Aim:To assess the surgical outcome of myasthenia gravis (MG) following thymectomy and to determine the outcome predictors to such therapeutic approach.Materials and Methods:This study is a retrospective review of 80 consecutive thymectomies performed for MG over a 16-year period.Results:There were 41 females and 39 males (mean age, 34.32 years) with mean disease duration of 17.45 months prior to surgery. Stagewise distribution of the patients revealed 2.5% in stage I, 48.7% in stage IIA, 33.8% in stage IIB, 8.7% in stage III, and 6.3% in stage IV. The surgical approach was either trans-sternal (n=67) or video-assisted thoracoscopic route (n=13). Follow-up was obtained in 91.2% (n=73) of patients with mean duration of 67.7 months. At their last follow-up, 26.0% were in complete remission, 35.6% were asymptomatic on decreased medications, and 17.8% had clinical improvement on decreased medications. Overall, 79.4% of patients benefited from surgery, 8.2% had unchanged disease status, and 12.3% worsened clinically. Factors influencing favorable outcome include sex, disease stage, gland weight, and preoperative medication with anti-cholinesterase (P<0.05). There was one death in the perioperative period due to septicemia. Two patients died at fourth and seventh month following thymectomy.Conclusion:Thymectomy for MG is safe and effective. Certain influencing factors may shape treatment decisions and target higher risk patients.

The over-drainage of CSF after shunt implantation, particularly when the patient is in the vertical posture, is well documented. Problems associated with it are negative pressure syndrome (postural headache and postural irritability), abnormal skull size, craniosynostosis and subdural haematoma. The pressure gradient in the vertical position between the cranial cavity and the right atrium is 15 to 20 cm of water and between the cranial and peritoneal cavity it is 25 to 32 cm of water and both these are much higher than those needed for the optimum functioning of a conventional shunt. The need, therefore, has been for a self-regulating device that can adjust itself to any change of posture from horizontal to vertical and vice versa and regulate the flow of CSF from the cranial cavity. "Z" Flow hydrocephalus shunt system has this in-built self-regulating mechanism to prevent over drainage of CSF and the resultant abnormal low pressure in the cranial cavity. The rationale behind the functioning of "Z" Flow hydrocephalus shunt system has been discussed, its design has been described and illustrated and the results of pressure monitoring after Z Flow shunt implantation in five adult patients have been detailed. As the opening pressures of the "Z" Flow shunt system are 15-29 cm of water, it has been found to prevent over-drainage of CSF and maintain intraventricular pressure within normal limits.

QUESTIONS TO BE ANSWEREDIn this retrospective study we have correlated the clinical, ultrasonological and pathological findings of breast masses to answer whether we could rely on ultrasound and Fine Needle Aspiration (FNAC) findings for the further management of patients. MATERIAL AND METHODSThis is a retrospective study done at Vidya Cancer Hospital, Gwalior, Madhya Pradesh, India. This study has included patients from Jan. 2014 to Jan. 2016. The total number of patients is 50. The clinical examination is done by an oncology team which includes a surgical oncologist, medical oncologist, radiation oncologist and gynaecologist. The ultrasound is done by an oncoradiologist. The pathological examination is done by an oncopathologist. The ultrasonology findings assessment is done according to the American College of Radiology, Breast Imaging Reporting and Data System (BI-RADS). The statistical analysis is done by using standard formulas. DISCUSSIONIn our day-to-day practice, we often see so many breast lumps. All the patients and their family members are in great agony. We as clinicians have to give quick results by non-invasive methodology. In today's era nothing could be advocated merely on clinical experience, it has to be evidence based. To create evidence, we have done this study. We found even a good clinical examination and ultrasound by a good team could solve most of the diagnostic dilemmas of breast masses. In our study, the sensitivity and specificity of clinical examination were 100% and 88% respectively. We tried to compare it with other studies, but we were unable to compare it with because of wide variations in those studies for they were either not focusing on clinical examination or it was not a team effort. Yes, we have been able to compare the sensitivity and specificity of ultrasound and FNAC findings. In our study, the sensitivity and specificity of ultrasound was 100% and 88% respectively which was comparable to 95.7% and 89.2% respectively in Lehman et al Study. In our study the sensitivity and specificity of FNAC was 93.3% and 88% respectively, which was 66.6% and 81.8% in Homesh NA et al study. The difference in sensitivity and specificity may be because our pathologist was always in coordination with the clinicians and ultrasonologist. Apart from this, we came across very interesting finding that our pathologist was not able to give any conclusive findings in clinically suspicious an d BIRADS 4 findings. CONCLUSIONThis study has shown that a good team work could do wonders and a good clinical and ultrasonological examination could sort out most of the diagnostic dilemmas of breast masses. FNAC does well in frankly benign and malignant lesions. Any lesion which is suspicious and BIRADS 4 should undergo an upfront biopsy rather than FNAC. Fallacy was the number of patients included in this study was too small to make a final remark and secondly it is not a blinded study.

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