In 1974 an article appeared in Science magazine with the dry-sounding title “Judgment Under Uncertainty: Heuristics and Biases” by a pair of psychologists who were not well known outside their discipline of decision theory. In it Amos Tversky and Daniel Kahneman introduced the world to Prospect Theory, which mapped out how humans actually behave when faced with decisions about gains and losses, in contrast to how economists assumed that people behave. Prospect Theory turned Economics on its head by demonstrating through a series of ingenious experiments that people are much more concerned with losses than they are with gains, and that framing a choice from one perspective or the other will result in decisions that are exactly the opposite of each other, even if the outcomes are monetarily the same. Prospect Theory led cognitive psychology in a new direction that began to uncover other human biases in thinking that are probably not learned but are part of our brain’s wiring.

Thinking fast and slow.

Vitamin B12 deficiency.

BACKGROUND In 2013, New York began requiring hospitals to follow protocols for the early identification and treatment of sepsis. However, there is controversy about whether more rapid treatment of sepsis improves outcomes in patients. METHODS We studied data from patients with sepsis and septic shock that were reported to the New York State Department of Health from April 1, 2014, to June 30, 2016. Patients had a sepsis protocol initiated within 6 hours after arrival in the emergency department and had all items in a 3‐hour bundle of care for patients with sepsis (i.e., blood cultures, broad‐spectrum antibiotic agents, and lactate measurement) completed within 12 hours. Multilevel models were used to assess the associations between the time until completion of the 3‐hour bundle and risk‐adjusted mortality. We also examined the times to the administration of antibiotics and to the completion of an initial bolus of intravenous fluid. RESULTS Among 49,331 patients at 149 hospitals, 40,696 (82.5%) had the 3‐hour bundle completed within 3 hours. The median time to completion of the 3‐hour bundle was 1.30 hours (interquartile range, 0.65 to 2.35), the median time to the administration of antibiotics was 0.95 hours (interquartile range, 0.35 to 1.95), and the median time to completion of the fluid bolus was 2.56 hours (interquartile range, 1.33 to 4.20). Among patients who had the 3‐hour bundle completed within 12 hours, a longer time to the completion of the bundle was associated with higher risk‐adjusted in‐hospital mortality (odds ratio, 1.04 per hour; 95% confidence interval [CI], 1.02 to 1.05; P<0.001), as was a longer time to the administration of antibiotics (odds ratio, 1.04 per hour; 95% CI, 1.03 to 1.06; P<0.001) but not a longer time to the completion of a bolus of intravenous fluids (odds ratio, 1.01 per hour; 95% CI, 0.99 to 1.02; P=0.21). CONCLUSIONS More rapid completion of a 3‐hour bundle of sepsis care and rapid administration of antibiotics, but not rapid completion of an initial bolus of intravenous fluids, were associated with lower risk‐adjusted in‐hospital mortality. (Funded by the National Institutes of Health and others.)

Supplement to: Time to treatment and mortality during mandated emergency care for sepsis.

Open Artificial Intelligence (AI) published an AI chatbot tool called ChatGPT at the end of November 2022. Generative Pre-trained Transformer (GPT) architecture is the foundation of ChatGPT. On the internet, ChatGPT has been rapidly growing. This chatbot enables users to discuss with the AI by inputting prompts, and it is based on OpenAI’s language model. Although ChatGPT is fantastic and produces exciting results for writing tales, poetry, songs, essays, and other things, it has certain restrictions. Users may ask the bot questions, and it will reply with pertinent, convincing subjects and replies. ChatGPT has now risen to the top of several academic agendas. Administrators create task teams and hold institution-wide meetings to react to the tools, with most of the advice being to adopt this technology. This paper briefs about the ChatGPT and its need. Further, various Progressive Work Flow Processes of the ChatGPT Tool are stated diagrammatically. Specific features and capabilities of the ChatGPT Support System are studied in this paper. Finally, we identified and discussed the significant roles of ChatGPT in the current scenario. The neural language models that form the foundation of character AI have been developed from the bottom up with talks in mind. This technology implies that the programme uses deep learning methods to analyse and produce text. The model “understands” the subtleties of human-produced natural language using vast amounts of data from the internet. 

An era of ChatGPT as a significant futuristic support tool: A study on features, abilities, and challenges

Contemporary theories of clinical reasoning espouse a dual processing model, which consists of a rapid, intuitive component (Type 1) and a slower, logical and analytical component (Type 2) Although the general consensus is that this dual processing model is a valid representation of clinical reasoning, the causes of diagnostic errors remain unclear Cognitive theories about human memory propose that such errors may arise from both Type 1 and Type 2 reasoning Errors in Type 1 reasoning may be a consequence of the associative nature of memory, which can lead to cognitive biases However, the literature indicates that, with increasing expertise (and knowledge), the likelihood of errors decreases Errors in Type 2 reasoning may result from the limited capacity of working memory, which constrains computational processes In this article, the authors review the medical literature to answer two substantial questions that arise from this work: (1) To what extent do diagnostic errors originate in Type 1 (intuitive) processes versus in Type 2 (analytical) processes? (2) To what extent are errors a consequence of cognitive biases versus a consequence of knowledge deficits?The literature suggests that both Type 1 and Type 2 processes contribute to errors Although it is possible to experimentally induce cognitive biases, particularly availability bias, the extent to which these biases actually contribute to diagnostic errors is not well established Educational strategies directed at the recognition of biases are ineffective in reducing errors; conversely, strategies focused on the reorganization of knowledge to reduce errors have small but consistent benefits

The Causes of Errors in Clinical Reasoning: Cognitive Biases, Knowledge Deficits, and Dual Process Thinking

A 54-year-old man with type 2 diabetes presented to the emergency department via ambulance with a 3-day history of epigastric pain. He did not consume alcohol, had no previous abdominal complaints and was not on immunosuppressive medications. The patient had a fever and rebound tenderness in the 

Phlegmonous gastritis

We present a case of a 37-year-old Caucasian woman with abdominal distension and loss of weight. She was initially presumed to be a case of ovarian malignancy due to an elevated serum cancer antigen 125 (CA 125) level and imaging of abdomen and pelvis that showed ascites and bulky ovaries. However, histological examination of biopsy later revealed it to be a case of abdominal tuberculosis (AbT). Ascitic fluid was also found to be positive for Mycobacterium tuberculosis by whole genome sequencing. The patient was started on antituberculosis treatment following which she showed a significant improvement in her symptoms.

Costochondral gout

A 24-year-old woman without significant medical history presented with a 5-day history of lower abdominal discomfort and purulent secretion from her umbilicus. She was well until 5 days prior when she noticed periumbilical abdominal pain. She denied fever, nausea, diarrhoea and melaena.

Abdominal

https://casereports.bmj.com/content/bmjcr/12/8/e231139.full.pdf

Secretion from umbilicus.

Purpose The general internal medicine (GIM) department can be an effective diagnostic coordinator for undiagnosed outpatients. We investigated the contribution of GIM consultations to the diagnosis of patients admitted to specialty departments in hospitals in Japan that have not yet adopted a hospitalist system. Patients and Methods This single-center, retrospective observational study was conducted at a university hospital in Japan. GIM consultations from other departments on inpatients aged ≥20 years, from April 2016 to March 2021, were included. Data were extracted from electronic medical records, and consultation purposes were categorized into diagnosis, treatment, and diagnosis and treatment. The primary outcome was new diagnosis during hospitalization for patients with consultation purpose of diagnosis or diagnosis and treatment. The secondary outcomes were the purposes of consultation with the Diagnostic and Generalist Medicine department. Results In total, 342 patients were included in the analysis. The purpose of the consultations was diagnosis for 253 patients (74%), treatment for 60 (17.5%), and diagnosis and treatment for 29 patients (8.5%). In 282 consultations for diagnosis and diagnosis and treatment, 179 new diagnoses were established for 162 patients (57.5%, 95% confidence interval [CI], 51.5–63.3). Conclusion The GIM department can function as a diagnostic consultant for inpatients with diagnostic problems admitted to other specialty departments in hospitals where hospitalist or other similar systems are not adopted.

https://www.dovepress.com/getfile.php?fileID=88966

Survey of Inpatient Consultations with General Internal Medicine Physicians in a Tertiary Hospital: A Retrospective Observational Study

A 35-years-old Japanese man was evaluated for fever and right heel pain. One year prior, he had an episode of fever, stomatitis, oligoarthralgia, lumbago and blurred vision. Despite the extensive investigations, he only had a diagnosis of uveitis with unknown aetiology and all the symptoms remitted

https://casereports.bmj.com/content/bmjcr/12/11/e232056.full.pdf

Erythema nodosum-like lesion on heel in a patient assumed Behçet's disease.

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