title: Global manipulation of digital images can lead to variation in cytological diagnosis.
abstract: BACKGROUND
  With the adoption of a completely electronic workflow by several journals and the advent of telepathology, digital imaging has become an integral part of every scientific research. However, manipulating digital images is very easy, and it can lead to misinterpretations.
  
  
  OBJECTIVE
  To analyse the impact of manipulating digital images on their diagnosis.
  
  
  METHODS
  Digital images were obtained from Papanicolaou-stained smears of dysplastic and normal oral epithelium. They were manipulated using GNU Image Manipulation Program (GIMP) to alter their brightness and contrast and color levels. A Power Point presentation composed of slides of these manipulated images along with the unaltered originals arranged randomly was created. The presentation was shown to five observers individually who rated the images as normal, mild, moderate or severe dysplasia. Weighted κ statistics was used to measure and assess the levels of agreement between observers.
  
  
  RESULTS
  Levels of agreement between manipulated images and original images varied greatly among observers. Variation in diagnosis was in the form of overdiagnosis or under-diagnosis, usually by one grade.
  
  
  CONCLUSIONS
  Global manipulations of digital images of cytological slides can significantly affect their interpretation. Such manipulations should therefore be kept to a minimum, and avoided wherever possible.
authors.affiliation: Department of Oral Pathology and Microbiology, Modern Dental College and Research Centre, Indore, M.P - 453 112, India.
authors.forename: H
authors.initials: H
authors.lastname: Prasad
authors.forename: Sangeeta
authors.initials: S
authors.lastname: Wanjari
authors.forename: Rajkumar
authors.initials: R
authors.lastname: Parwani