Possible benefits, challenges, pitfalls, and future perspective of using ChatGPT in pathology.

The much-hyped artificial intelligence (AI) model called ChatGPT developed by Open AI can have great benefits for physicians, especially pathologists, by saving time so that they can use their time for more significant work. Generative AI is a special class of AI model, which uses patterns and structures learned from existing data and can create new data. Utilizing ChatGPT in Pathology offers a multitude of benefits, encompassing the summarization of patient records and its promising prospects in Digital Pathology, as well as its valuable contributions to education and research in this field. However, certain roadblocks need to be dealt like integrating ChatGPT with image analysis which will act as a revolution in the field of pathology by increasing diagnostic accuracy and precision. The challenges with the use of ChatGPT encompass biases from its training data, the need for ample input data, potential risks related to bias and transparency, and the potential adverse outcomes arising from inaccurate content generation. Generation of meaningful insights from the textual information which will be efficient in processing different types of image data, such as medical images, and pathology slides. Due consideration should be given to ethical and legal issues including bias.

Airway management in the paediatric difficult intubation registry: a propensity score matched analysis of outcomes over time.

Background: The Paediatric Difficult Intubation Collaborative identified multiple attempts and persistence with direct laryngoscopy as risk factors for complications in children with difficult tracheal intubations and subsequently engaged in initiatives to reduce repeated attempts and persistence with direct laryngoscopy in children. We hypothesised these efforts would lead to fewer attempts, fewer direct laryngoscopy attempts and decrease complications. Methods: Paediatric patients less than 18 years of age with difficult direct laryngoscopy were enrolled in the Paediatric Difficult Intubation Registry. We define patients with difficult direct laryngoscopy as those in whom (1) an attending or consultant obtained a Cormack Lehane Grade 3 or 4 view on direct laryngoscopy, (2) limited mouth opening makes direct laryngoscopy impossible, (3) direct laryngoscopy failed in the preceding 6 months, and (4) direct laryngoscopy was deferred due to perceived risk of harm or poor chance of success. We used a 5:1 propensity score match to compare an early cohort from the initial Paediatric Difficult Intubation Registry analysis (August 6, 2012-January 31, 2015, 785 patients, 13 centres) and a current cohort from the Registry (March 4, 2017-March 31, 2023, 3925 patients, 43 centres). The primary outcome was first attempt success rate between cohorts. Success was defined as confirmed endotracheal intubation and assessed by the treating clinician. Secondary outcomes were eventual success rate, number of attempts at intubation, number of attempts with direct laryngoscopy, the incidence of persistence with direct laryngoscopy, use of supplemental oxygen, all complications, and severe complications. Findings: First-attempt success rate was higher in the current cohort (42% vs 32%, OR 1.5 95% CI 1.3-1.8, p < 0.001). In the current cohort, there were fewer attempts (2.2 current vs 2.7 early, regression coefficient -0.5 95% CI -0.6 to -0.4, p < 0.001), fewer attempts with direct laryngoscopy (0.6 current vs 1.0 early, regression coefficient -0.4 95% CI -0.4 to 0.3, p < 0.001), and reduced persistence with direct laryngoscopy beyond two attempts (7.3% current vs 14.1% early, OR 0.5 95% CI 0.4-0.6, p < 0.001). Overall complication rates were similar between cohorts (19% current vs 20% early). Severe complications decreased to 1.8% in the current cohort from 3.2% in the early cohort (OR 0.55 95% CI 0.35-0.87, p = 0.011). Cardiac arrests decreased to 0.8% in the current cohort from 1.8% in the early cohort. We identified persistence with direct laryngoscopy as a potentially modifiable factor associated with severe complications. Interpretation: In the current cohort, children with difficult tracheal intubations underwent fewer intubation attempts, fewer attempts with direct laryngoscopy, and had a nearly 50% reduction in severe complications. As persistence with direct laryngoscopy continues to be associated with severe complications, efforts to limit direct laryngoscopy and promote rapid transition to advanced techniques may enhance patient safety. Funding: None.

Spindle cell variant of papillary thyroid carcinoma: A diagnostic challenge - A rare case report with brief review of literature.

OBJECTIVE: Primary Spindle cell tumors of the thyroid are very rare and comprise a myriad of differential diagnoses ranging from reactive proliferations to neoplastic processes. Differentiation amongst these rare entities is of utmost importance as it defines the prognosis and also guides future therapy. CASE REPORT: Hereby, we present a rare case of spindle cell variant of papillary thyroid carcinoma in a sixty-four-year-old female which posed a diagnostic challenge on histology. Microscopy showed a well-circumscribed spindle cell lesion with areas of infiltration and entrapment of colloid-filled thyroid follicles. There were no characteristic features of papillary carcinoma. A panel of immunohistochemistry markers was advised which clinched the diagnosis as the spindle tumor cells were positive for thyroid papillary carcinoma markers. Although papillary carcinoma usually has an indolent course, however interestingly this patient presented with lymph node metastasis one month after surgery which cytologically showed features of malignant spindle cell neoplasm. CONCLUSION: Through this case report we wish to highlight the cytological, histopathological as well as immunohistochemical features of this rare variant of papillary carcinoma.

Cytological Diagnosis of Pilomatrixoma and its Diagnostic Pitfalls.

Background: Pilomatrixoma (PMX) is a relatively uncommon benign cutaneous neoplasm arising from skin adnexa. It presents as a subcutaneous asymptomatic nodule mostly in the head and neck region and is frequently misdiagnosed by the clinicians. Although easily diagnosed on histopathology, the cytologic features of PMX are less distinctive, depending on the stage and evolution of disease and may mimic other benign or even malignant lesions. Aim: To study the cyto-morphological features of this uncommon neoplasm and identify its potential diagnostic pitfalls on fine needle aspiration cytology (FNAC). Material and Methods: Archival records of histopathologically diagnosed Pilomatrixoma were analyzed during study period of 2.5 years. Clinical diagnosis, preoperative FNA characteristics, and histopathological details were studied in each case. Cytologic pitfalls resulting in misdiagnosis of PMX cases on FNAC were evaluated in discordant cases. Results: The series showed male preponderance, with head and neck being the commonest site. Out of 21 histopathologically proven cases of PMX, cytological correlation was available in 18 cases. A correct cytologic diagnosis of PMX/adnexal tumor was rendered in 13 cases. Erroneous diagnosis was given in 5 cases mainly because of the predominance of one component over the other or non-representative-aspirated material. Conclusion: The present study highlights the importance of careful screening of FNAC smears keeping in mind the variability in the relevant cytologic features of PMX and creates awareness about the lesions that can mimic Pilomatrixoma resulting in diagnostic dilemma.

Deciphering the Precise Target for Saroglitazar Associated Antiangiogenic Effect: A Computational Synergistic Approach.

Antidiabetic drugs that have a secondary pharmacological effect on angiogenesis inhibition may help diabetic patients delay or avoid comorbidities caused by angiogenesis including malignancies. In recent studies, saroglitazar has exhibited antiangiogenic effects in diabetic retinopathy. The current study investigates the antiangiogenic effects of saroglitazar utilizing the chicken chorioallantoic membrane (CAM) assay and then identifies its precise mode of action on system-level protein networks. To determine the regulatory effect of saroglitazar on the protein-protein interaction network (PIN), 104 target genes were retrieved and tested using an acid server and Swiss target prediction tools. A string-based interactome was created and analyzed using Cytoscape. It was determined that the constructed network was scale-free, making it biologically relevant. Upon topological analysis of the network, 37 targets were screened on the basis of centrality values. Submodularization of the interactome resulted in the formation of four clusters. A total of 20 common targets identified in topological analysis and modular analysis were filtered. A total of 20 targets were compiled and were integrated into the pathway enrichment analysis using ShinyGO. The majority of hub genes were associated with cancer and PI3-AKT signaling pathways. Molecular docking was utilized to reveal the most potent target, which was validated by using molecular dynamic simulations and immunohistochemical staining on the chicken CAM. The comprehensive study offers an alternate research paradigm for the investigation of antiangiogenic effects using CAM assays. This was followed by the identification of the precise off-target use of saroglitazar using system biology and network pharmacology to inhibit angiogenesis.

Metallosis and Nonunion: A Case Series and Literature Review.

Metallosis, defined as the presence of free metal particles in the tissue, including bone and soft tissue, is a rare phenomenon seen in orthopedic practice. It is more commonly seen in arthroplasty surgeries, but its occurrence in the presence of other metal implants is also well recognized. Multiple hypotheses are suggested to explain the genesis of metallosis, but it is traditionally believed that abnormal contact between the metal surfaces leads to abrasive wear causing the release of metal particles into the surrounding tissue eliciting foreign body reactions from the body's immune system. The consequences can be local effects, which can be asymptomatic soft tissue lesions, or lead to significant osteolysis, tissue necrosis, joint effusion, and large soft tissue masses, causing secondary pathological effects. The systemic distribution of these metal particles can also contribute to the clinical picture. The literature contains multiple case reports of metallosis following arthroplasty surgeries, but there is limited information on metallosis resulting from osteosynthesis of fractures. In this review, we are presenting our experience with a few patients who developed nonunion following the index surgeries and on revision were found to have metallosis as well. It is difficult to postulate whether metallosis was contributory to the nonunion or the other way around or whether the occurrence of nonunion in face of metallosis was a pure coincidence. Additionally, one of our patients had a positive intraoperative culture, further complicating the picture. In addition to the case series, we present a succinct review of the literature on metallosis found in previous studies.

Critical Analysis of Laboratory Requisition Forms Received in a Cytopathology Laboratory of a Tertiary Care Centre: An Audit and Review of Literature.

Background: A laboratory requisition form (LRF) is the main communication link between the laboratories and the clinicians. In a cytopathology laboratory, incomplete forms with inadequate information significantly impact the quality of the results and waste precious time of the lab. Aims: The aim of this study was to audit the LRFs for adequacy of demographic and clinical data and to analyze the reasons for the same. Settings and Design: A retrospective study was conducted in the cytopathology laboratory of a tertiary care center. Materials and Methods: All the original LRFs received for Pap smears and FNACs of 1-month duration were retrieved. The forms were scrutinized for the presence of specific parameters which were classified as patient information, clinician information and clinical information. In addition to the completeness of the form, clarity of the data was also noted. Statistical Analysis: The data were entered on excel worksheets and percentage of Pap smear and FNAC forms lacking information of various parameters was calculated. Results: A total of 431 LRFs were received in the month of January 2020. These included 274 Pap smear LRFs and 157 FNAC LRFs. Patient information was mentioned in predominantly all the forms, however, clinician and clinical information, which is indispensible for reporting, was missing in a significant proportion of the Pap smear and fine needle aspiration cytology (FNAC) forms. Conclusions: Receiving inadequately filled LRFs has been an age-old problem in all medical laboratories. Audit of inadequacy of LRFs helped in assessing the prevailing practices in the hospital and gave an insight into the quality of information available to the cytologists for reporting. Many clinicians withhold information out of ignorance about its importance or due to lack of time to fill up the details on the LRF. Also, filling out a LRF is a task usually delegated to the junior doctor in the OPD and the significance of filling the LRF correctly and comprehensively is often not emphasized upon adequately by the senior clinicians. This audit helped us taking preventive action by giving feedback to the clinicians and emphasizing to them the importance of clinical data on the LRF and in improvising the LRF using a more objective and user-friendly format.

Unilateral 'Crazy-Paving' pattern: An exceptional presentation of squamous cell carcinoma of the lung.

The 'crazy-paving' pattern on high resolution computed tomography (HRCT) is a distinct imaging appearance that is still considered to be a radiological hallmark of pulmonary alveolar proteinosis. However, since its first description about three decades ago, more than 40 different clinical entities presenting as 'crazy-paving' patterns have been documented. This rather remarkable but uncommon imaging appearance is now considered to be a non-specific manifestation. A 62-year-old male referred for evaluation of productive cough, breathlessness and fever presented with 'crazy-paving' pattern on HRCT. Endobronchial biopsy done on presentation was consistent with the diagnosis of squamous cell carcinoma. This report highlights this atypical presentation of squamous cell carcinoma of the lung and adds to the increasing list of clinical entities presenting as a 'crazy-paving' pattern. To our knowledge, squamous cell carcinoma presenting as a 'crazy-paving' pattern on HRCT is yet to be documented.

Importance of eosinophilic structures and its correlation with acid fast bacilli in fine needle aspiration smears of tubercular lymphadenitis.

BACKGROUND: The hallmark of tuberculosis in cytological smears is the presence of epithelioid cell granulomas, necrosis and AFB. In cases, where AFB not detected, diagnosis of tuberculosis can be made by ancillary tests like PCR which requires infrastructure besides being expensive. In India, where majority of population is rural-based there is an imminent need of some morphological change in cytological smears which can point towards diagnosis of tuberculosis in absence of AFB. This study was done to assess the importance of eosinophilic structures (ES) and its correlation with presence of AFB. MATERIAL & METHODS: This was a retrospective study over a period of one year. Lymph node aspirates reported as granulomatous lymphadenitis, tubercular lesion or suppurative lesion were included. All smears for each case, stained with May Grunwald Giemsa (MGG), Hematoxylin and Eosin (H&E) and ZN stain were retrieved and rescreened for the presence of eosinophilic structure, necrosis, granulomas and AFB. RESULTS: Our study included 256 cases. Most common age group was 21-30 years with female predominance. Cervical lymph nodes were most commonly involved. In relation to ES and AFB four cytological pictures were seen i.e ES + AFB+ (44.54%) ES + AFB- (5.46%) ES- AFB+ (14.45%) ES - AFB- (35.55%). Chi square test showed a high significant statistical association between ES and AFB(p = 0.00001). CONCLUSION: In developing countries with very high TB prevalence like India, where new diagnostic modalities are unaffordable by rural population, presence of ES should be included as a morphological parameter in routine cytology reporting of tubercular lesions.

Xanthogranulomatous cholecystitis mimicking advanced gallbladder carcinoma - Analysis of 8 cases.

BACKGROUND/AIM: Xanthogranulomatous cholecystitis (XGC) is a rare destructive inflammatory disease of the gallbladder. It is frequently misdiagnosed as gallbladder carcinoma (GBC) as it mimics latter with regard to clinical manifestations, imaging and intraoperative findings, often leading to extended surgical resection in these patients. The aim of this study was to evaluate the diagnostic dilemma of XGC cases clinico-radiologically diagnosed with GBC. MATERIALS AND METHODS: From January 2017 to June 2019, a total of eight cases histopathologically diagnosed as XGC, were misdiagnosed with GBC based on preoperative and intra-operative findings. The clinical characteristics, imaging, intra-operative findings, and surgical data of these patients were collected and analyzed. RESULTS: A total of 2154 cholecystectomy specimens were received in the histopathology section during the study period. Sixty-nine cases (3.2%) were histologically diagnosed as XGC, of which 8 cases (11.6%) were preoperatively diagnosed with GBC. These cases were predominantly seen in males in the age range of 24-62 years. The most common clinical presentation was chronic cholecystitis. Gallstones were present in all the 8 cases. Six cases presented with heterogeneous enhancement within thickened gallbladder walls on imaging. Intraoperatively, adhesions to adjacent organs were observed in seven cases. All these eight cases misdiagnosed with GBC underwent aggressive surgical treatment following which histopathology ultimately revealed XGC. CONCLUSION: Neither clinical manifestations nor laboratory tests/radiological methods can provide an effective means of differentiating between XGC and GBC. Preoperative diagnosis is difficult, and histopathology remains the gold standard to differentiate the two entities.

Case Report: Expanding the Phenotypic Spectrum of Timothy Syndrome Type 1: A Sporadic Case With a de novo CACNA1C Pathogenic Variant and Segmental Ileal Dilatation.

Background: Long QT syndactyly syndrome (long QT syndrome type 8), also known as Timothy Syndrome (TS) was first described in 1994 with still <50 case reported in the literature. The full spectrum of the syndrome is not yet known. Results: Here we report a girl who presented with new onset refractory seizures and an undiagnosed cause of intermittent abdominal distention. She also had syndactyly of her fingers and toes and was found to have prolonged QT. Upon further investigations she was found to have a de novo pathogenic variant in CACNA1C, along with Segmental Ileal Dilatation (SID), and subsequently diagnosed with Timothy syndrome. Conclusion: To our knowledge, the association of Timothy Syndrome with Segmental Ileal Dilatation, was not described before.

Recently Described Entity of Intracholecystic Papillary Neoplasm of Gallbladder with Coexisting Xanthogranulomatous Cholecystitis: an Unusual Association.

Intracholecystic papillary neoplasm (ICPN) of the gallbladder is a relatively new concept and is suspected to share clinicopathologic features with intraductal papillary mucinous neoplasm (IPMN) of the pancreas and intraductal papillary neoplasm of the bile duct (IPNB). The literature on the clinicopathologic characteristics of preinvasive intraepithelial neoplasms of the gall bladder is fairly limited, partly owing to variability in its definition and terminology. We report an extremely rare case of coexistent xanthogranulomatous inflammation and intracholecystic tubulo-papillary neoplasm with low-grade dysplasia in a 48-year-old male patient. Although there are many case reports of simultaneous carcinoma gallbladder with xanthogranulomatous cholecystitis (XGC), however, the association of ICPN with XGC has not been previously described. To the best of our knowledge, this is the first case report of ICPN of gallbladder coexisting with xanthogranulomatous cholecystitis.

Integration in Medical Education.

The term integration has gained importance in Medical education over the last two decade, and is believed to facilitate knowledge, that is more meaningful to clinical practice. A move towards integration in medical education is likely to reduce fragmentation of the medical course and motivate students towards better learning, It aims to improve medical education by bridging the traditional barrier between basic and clinician sciences. Integration is one of the major changes incorporated in the new competency based curriculum for undergraduate medical program in India. There are associated changes in the assessment system too in relation to integration. However, the concept of integration/integrated curriculum lacks significant clarity as how to implement it in medical institutions with added paucity of literature on this important topic. Integrated teaching is the integration of the concepts wherein various subject-based knowledge or aspects of one theme or topic are assimilated to provide the holistic approach. Our review focusses on the need for integration with comparative analysis of the two most important models of integration (Fogarty and Harden) which are being followed, delving on their common features for simplifying this complex topic as well as for better understanding of the concept. We have also proposed six steps for implementation of integration. We conclude that the proposed change from conventional to new integrated curriculum requires robust planning and coordination amongst the various stakeholders in medical institutions.

Online Medical Teaching in COVID-19 Era: Experience and Perception of Undergraduate Students.

Introduction: Rapid emergence of COVID-19 as pandemic has affected the life of almost every human being and has changed the way people used to interact. It has also affected medical education and clinical training, and forced medical schools to switch over to online mode of teaching. The aim of this study was to learn about the experience and perception of undergraduate students regarding online teaching. Methods: This is a cross sectional observational study conducted among the undergraduate students of Hamdard Institute of Medical Sciences and Research, New Delhi, India. A validated electronic questionnaire with nine questions was sent to 177 students as Google FormsTM. Responses from 161 students were received and analyzed using SPSS software. Results:The majority of students were satisfied with the frequency, organization, content and preparedness of classes. Half of students were neither satisfied with the amount of syllabus covered nor online teaching method. Among various teaching methods, live online lectures were most common and they were also preferred by the majority of students. Most students want hybrid or blended teaching in the post COVID-19 era. Conclusion: Online or e-teaching alone is not preferred by the majority of students. Lack of interpersonal interaction is the most likely reason for this. Hybrid or blended teaching holds the future of medical education as it is more student friendly and efficient.

Video projected practical examination as an introduction to formative assessment tool for undergraduate examination in pathology.

BACKGROUND: Assessment of the medical students includes theory as well as practical assessment. Traditional practical examination in pathology which includes viva and spots is now increasingly being questioned because of their inherent lack of validity and reliability, time consumption, and human resource requirement. Therefore, a need was felt for another form of practical examination which can be used as formative assessment, and if found feasible, can be employed in summative assessment too. AIM: The aim of the study was to develop and implement a new method of video projected practical examination (VPPE) as a formative assessment tool for MBBS second professional students so as to improve their learning and academic performance in practical pathology and also to obtain students' perception regarding the effectiveness of VPPE. METHODOLOGY: The study was carried out with the MBBS second professional students before their end-of-semester examination in the Department of Pathology. In this new method, slide video projection was used as a formative assessment tool during practical examination. Students were randomly divided into two groups. Group I was subjected to VPPE, while simultaneously conventional practical examination was held for Group II. Assessment results of VPPE were compared with conventional practical examination. Faculty and students feedback was also taken at the end of the examination. RESULTS: Mean marks of the students who undertook VPPE was higher than those who gave conventional practical examination. Majority (95.3%) of the students agreed that VPPE is better than conventional practical examination. Most of the faculty members also felt that it is a more valid and reliable assessment tool. CONCLUSIONS: Introducing VPPE as a formative assessment tool in practical pathology enhanced their learning and academic performance. Opinion of examiners and students also showed that VPPE has several advantages over conventional practical examination.

Synchronous benign Brenner's tumor of ovary with leiomyoma and endometrial adenocarcinoma in a postmenopausal female.

Brenner tumors of ovary are usually an incidental finding. It is an uncommon tumor which is seen affecting women of fifth to sixth decade. It is classified under transitional cell tumors of ovary, which includes benign, borderline, and malignant Brenner tumors and transitional cell carcinoma. These tumors have been associated with synchronous and metachronous neoplasia, most commonly other ovarian epithelial tumors such as mucinous cystadenoma. Occasionally, these tumors may be associated with endometrial hyperplasia or carcinomas which are due to hormones elaborated by the stromal component of Brenner tumor. The hormone produced is estrogen and less commonly androgens, which alters the estrogen and progesterone levels, causing hyperstimulation of endometrium. We present a case of 50-year-old postmenopausal women who presented with coexisting incidental Brenner tumor with leiomyoma and Endometrial adenocarcinoma. Only few authors have reported similar tumor occurrence in the past.

Retained Fetal Bones: An Unusual Cause of Granulomatous Reaction on Papanicolaou Smear.

Granulomas are a rare finding on Papanicolaou (Pap) smear which if encountered are usually attributed to tuberculosis, especially in an endemic country like India. Here, we report an interesting case of a 40-year-old female presenting with blood-stained discharge and chronic pelvic pain for 8 years. She was advised Pap smear which showed granulomatous inflammation suggestive of tuberculosis. The patient was worked up for tuberculosis which was noncontributory. Dilatation and curettage was done which revealed multiple small bones and bony chips in the endometrial cavity. Following the removal of bones, the patient showed considerable symptomatic improvement. Repeat Pap smear did not reveal any evidence of granuloma. Even after extensive search of literature, we did not come across any such case report in which intrauterine retention of fetal bones evoked a granulomatous response in cervical smears though the presence of uterine granulomas in response to foreign body has been well documented.

Diagnostic challenges of tubercular lesions of breast.

INTRODUCTION: Tuberculosis (TB) in the developing countries presents with both pulmonary and extrapulmonary manifestations. Breast TB, however, remains a rare presentation. Its importance lies in the fact that it may mimic malignancy or present as inflammatory lump/abscess. AIMS AND OBJECTIVE: The aim of the present study is to highlight the importance of breast TB and its diagnostic challenges. MATERIALS AND METHODS: It was a retrospective study conducted at a tertiary care hospital, over 2 years between 2013 and 2015 during which eight cases of breast lesions were diagnosed as of tubercular origin. RESULTS: Granulomas were seen in five cases while three cases revealed only few epithelioid cells, and necrosis was seen in all cases on fine-needle aspiration cytology. Histopathological evaluation was available in six out of the eight cases, while acid-fast bacilli were positive in three cases, the characteristic granulomas were seen in all the six cases evaluated. CONCLUSION: Significance of TB breast lies in the fact that it may masquerade as breast malignancy or pyogenic abscess. India is a developing country where TB is endemic, a high index of suspicion should be expressed in evaluating breast masses, and TB should be considered in the differential diagnosis.

Traumatic Tracheobronchial Laceration Causing Complete Tracheal Resection: Challenges of Anesthetic Management.

We report the case of a 9-year-old girl who sustained blunt trauma to the chest and presented for emergent repair of a complete tracheobronchial laceration. Tracheobronchial laceration is potentially life threatening. While conservative management has been described for simple tears, more complex injuries require surgical repair. We discuss the anesthetic challenges, airway management, and ventilation options for surgical repair in a child with a complex laceration involving the tracheobronchial tree.