Digital mammography represents a potential new and exciting development in the interface between computers and health care. Your paper highlights some of the emerging issues which might be expected with new technology. You have noted the increase in incidence of breast cancer, together with a large increase in recall rates. Reports from the radiologists also indicate that between 6% and 10% of tumors are identified clinically following mammography.

The protocol presented by those involved in the screening program differs in a number of significant aspects from conventional screen film mammography. The instructions provided to women attending for screening do not include any advice regarding using talcum powder. This advice had always previously been given both in writing and orally to those attending for mammograms.

All X-rays are reported and scored by two specialist radiologists. However, the reports, when issued, do not identify the radiologists, nor is the panel from which they are selected apparent. The Quality Assurance manual indicates that targets are set for the incidence of breast cancer. A Standarised Detection Ratio (S.D.R.)is the preferred method for correcting unit performance. This raises the possibility that the computer can over-ride the results from the individual radiologists. Such a mechanism might again contribute to an increase in detection of breast cancer.

The new digital equipment relies much less on X-ray exposure and has substituted pressure to compensate for the reduction in the X-ray content. Is it possible that the increase in pressure on breast tissue might contribute to the increase in incidence of second round breast cancers from 4.4 to 5.7/1,000 when the older SFM machine is compared to the newer FFDM machine, reported by Hambly et al in the American Journal of Radiology, October 2009.

Is the observed interval tumor rate a result of the reduced penetration in the new machine, with consequent diminution in accuracy of detecting mass lesions? Alternatively, is the increased pressure in the new machine causally related to the number of women who present with mass lesions following mammography?

Conflict of Interest:

None declared

This study by Prof Abbas et al of German Pathology Institute is in the very important domain of transitional medicine, requiring molecular definition and designation for the lesions or morbid entities previously held diagnosable on the histopathological basis with or without special staining. Molecular basis of defining disease as in the case under consideration of IgG-4 related systemic disease, is to take into account the molecule(s), like IgG-4 here, so varied histopathological inflammatory, sclerotic, fibrotic, and phlebitic entities in bone, joint, pancreas, salivary glands, skin, lymph nodes or else, if present with serum IgG-4 elevation/ presence of IgG-4 plasma cells, such lesions/morbidities are being by the researchers labelled as IgG-4 associated inflammatory expression diseases (Kim HJ 2000, Fragoulis GE 2010, Stone JR 2011). As evident in the present study, there may be IgG-4 plasmoinflammatory (mean 55/hpf) Rheumatoid (RF+ve) Synovitis, and IgG-4 plasmoinflammatory Rheumatoid factor negative (RF-ve) Synovitis as also reported by previous studies above. Likewise in oral including neoplastic lesions, skin diseases previously defined as allergies like pemphigus, Salivary sclerotic inflammations; where ever lesion is accompanied by tumifective inflammatory component and shows serum IgG-4 above normal levels and/or IgG-4 plasma cells infiltration 5-50 or more cells/hpf, the diagnostician is bound to tag diagnosis as IgG-4 associate say Rheumatoid arthritis. As such any anti nuclear, anti cytoplasm or anti membranous features could not be demonstrated in the IgG-4 or related plasma cells, which also appeared to be consequence of (B lymphocyte irritation) disease rather than cause. Hence designations like IgG-4 associated disease may not be proper in view of the consequent confusion. Better it may be identified as a common feature in several varied inflammation manifesting diseases requiring treatment for IgG-4 plasmoinflammation, besides for the cause and symptoms of the disease. What the authors concluded in this study appeared to constitute IgG-4 related transition defect (TD) or transition ambiguity (TA).

Conflict of Interest:

None declared

In this study, from reputed medical institutions of Toronto, Canada, novel observation of organising micro-plaque placental thrombotic-process on foetal side of the basal plate are reported by the authors, inviting reports on larger organising thrombi in the same loci on the villous margin depression in the basal plate. On this subject, however, Craven CM and Chedwick (2002) reported that the basal plate of placenta is formed as a result of fibrin deposition from the decidual vein on the uterine face of the invading trophoblasts. The authors presently observed organising thrombus micro-plaque, thus, between the basal plate made of fibrin- deposit and the trophoblast layer of villi limiting the foetal aspect of the basal plate. It requires explanation how thrombus formed on villous side of the fibrin/basal plate. Authors may be in better position to explain this aspect of the present findings.

Conflict of Interest:

None declared

The Hematologists(Pathologists trained in hematology) of kolkata, West Bengal( in private setup tertiary care hospitals or in diagnostic laboratories or in Govt. set up secondary or tertiary care teaching hospitals) are being mostly trained with performing, interpretation, evaluation and diagnosis of common hematological problems, requiring Bone Marrow studies, by Bone Marrow aspiration(for diagnostic and follow up after any therapy) than by Bone Marrow Trephine biopsy, unless there is1) failed aspirate due to no marrow fragments in conditions when there is Marrow fibrosis or Marrow aplasia or 2) when there is suspected Pathology in Bone or 3) Marrow is cellular but poor aspiration happens due to tightly packed marrow. In Kolkata the interpretation and reporting of Bone Marrow aspiration is usually done by consultant pathologists trained specially in hematology division in a laboratory or in a teaching hospital Pathology dept set up. A very few centers[ one or two] are there in kolkata in the medical colleges where there are post doctoral trainees in hematology who also perform and report Bone marrow aspiration mainly and occasionally by trephine biopsy.

We authors consider however that there are till many advantages of performing and reporting Bone Marrow aspiration then reporting Bone Marrow Trephine biopsy, some of them can be summarized as follows • The Marrow aspiration needles are less costly, supplied and easily available in the kolkata market, in each &every laboratories and can be easily sterilized then islam or Jamshedi needles for marrow trephine biopsy ** the procedure can be repeated if and when necessary *** Multiple numbers of slides can be drawn from a single aspirate and may be used thus for special stain, cyto-chemistry and immuno histochemistry when necessary **** Report can be handed over to patient by 24 hours in most cases unless special stains or immunostains are asked for.***** Cytogenetic studies including flow cytometry can be performed with aspirated materials******The technique and interpretation can be percolated even at secondary health care level where there is a trained pathologists(at district and sub divisional level hospitals or diagnostic laboratories) and thus necessary treatment can be given earlier by General physicians or primary care physicians. • However there remain recognized problems with Bone Marrow aspiration studies 1) That the aspirated material often becomes diluted with much aspirated blood and in that case it is wiser to suck off blood before making smears with a blotting paper edge 2) the smear drawn by the trainee Post doctorals may not be equally enough thin and spreaded and clumping of many cells at some patchy areas of the slide 3) Marrow material may be drawn inadequate for interpretation 4) while Interpretation of cases and diagnosis are given erythriod hyperplasia particularly in children-the underlying diseases is not well described and many reports realy are such 5) When there is suspected focal lesion –in the bone marrow itself marrow aspiration can miss diagnosis 6) suspected &focal bone marrow fibrosis 7) when there is need to study the bone marrow architecture or bone structure or bone marrow blood vessels, Bone marrow aspiration may not be adequate study • Besides there may be many indications for performing Bone marrow Trephine biopsy like in Aplastic anemia; Myelofibrosis; MDS; Hairy cell leukemia; smoldering Multiple Myeloma; Early Multiple Myeloma Granulomatous lesions in Marrow [ may be from bacterial, viral, rickettsial, fungi, parasitic and sarcoidosis]; Osteopatheis. hypocellular MDS and investigation of suspected MDS or MDS with fibrosis; investigation for suspected amylodosis in cases of Multiple Myeloma ; Hypoplastic acute leukemia; AML M7; After Bone marrow transplant assessments; in CML for sub-typing the disease or to detect early blast crisis and to assess marrow fibrosis; for staging of Hodgkin disease(Bone marrow involvement is(2-32%) diagnosis and staging of small cell tumors of childhood; investigations for unexplained luekoerythroblastic blood picture and trephine biopsy can diagnose occult or micro metastasis if any or necrosis of bone marrow when there is infraction of bone which are missed or become difficult to diagnose by Bone Marrow aspiration studies. • The problem of trephine biopsy is that needles( Islam or jamshidi or westermann-jensen) needles are not available in every laboratories even at tertiary care teaching hospitals Pathology department and disposable needles are very costly for patient* it is always necessary to carry out aspiration at same time** Requires tissue processing set up with fixation facility {microwave fixation is better then10% buffered formalin or zinker fixative as often requires immuno stain as style] and decalcification fluid and making paraffin or resin blocks *** Training for interpretation and evaluation of Trephine biopsy is not adequate; Adequacy of length of Marrow tissues often not obtained (25% shrinkage is natural for fixation and at least 5-6 trabecular space is required for interpretation as per authors] and there remains also word of cautions for patients with coagulation disorders, liver failure and in patients with thrombocytopenia{< 1.5 lack/cumm] • Finally Bone Marrow aspiration and Bone Marrow trephine biopsy are complementary to each other as per authors at least if aspirations are not done then bone marrow imprint should be seen before evaluating Trephine biopsy.

Conflict of Interest:

None declared