Whether M.D. Pathology curriculum is sufficient to meet pathology practice requirements in India? A survey of newly qualified pathologists

Background and Objectives: Pathology is a broad subject consisting of various branches, such as hematology, clinical pathology, biochemistry, histopathology, cytology, blood banking, and others. All the subspecialties are difficult to cover in depth in a 3-year MD Pathology course and curriculum. Hence, it was decided to investigate whether the MD Pathology curriculum is able to meet the challenges of today's laboratory medicine practice. So, a survey was conducted among newly qualified pathologists who have passed their exam within last 5 years. Purpose was to know their views about MD Pathology curriculum with special emphasis on challenges they face during their day-to-day practice. Materials and Methods: Study is designed as cross-sectional survey conducted via web-based Google forms questionnaire. Study population is pathologists qualified within last 5 years. A convenience sample of eligible pathologists was taken by sending a web-based Google form to various pathology groups on social media apps. Data were collected in the Google spreadsheet software and various responses were summarized as percentages, graphs, and pie-charts as necessary. Chi square test was used to find the significance of difference in responses from government, private, and deemed university respondents. Results: Different numbers of responses were received to different survey questions. Out of 187 respondents, 65 (34.8%) worked in a hospital-based laboratory, 61 (32.6%) did jobs in a private laboratory, 49 (26.2%) worked in a medical college, and 37 (19.8%) worked in their own private laboratories. Out of 193 respondents, 158 (81.9%) were working in hematology, 149 (77.2%) in clinical pathology, 139 (72%) in cytopathology, 118 (61.7%) in histopathology, whereas 103 (53.4%) worked in clinical biochemistry, and least number of respondents, i.e., 38 (19.7%) were working in blood bank. Almost all the respondents had overlapping work in hematology and other areas. The level of confidence rated by the respondents was best in hematology, followed by clinical pathology; it was least for clinical biochemistry and blood bank. Out of 192 respondents, 64.1% (123) felt that the curriculum does not equip them for lab management and administration, 21.9% (42) felt that the curriculum somewhat equipped them; whereas only 14.1% (27) felt that curriculum equips them for this task. There were 191 responses to the question regarding satisfaction with MD Pathology curriculum; out of which, 51.8% (99) were not satisfied, 24.6% (47) said they may be satisfied, whereas 23.6% (45) were satisfied with the curriculum. There was no significant difference in responses from government, private, and deemed university respondents. Conclusions: The graduating MD Pathology students expressed confidence in reporting routine cases of hematology, clinical pathology, routine cytology, and histopathology. However, there is difficulty in clinical biochemistry, blood banking, and reporting of malignancies. The laboratory management and administration, communication skills, and quality assurance are also other areas of weakness. MD Pathology program needs more focus on these weaknesses, so that newly qualified graduate would feel confident in day-to-day laboratory working.

Survey of semen analysis practices in India and need for standardization and improvement

Background and Objectives: Infertility is a sensitive subject carrying with it economic, social, and psychological implications. Work up of male infertility is often hampered by a lack of infrastructure and facilities, as well as inadequate training of pathology residents. The purpose of this research survey was to evaluate the current status of semen analysis practices and compare them to the standards laid down by the World Health Organization (WHO). Materials and Methods: A web-based questionnaire was designed consisting of questions related to semen analysis practices and procedures being followed currently by pathologists in India. A total of 194 pathologists responded. Questions regarding the procedures followed for semen collection, sperm count, volume, normal range, lower normal limit of sperm count, morphology, etc., were included in the survey. These data were recorded. The differences and gaps in the practice with respect to the WHO standards were analyzed. Results: The survey revealed that the printed instructions for semen analysis were available with 38.7% of the respondents; 58.8% of the respondents had a separate room for semen collection; 95.9% performed the analysis manually, and; only 4.1% used automated analyzers. Only 53.6 and 52.6% of the respondents were correctly reporting the normal range of semen volume and sperm counts, respectively. Only 19.6% stated as having read the WHO manual and were also practicing its guidelines, while 14.4% had not read the WHO manual even once. Conclusion: The present study showed a large gap between the practice of semen analysis by respondents from various parts of India and standard procedures as laid down by the WHO. Many laboratories do not follow the standard instructions. There is a need to improve the quality of practice related to semen analysis in this country through appropriate teaching and training in medical institutions as well as through Continuing Medical Education (CMEs) or regular update programs.

A clinicopathological study of primary central nervous system lymphomas & their association with Epstein-Barr virus.

Background & objectives: Primary central nervous system lymphomas (PCNSLs) are relatively uncommon, accounting for 2-3 per cent of primary brain tumours. Majority of these are diffuse large B cell lymphomas (DLBCL) occurring both in immunocompromised and immunocompetent patients. We undertook this study to classify PCNSL into germinal centre (GC) and non-germinal centre (NGC) type based on Hans classification and to find the role of Epstein-Barr virus (EBV) in pathogenesis both by conventional immunohistochemistry (IHC) and chromogenic in situ hybridization (CISH). Methods: The consecutive cases of PCNSL during a 10 years period were analysed by IHC for CD45, CD20, CD3, B-cell lymphoma 2 and 6 (Bcl-2 and Bcl-6), B-cell specific octamer binding protein-1 (BOB-1), multiple myeloma oncogene-1 (MUM-1), EBV latent-membrane protein 1 (LMP-1), cyclin-D1, CD10, CD5 and CD23, as well as by CISH for EBV. Results: During a period of 10 years, 65 PCNSL were diagnosed which comprised 0.69 per cent (65/9476) of all intracranial tumours. The mean age of presentation was 49 yr with sex ratio (M:F) of 1.4:1. Most common location was supratentorial region with predominant involvement of frontal lobe. Single lesions were seen in 38 (58.4%) and multifocal lesions in 27 (41.5%) patients. None of the patients were immunocompromised. All cases were B cell immunophenotype and were DLBCL except one case of follicular lymphoma. According to Hans classification, majority of them were NGC (n=51, 79.6%) and 13 (20.3%) were GC type. Bcl-2 expression was noted in 34 (52.3%) tumours. EBV was positive in three (4.6%) cases; two were detected both by IHC and CISH and one case by CISH only. Interpretation & conclusions: In Indian population, PCNSL occurs mainly in immunocompetent patients, and a decade earlier than in western population. Immunophenotyping revealed that all cases were DLBCL with predominance of NGC type. No prognostic difference was seen between GC and NGC DLBCL. Association of EBV was rare and this virus was possibly not involved in the pathogenesis of PCNSL in immunocompetent individuals. CISH was an easy, economical and less cumbersome method for detection of EBV in PCNSL.

An experience with 156 patients attending a newly organized pain and palliative care clinic in a tertiary hospital.

Context: Pain and palliative care clinic (PCC). Aims: The primary object of this study was to enumerate the demographic characteristics of patients attending a newly organized PCC. The secondary purpose was to detect symptom prevalence and frequency of different cancers in these patients. Settings and Design: Prospective cross-sectional descriptive study. Materials and Methods: A prospective cross-sectional descriptive study was done on patients referred to the PCC of a tertiary hospital in North India. Comprehensive details of all patients were recorded systematically on the first visit on a proforma specially prepared for the newly established palliative care clinic. Statistical Analysis Used: The descriptive statistics of palliative care data was presented in terms of frequencies and percentages (%) for categorical variables. Results: The data collected at our PCC showed that out of 156 patients, 87 were males and 69 were females. Patients of all ages varying from 6 to 85 years were seen. Most patients (82.1%) lived with their families, and 28 (17.1%) patients lived alone and had no financial support. The most common primary diagnoses were head and neck cancers (38.5%), carcinoma cervix (15.4%), breast cancer (10.3%), colorectal cancer (6.4%), and lung cancer (4.5%). Frequency of seven most common symptoms was pain (100%), insomnia (64.1%), loss of appetite (34.6%), nausea (32.7%), vomiting (32.1%), constipation (31.4%) and sore mouth (28.8%). Conclusions: Population-based studies determine the actual magnitude of sufferers and suffering and show that palliative care services should be included as an essential component in a tertiary care hospital. The objective should be to reach out to the patient and help in improving the patent's quality of life in every way possible.

Gamma knife radiosurgery for glomus jugulare tumors: Therapeutic advantages of minimalism in the skull base.

Context: Glomus jugulare (GJ) tumors are paragangliomas found in the region of the jugular foramen. Surgery with/without embolization and conventional radiotherapy has been the traditional management option. Aim: To analyze the efficacy of gamma knife radiosurgery (GKS) as a primary or an adjunctive form of therapy. Settings and Design: A retrospective analysis of patients who received GKS at a tertiary neurosurgical center was performed. Materials and Methods: Of the 1601 patients who underwent GKS from 1997 to 2006, 24 patients with GJ underwent 25 procedures. Results: The average age of the cohort was 46.6 years (range, 22-76 years) and the male to female ratio was 1:2. The most common neurological deficit was IX, X, XI cranial nerve paresis (15/24). Fifteen patients received primary GKS. Mean tumor size was 8.7 cc (range 1.1-17.2 cc). The coverage achieved was 93.1% (range 90-97%) using a mean tumor margin dose of 16.4 Gy (range 12-25 Gy) at a mean isodose of 49.5% (range 45-50%). Thirteen patients (six primary and seven secondary) were available for follow-up at a median interval of 24 months (range seven to 48 months). The average tumor size was 7.9 cc (range 1.1-17.2 cc). Using a mean tumor margin dose of 16.3 Gy (range 12-20 Gy) 93.6% coverage (range 91-97%) was achieved. Six patients improved clinically. A single patient developed transient trigeminal neuralgia. Magnetic resonance imaging follow-up was available for 10 patients; seven recorded a decrease in size. There was no tumor progression. Conclusions: Gamma knife radiosurgery is a safe and effective primary and secondary modality of treatment for GJ.

Effects of drop acceleration and deceleration on particle capture in a cross-flow gravity tower at intermediate drop Reynolds numbers.

Cross-flow gravity towers are particle scrubbing devices in which water is sprayed from the top into particle-laden flow moving horizontally. Models for predicting particle capture assume drops traveling at terminal velocity and potential flow (ReD > 1000) around it, however, Reynolds numbers in the intermediate range of 1 to 1000 are common in gravity towers. Drops are usually injected at velocities greater than their terminal velocities (as in nozzles) or from near rest (perforated tray) and they accelerate/decelerate to their terminal velocity in the tower. Also, the effects of intermediate drop Reynolds number on capture efficiency have been simulated for (a) drops at their terminal velocity and (b) drops accelerating/decelerating to their terminal velocity. Tower efficiency based on potential flow about the drop is 40%-50% greater than for 200 mm drops traveling at their terminal velocity. The corresponding values for 500 mm drops are about 10%-20%. The drop injection velocity is important operating parameter. Increase in tower efficiency by about 40% for particles smaller than 5 mm is observed for increase in injection velocity from 0 to 20 m/s for 200 and 500mm drops.

Serous fluid leakage following modified Blalock-Taussig operation using PTFE grafts.

BACKGROUND: Serous fluid leakage is an unusual but often devastating complication following the placement of a modified Blalock-Taussig shunt using a polytetrafluoroethylene graft. METHOD AND RESULTS: Between September 1994 and September 1999, out of 268 patients undergoing a modified Blalock-Taussig shunt using polytetrafluoroethylene grafts, 10 developed massive pleural effusion or seroma due to a leak from the surface of the shunt. The age of the patients ranged from 9 days to 7 years. There were 7 males and 3 females. Nine patients presented with respiratory distress between 2 and 12 weeks of shunt surgery and one presented with sudden cardiac arrest. The shunt was patent in all the patients. Initial management was conservative. i.e. by pharmacological means and tube thoracostomy. Reoperation was undertaken in 9 patients when conservative treatment failed. All patients survived except one who had a cardiac arrest before any intervention could be carried out. CONCLUSIONS: Patients with serous effusion have significant morbidity and mortality and often require reoperation. The initial management remains conservative but, if unsuccessful, re-exploration can be undertaken as it proved to be uniformly successful in our experience.

Bilateral Tessier no. 4 facial cleft with left eye anophthalmos: a case report.

Craniofacial clefts are very rare and manifest in a variety of patterns. Tessier classified these clefts in 1973 and numbered them 0 to 14. Tessier No. 4 Facial cleft is a rare variant of craniofacial cleft. Not more than 50 cases are reported in world literature, amongst which only 5 cases are true bilateral in nature. However, combinations of two different variants are not very uncommon. A case of male Indian child aged 4 years with a true bilateral Tessier No. 4 Facial cleft is reported. He also had anophthalmos of the left eye. This is probably the first case in which true bilateral Tessier No. 4 Facial cleft with anophthalmos of one eye is noticed.

Is McMurray's osteotomy obsolete?

A review of the method of performing, advantages, disadvantages of McMurray's displacement osteotomy with regard to treatment of nonunion of transcervical fracture neck femur with viable femoral head was carried out in this study of ten cases, in view of the abandonment of the procedure in favour of angulation osteotomy. Good results obtained in the series attest to the usefulness of McMurray's osteotomy in the difficult problem of nonunion of transcervical fracture neck femur in well selected cases with certain advantages over the angulation osteotomy due to the 'Armchair effect'.

Haemopoietic stem cells during development of mouse embryo.

Haemopoiesis in mammals takes place in yolk-sac and in mouse it can be detected on the 7th day of gestation. Erythropoietin (EPO) responsive cells can be detected from 7th day onwards. However, the cells committed to the myeloid lineage which can respond to the haemopoietic growth factor (viz. granulocyte macrophage colony stimulating factor; GM-CSF) can be demonstrated only on 10th day of gestation. At the same time, the 12-day spleen colony forming cells i.e. the late colony forming unit spleen (CFU-s) which are multipotent stem cells can also be detected. Data suggest that the stem cells seen in the embryo from 7-10 days of gestation may be a primitive population confined only to the yolk-sac. Liver haemopoiesis which begins in the liver of 13-day embryos is due to primitive haemopoietic pluripotent stem cells, arising de novo in the embryo and not in the yolk-sac, since no primitive pluripotent stem cells capable of repopulating lethally irradiated bone-marrow can be detected in the yolk-sac.

Characterization of temperature sensitive mutants of Japanese encephalitis virus isolated from persistently infected mammalian cells.

Four new temperature-sensitive (ts) mutants of Japanese encephalitis virus (JEV) isolated from porcine kidney cells persistently infected with JEV and seven previously isolated ts mutants were studied. Of the eight mutants tested, five mutants ts1, ts14, ts36, ts48 and ts71, were thermolabile. Analyses of virus induced intracellular polypeptides revealed that with majority of the ts mutants, when grown at restrictive temperature, the viral proteins were quantitatively affected. All the five ts mutants tested for mouse virulence showed attenuation in infant mice by the intracerebral route. Two ts mutants, ts36 and ts48, escaped neutralization with two anti-JEV envelope protein specific monoclonal antibodies, however, these escape mutants reacted efficiently with the same monoclonal antibodies in antigen capture ELISA.

Potassium homeostasis during & after cardiopulmonary bypass.

Potassium homeostasis was studied in 30 patients undergoing cardiac surgery by employing cardiopulmonary bypass (CPB) and moderate hypothermia, and using morphine, N2O, relaxant anaesthesia. There was a trend for hypokalemia, and for maintaining a K+ level of 4-4.5 mmol/l, K+ infusion was required during CPB (9.017 mmol/m2 BSA/h). K+ infusion required in the post-operative period was considerably less (1.532 mmol/m2 BSA/h). There was no significant difference in the K+ levels of patients receiving preoperative diuretic therapy, as compared to those not receiving such therapy. Potassium requirement was significantly higher in patients under-going CABG and valvular heart disease, as compared to congenital heart disease. The mean urinary loss of K+ during bypass was found to be 2.95 mmol/m2 BSA/h, which was only 32 per cent of that required to be infused (9.017 mmol/m2 BSA/h). The mean excretion of K+ in the post operative period was significantly higher (4.53 mmol/m2 BSA/h) than K+ required to be infused during this period (1.532 mmol/m2 BSA/h).