Medical Diagnosis Reimagined as a Process of Bayesian Reasoning and Elimination.

This article delves into the interface between the art of medical diagnosis and the mathematical foundations of probability, the Bayes theorem. In a healthcare ecosystem witnessing an artificial intelligence (AI)-driven transformation, understanding the convergence becomes crucial for physicians. Contrary to viewing AI as a mysterious "black box," we demonstrate how every diagnostic decision by a medical practitioner is, in essence, Bayesian reasoning in action. The Bayes theorem is a mathematical translation of systematically updating our belief: it quantifies how an additional piece of information updates our prior belief in something. Using a clinical scenario of Kartagener syndrome, we showcase the parallels between a physician's evolving diagnostic thought process and the mathematical updating of prior beliefs with new evidence. By reimagining medical diagnosis through the lens of Bayes, this paper aims to demystify AI, accentuating its potential role as an enhancer of clinical acumen rather than a replacement. The ultimate vision presented is one of harmony, where AI serves as a symbiotic partner to physicians, with the shared goal of holistic patient care.

Tennis Courts in the Human Body: A Review of the Misleading Metaphor in Medical Literature.

Medical literature is home to fancy descriptions, poetic metaphors, and ingenious comparisons. However, some comparisons can disguise the knowledge gap. Large surfaces in the human body, like the alveolar surface for gas exchange, villi for food absorption, and the endothelial lining of blood vessels, are frequently compared to a "tennis court." This narrative review explores this metaphor in detail, the discrepancies and factual inaccuracies across medical literature. It highlights the inappropriate use of Euclidean geometry and introduces fractal geometry, a language to define roughness.

Patients With Suicidal Patterns in the Emergency Room: A Clinical and Social Reflection.

Background and objective Emergency physicians come across a myriad of medical afflictions resulting from suicide attempts. The Indian contribution to global suicide deaths is alarming; the social construct of India is unique, and so are the problems and challenges. This study aims to describe the social background, demographic parameters and correlate the clinical profile and outcomes of all patients presenting with an attempted or completed suicide. Materials and methods The present study is a hospital-based prospective observational study conducted by the Department of Emergency Medicine at RL Jalappa Hospital and Research Centre, a rural tertiary-care center in Karnataka, India, from June 2020 to February 2021. After stabilizing the patient, a detailed socio-demographic history was recorded. Details of the suicide attempt and findings of the clinical examination were noted. Results The final study sample consisted of 89 patients who presented to the emergency room (ER). Fifty-three patients were female, and thirty-six were males; the average age of the sample was 28.4 ± 11 years. A higher proportion of men who completed pre-university education (p= 0.0005, c2= 11.98) or had a graduate degree (p= 0.009, c2= 6.71) attempted suicide. Amongst all women who attempted suicide, 73.6% (n=39) were married at the time of the event (p= 0.0006, c2= 11.79). Poisoning (n=59) was the most common method of attempting suicide. We also observed that it was primarily men who attempted suicide when under the influence of alcohol (p= 0.006, c2= 7.57). The most common reason for attempting suicide was familial disharmony, including domestic violence. A Glasgow Coma Scale (GCS) score of 9/15 and less at the time of presentation resulted in a mortality rate of 28.6%, whereas patients with a GCS score of 10 and above had a mortality rate of 6.1% (p= 0.04, c2= 4.14). Discussion Marriage appears to be less protective for Indian women than Indian men. Poisoning was the most common method of attempted suicide in our study, followed by tablet overdose. The reason for the above could be ease of access to household poisons. Insecticides have been a preferred method in the Indian population over the years. Aluminum phosphide poisoning, a common constituent of rodenticides, is associated with a high mortality rate. However, in the West, firearm-related incidents have the highest mortality. Multiple correspondence analysis (MCA) of the National Crime Records Bureau (NCRB), India, data showed that adult males succumb majorly to romantic relations, unemployment, and failure in examinations. The use of alcohol was more in the illiterate and unskilled workers; however, high school educated persons and students used alcohol intentionally to facilitate suicide. Lower Glasgow Coma Scale values are associated with higher fatality; however, some studies found that Full Outline of Unresponsiveness (FOUR) and Acute Physiology and Chronic Health Evaluation Score (APACHE) II scores are better mortality indicators. Conclusion Besides the presentation and GCS score, cognizance of the lethality of different methods in attempting suicide provides clues in anticipating the patient's clinical course. The social patterns of suicide must be considered while designing awareness campaigns and focused outreach programs to decrease suicides. A strict policy must be made and enforced to limit the availability of household poisons.

A Needle in the Fetal Brain: The Rare Role of Transabdominal Cephalocentesis in Fetal Hydrocephalus.

Fetal hydrocephalus is a fairly common occurrence in pregnant women, surfacing early or late in the pregnancy. The perinatal and pediatric outcomes are largely determined by the cause of hydrocephalus and the extent of the irreversible destruction of the brain tissue. In pregnancies where the fetal prognosis is unfavorable, aspirating the cerebrospinal fluid (CSF) to facilitate vaginal delivery is an option. In this report, we present the case of a primigravida with term fetal hydrocephalus who underwent ultrasound-guided transabdominal cephalocentesis and subsequently delivered vaginally without any adverse perinatal outcomes.

Prognosis of COVID-19: Red Cell Distribution Width, Platelet Distribution Width, and C-Reactive Protein.

Introduction Cytokine storm is central in the pathobiology of Coronavirus disease 2019 (COVID-19). The pro-inflammatory state and hypoxia disrupt erythropoiesis leading to alterations in red cell distribution width (RDW) and hematocrit. Platelet production increases alongside its destruction, inviting newly formed immature platelets into the circulation. Thus, the platelet distribution width (PDW) and mean platelet volume (MPV) are also affected. The study's objective is to analyze these indices and C-reactive protein (CRP) to elucidate prognostic insights in COVID-19 patients at the time of admission. Methodology This study was a retrospective cross-sectional study conducted at Chigateri General Hospital, attached to JJM Medical College, Davangere, over two months, July and August of 2020. Patients falling under categories B and C according to the interim guidelines issued by the Ministry of Health and Family Welfare, Government of India were enrolled in this study. Patients requiring mechanical ventilation and those with a prior diagnosis of malignancy were excepted from the study. Results The study population comprised a total of hundred patients. Seventy-five patients survived the disease and were discharged; twenty-five patients succumbed to the viral illness. The mean age of survivors (43.0 +/- 13.6 years) was significantly lesser than that of non-survivors (59.1 +/- 11.5 years) (p <0.001). RDW was significantly different among survivors (p=0.002); PDW and CRP were lower among the deceased (p=0.05 and p=0.10, respectively). Cut off values for RDW as 15%, CRP as 67 mg/l, and PDW as 17% were significantly associated with mortality. Hematocrit and MPV were not significantly associated with mortality. RDW has a sensitivity of 92% and a negative predictive value of 95% in predicting mortality. Discussion RDW showed a significant association with increased mortality. Impaired cell-mediated immunity at the onset of infection is responsible for rapid progression to moderate or even severe COVID disease. Since the investigations in our study were ordered at the time of admission, it may lead us to believe that higher RDW is associated with a better patient outcome. Lower C-reactive protein levels are associated with higher mortality. CRP is a non-specific marker for inflammation. Raised CRP is customarily an indicator of acute inflammation. Notwithstanding, the raised CRP may be an indicator of baseline immune response in early COVID infection. High PDW shows a significant association with increased mortality. The pathobiology of change in platelet indices in COVID-19 patients is presumably multifactorial: infection of the bone marrow; autoimmune platelet destruction; platelet sequestration.  Conclusion Red cell distribution width, platelet distribution width, and C-reactive protein are useful early predictive markers of mortality in COVID-19. Although serial investigations would provide a better picture, these indices at admission can gauge the clinical outcome early in the disease. As there is still a lot to be understood about the natural history of COVID-19, our study aims to propose relatively inexpensive indices of mortality that can aid efficient management.

Insulin, Insulin Everywhere: A Rare Case Report of Rabson-Mendenhall Syndrome.

Rabson-Mendenhall syndrome (RMS) is a rare autosomal recessive disorder characterized by severe insulin resistance, a condition in which the body's tissues and organs do not respond appropriately to the hormone insulin. Insulin resistance impairs blood sugar regulation and ultimately leads to diabetes mellitus. A 19-year-old male presented with joint pain, blurring of vision, and generalized weakness. Investigations revealed hyperglycemia (random blood sugar (RBS) > 625 mg/dL, glycosylated hemoglobin (HbA1c) 18%), as well as sugars, protein, and ketone bodies in urine routine examination. An ultrasound of the abdomen was normal. Cardiac status was normal. Based on the clinical features, particularly the head to toe examination, skin changes, and the onset of type 2 diabetes mellitus, RMS syndrome was considered. The joint pain was alleviated with intravenous tramadol. Actrapid®, a fast-acting insulin, was given to control sugar levels, along with metformin. Vitamin B12 and pregabalin were also supplemented. A dermatological cream containing ammonium chloride, calcium lactate, glycerin, potassium chloride, sodium dihydrogen phosphate, and urea was given for skincare. It is an extremely rare disease with a frequency of fewer than one million people worldwide. Most patients survive only up to 15 years of age, although some can live into their third decade of life. Hepatic gluconeogenesis and fatty acid oxidation are affected, leading to ketoacidosis. The progression is much faster in RMS. In RMS, the genetic defect affects the insulin receptor (INSR) gene transcription with non-sense mutations and causes splicing defects. This results in premature chain termination and eventually to lower amounts of the insulin receptor messenger ribonucleic acid (mRNA). Ultimately, the number and density of insulin receptors in the plasma membrane are smaller, making the cells resistant to insulin. Herein, we report the case of a 19-year-old patient with RMS who was treated in our hospital, leading to a successful improvement in symptoms and discharge of the patient.

Neutrophil-to-Lymphocyte, Lymphocyte-to-Monocyte, and Platelet-to-Lymphocyte Ratios: Prognostic Significance in COVID-19.

Background and objective Neutrophils are primarily responsible for activating the immune system, and systemic inflammation destroys CD4+ T lymphocytes and increases suppressor CD8+ T lymphocytes, thereby leading to an increased neutrophil-to-lymphocyte ratio (NLR). An increase in the apoptosis of lymphocytes leads to lymphopenia and elevated thrombopoietin (THPO) promotes megakaryocyte production. The reflections of these inflammatory changes can be vital in gauging the progression of the disease. This study aimed at examining the prognostic value of normal and derived neutrophil-to-lymphocyte, lymphocyte-to-monocyte, platelet-to-lymphocyte, and mean platelet volume (MPV)-to-platelet count ratios in patients with coronavirus disease 2019 (COVID-19). Methodology This was a retrospective cross-sectional study conducted in the wards of Chigateri General Hospital, Davangere for a period of two months. Complete blood count was ordered for all patients at the time of admission along with confirmation of the disease by reverse transcription-polymerase chain reaction (RT-PCR). Results The final study population consisted of 100 patients. The mean age of patients who survived (43 years) was significantly lower than the mean age of non-survivors (59.1 years), with a p-value of <0.001. NLR was raised in 60% of the population and was significantly higher in patients who survived the disease, with a p-value of 0.004. The platelet-to-lymphocyte ratio (PLR) also followed a similar trend with a p-value of 0.017. Even though the lymphocyte-to-monocyte ratio (LMR) also mimicked the trend, the statistical association was not significant (p-value: 0.09). The derived NLR and MPV-to-platelets ratios were not found to be significantly associated with mortality in this study. Discussion Younger patients had better clinical outcomes in our study population compared to the geriatric age group. A significant correlation between LMR and mortality was observed when a cut-off of 2.5 was considered as a differentiating benchmark. Conflicting trends were observed in NLR and PLR in our study; however, LMR was in accordance with most other studies. The phase that a patient is in with regard to the natural history of the disease also influences the blood cell ratios. Nonetheless, all three ratios can be used as crucial screening and prognostic tools as they are readily available with the help of a complete hemogram. This is an investigation modality that is widely accessible even in remote areas and resource-limited settings. Conclusion These hematological ratios can facilitate in categorizing the disease severity and progression in patients, thereby enabling us to make appropriate and informed clinical decisions. Since the second wave of the novel coronavirus is on the verge of arrival, it is imperative to channel resources for the patients early in their disease course to ultimately prevent complications and reduce mortality.

Dengue Fever: Prognostic Insights From a Complete Blood Count.

Introduction Dengue fever is endemic in more than 100 countries. Early indicators of prognosis are vital to reduce the fatality rate associated with dengue fever. The objective of this study is to investigate the value of a complete blood count (CBC) in determining the prognosis of dengue fever. Methodology This was a retrospective study of all patients admitted to Chigateri General and Bapuji hospitals, Davangere over two months. Fifty-six patients were included in the study. Medical records were accessed to obtain data on the clinical profile and laboratory investigations. Results Thrombocytopenia was the most common hematological feature, in 50 cases (~90%), followed by leukopenia in 43 cases (~76%). The duration of hospital stay ranged from two to seven days. Interestingly, the percentage of lymphocytes in the differential leukocyte count at the time of admission showed a significant negative correlation with the duration of hospital stay (p=0.028). Also, three distinct trends were observed in the sequence of recovery of platelets and white blood cells (WBCs). Discussion A repertoire of prognostic indicators have been described to predict the course and outcome of dengue fever: liver enzymes, interleukins 4 and 10, tumor necrosis factor α (TNFα), some proteases, soluble adhesion molecules, the surface area of atypical lymphocytes, high fluorescent lymphocyte counts, immature granulocytes and immature platelet factor (IPF). However, these markers are not routinely employed due to financial constraints and lack of infrastructure. The percentage of lymphocytes in the differential leukocyte count performed at the time of admission predicted the length of hospital stay. The higher the percentage of lymphocytes, the faster the recovery from dengue and shorter the duration of stay in the hospital. This is particularly important in remote areas with limited laboratory facilities. High-risk patients can be referred to a higher centre before they develop complications of the disease. Conclusion The complete blood count can function as an early indicator of prognosis in dengue fever even in areas where sophisticated biomedical infrastructure is lacking. The lymphocyte percentage on admission could significantly predict the length of hospital stay.