to transmission through the passage of P. multocida through animal licking alone without skin disruption. Here, we present a case of a nonagenarian female presenting with septic shock secondary to P. multocida with the source of transmission found to be secondary to the patient's dog licking her chronic leg wounds. We also highlight other instances of similar transmission through a literature review, including common treatment courses. We aim to raise awareness of common transmissions of bacteria, specifically P. multocida, along with broadening differentials when one presents with skin and soft tissue infections.

CardioMEMS monitoring device migration: A rare complication.

We present a rare case of CardioMEMS device migration six years post-implantation. Much is still being learned about endothelization of pulmonary vasculature and this case highlights the importance of device surveillance and device-related complications.

Understanding the impact of numerical solvers on inference for differential equation models.

Most ordinary differential equation (ODE) models used to describe biological or physical systems must be solved approximately using numerical methods. Perniciously, even those solvers that seem sufficiently accurate for the forward problem, i.e. for obtaining an accurate simulation, might not be sufficiently accurate for the inverse problem, i.e. for inferring the model parameters from data. We show that for both fixed step and adaptive step ODE solvers, solving the forward problem with insufficient accuracy can distort likelihood surfaces, which might become jagged, causing inference algorithms to get stuck in local 'phantom' optima. We demonstrate that biases in inference arising from numerical approximation of ODEs are potentially most severe in systems involving low noise and rapid nonlinear dynamics. We reanalyse an ODE change point model previously fit to the COVID-19 outbreak in Germany and show the effect of the step size on simulation and inference results. We then fit a more complicated rainfall run-off model to hydrological data and illustrate the importance of tuning solver tolerances to avoid distorted likelihood surfaces. Our results indicate that, when performing inference for ODE model parameters, adaptive step size solver tolerances must be set cautiously and likelihood surfaces should be inspected for characteristic signs of numerical issues.

Journey to the other side of the brain: asymmetry in patients with chronic mild or moderate traumatic brain injury.

Aim: Patients with chronic mild or moderate traumatic brain injury have some regions of brain atrophy (including cerebral white matter) but even more regions of abnormal brain enlargement (including other cerebral regions). Hypothesis: Ipsilateral injury and atrophy cause the eventual development of contralateral compensatory hypertrophy. Materials & methods: 50 patients with mild or moderate traumatic brain injury were compared to 80 normal controls (n = 80) with respect to MRI brain volume asymmetry. Asymmetry-based correlations were used to test the primary hypothesis. Results: The group of patients had multiple regions of abnormal asymmetry. Conclusion: The correlational analyses supported the conclusion that acute injury to ipsilateral cerebral white matter regions caused atrophy, leading eventually to abnormal enlargement of contralateral regions due to compensatory hypertrophy.

Diabetes and hyperglycemia quality improvement efforts in hospitals in the United States: current status, practice variation, and barriers to implementation.

OBJECTIVE: To determine the status of diabetes and hyperglycemia quality improvement efforts in hospitals in the United States. METHODS: We designed and administered a survey to a convenience sample of hospitals, and the responses were analyzed statistically. RESULTS: We received 269 responses from 1,151 requested surveys. The sample was similar to hospitals in the United States on the basis of hospital type and geographic region (P = no significant difference) but not on the basis of number of beds (P<.001). Among responding hospitals, 39%, 21%, and 15% had fully implemented inpatient diabetes and hyperglycemia quality improvement programs for critically ill, non-critically ill, and perioperative patients, respectively. Moreover, 77%, 44%, and 49% had fully implemented protocols for hypoglycemia, hyperglycemic crises, and diabetic ketoacidosis, respectively. Variations in glucose target ranges were noted. The responding hospitals had no standard biochemical definition of hypoglycemia; 47% defined hypoglycemia as a glucose level

Inhaler devices for children.

The use of inhaled medicines for the management of asthma is common and is the preferred method of treatment (NICE, 2000a). It is recommended that bronchodilating drugs, such as beta 2-agonists, which provide symptom relief, and anti-inflammatory drugs, such as corticosteroids, are administered by inhalation (NICE 2000a). However, the number of devices available can leave the practitioner and the patient confused about which is the most appropriate inhaler. Guidance from the National Institute for Clinical Excellence states that: 'It is important to ensure that an inhaler device delivers the drugs to the airways consistently and in the appropriate quantity' (NICE, 2000a).