2009

Low SW, Ng YJ, Yeo TT, Chou N
Correspondence: Dr Low Shiong Wen, swlow@singnet.com.sg

ABSTRACT
Introduction The aim of this study was to evaluate the outcome of Osteoplug^TM, a novel biodegradable polymer burr-hole cover implant, used in patients with burr holes done for drainage of chronic subdural haematoma.
Methods 12 patients with chronic subdural haematoma had Osteoplug^TM implants inserted into their burr holes after evacuation of the haematoma. Osteoplug^TM is a biodegradable polycaprolactone implant with a mushroom-button shape, designed specifically to fit into a 14-mm diameter burr hole. It has an upper rim of 16-mm diameter and a body diameter of 14 mm, with a honeycomb-like architecture of 400-600 µm pore size. The Osteoplug^TM snaps onto the 14-mm diameter burr hole snugly after the evacuation of the liquefied haematoma is done. All 12 patients were followed up for a period ranging from ten months to two years (mean 16 months) postoperatively. They were evaluated for their clinical, radiological and cosmetic outcomes.
Results Osteoplug^TM provided good cosmesis by preventing unsightly depressions over the skull postoperatively in all the 12 patients. Postoperative computed tomography, done at one year, showed signs of good osteointegration into the surrounding calvarial bone, with multifoci mineralisation throughout the scaffold in one patient. There was no case of infection or any adverse systemic reaction noted. Patient satisfaction was high.
Conclusion The Osteoplug^TM polycaprolactone burr-hole covers are suitable, biodegradable implants with good medium-term results. They provide an ideal scaffold for osteogenesis and excellent cosmesis. There were no adverse events in all 12 patients, with a mean follow-up of 16 months.

Keywords: biodegradable polymer, burr-hole covers, osteoconduction, osteogenesis, Osteoplug^TM, polycaprolactone implants
Singapore Med J 2009; 50(8): 777-780

Leong BDK, Chuah JA, Kumar VM, Rohamini S, Siti ZS, Yip CH
Correspondence: Dr Benjamin Dak Keung Leong, bleongdk@yahoo.com

ABSTRACT
Introduction Sabah, formerly known as North Borneo, is part of East Malaysia. 52.2 percent of patients with breast cancer in Sabah presented at advanced stages and up to 20.4 percent of patients defaulted proper treatment, opting for traditional therapy. We performed a two-year prospective study looking at the treatment trends of breast cancer in Sabah.
Methods Our subjects were all newly-diagnosed breast cancer cases seen at the hospital in 2005 and 2006. Type of surgery, chemotherapy, radiotherapy, hormonal therapy and surgical complication for each patient were studied.
Results Out of 186 newly-diagnosed cases, 152 (81.7 percent) had surgery, 126 (67.7 percent) had chemotherapy, 118 (63.4 percent) had radiotherapy and 92 (49.5 percent) had hormonal therapy. 18.3 percent did not have surgery either due to refusal of treatment or advanced disease. They were more likely to be non-Chinese (91.1 percent, p-value is 0.02). Only 15.8 percent had breast-conserving surgery. The most frequent surgical complication was seroma formation (15.0 percent). The commonest chemotherapy regime and hormonal therapy were anthracycline-based regime (88.1 percent) and tamoxifen (95.8 percent), respectively.
Conclusion The proportion of breast-conserving surgery and usage of modern adjuvant therapies are low in Sabah. This can be attributed to lack of breast cancer awareness leading to late presentation and refusal of treatment, coupled with insufficient health service funding.

Keywords: advanced cancer, breast cancer, cancer awareness, cancer treatment
Singapore Med J 2009; 50(8): 772-776

Gill SS, Sebastian MG, Tan SG, Chia KH, Tan BS, Tay KH
Correspondence: Dr Mathew George Sebastian, mathewg.sebastian@sgh.com.sg

ABSTRACT
Introduction Endovascular aortic repair (EVAR) has gained prominence as a means of treating aortic disease, with lower perioperative morbidity and mortality compared to open surgery. This article aimed to describe the experience of two tertiary hospitals in a Southeast Asian population.
Methods A retrospective review of 100 consecutive patients undergoing EVAR in two hospitals in Singapore was conducted. This included patients undergoing elective as well as emergency repair.
Results The mean duration of follow-up was 31.8 months. The mean aneurysm size was 6.3 cm and the mean length of stay was 12.1 days. 64 percent of the patients were of American Society of Anesthesiologists class III or above. The deployment success was 98 percent. Major complications (acute myocardial infarction, pneumonia, cerebrovascular accidents, renal failure, colonic infarction and spinal cord infarction) occurred in 18 patients. Perioperative mortality occurred in six percent of cases. The endoleak rate was 28 percent. Both patients with colonic infarction had a single patent internal iliac artery post-procedure, and end-stage renal failure.
Conclusion Our results are comparable to published experiences in aortic stenting. Our population possibly had a higher incidence of short common iliac arteries. Revascularisation of internal iliac arteries should be considered for patients with end-stage renal failure and a single patent internal iliac artery.

Keywords: aorta, aortic aneurysm, aortic stent, endovascular aortic repair
Singapore Med J 2009; 50(8): 768-771

Ng KH, Lim YK, Ho KS, Ooi BS, Eu KW
Correspondence: Prof Eu Kong Weng, eu.kong.weng@sgh.com.sg

ABSTRACT
Introduction The use of robotics in colorectal surgery is relatively new. The first few cases of colonic surgery using da Vinci Surgical System were reported in 2002. Since then, several centres had reported on their experience, with favourable outcomes. Our department started to embark on robotics in colorectal surgery in December 2007. The aim of our paper was to share our early experience with robotics in colorectal surgery and provide an update on the current status of robotics.
Methods Preparations included formal training with the da Vinci Surgical System, certification of the surgeons, and obtaining Hospital Ethics committee approval. We used a hybrid technique of laparoscopic and robotic assistance in the resection of mid- to low-rectal cancer (total mesorectal excision). Laparoscopic approach was used to isolate the inferior mesenteric artery and for mobilisation of the left colon. The da Vinci robot was used in the dissection of the rectum down to the pelvic floor. We reviewed the outcomes of our early experience with emphasis on feasibility and safety.
Results Over a period of three months, we performed eight cases of robotic-assisted colorectal surgery for cancer. The median age of the patients was 55 (range 42–80) years. The median operating time was 192.5 (range 145–250) minutes. There were no intraoperative or postoperative complications related to the use of robotics. The median length of hospital stay was five (range 4–30) days.
Conclusion Robotic-assisted laparoscopic colorectal surgery is a safe and feasible procedure.

Keywords: da Vinci robotics, laparoscopic surgery, rectal cancer, robotic surgery, total mesorectal excision
Singapore Med J 2009; 50(8): 763-767

Peh WCG, Ng KH
Correspondence: Prof Wilfred CG Peh, smj.editor@sma.org.sg

ABSTRACT
Good manuscripts are sought by journals and publication marks the endpoint of a scientific research project. In preparing a manuscript for submission, the material should be organised into a structure that best showcases the author’s material. The manuscript should be written in a style that transmits the author’s message with clarity. The author’s material should be matched to the most appropriate paper category and the target journal. Having the help of an experienced mentor is invaluable. Authors need to prepare the manuscript meticulously and exactly according to the journal’s “Instructions to Authors”.

Keywords: manuscript preparation, manuscript submission, medical writing, scientific paper
Singapore Med J 2009; 50(8): 759-762

George S, Moreira K
Correspondence: Dr Sanju George, sanju.george@talk21.com

ABSTRACT
There is an ever-increasing expectation on trainees and junior doctors to publish more. Not all doctors are fortunate enough to participate in and publish high-quality original research. This paper provides some practical tips to trainee doctors, who are novice researchers and who have few or no published papers, on how to publish (not how to write) non-research papers. Although we acknowledge that not all these tips may be relevant to all trainees aspiring to publish, we hope that some of these tips will be applicable to most trainees.

Keywords: publications, research, trainee doctors
Singapore Med J 2009; 50(8): 756-758

Kumar V, Upadhyay S, Medhi B
Correspondence: Dr Bikash Medhi, drbikashus@yahoo.com

ABSTRACT
The impact factor was created in the biomedical research field in order to measure a journal’s value by calculating the average number of citations per article over a period of time. It was initially developed to help libraries decide which highly-cited journals to subscribe to. However, at present, it is being misused to judge the quality of a researcher or medical scientist as well as the quality of the work done. It contains serious sources of errors and flaws, resulting in strong biases against culture-and language-bound medical subspecialties. The present article is aimed to highlight the impact of the impact factor in the biomedical research, as well as its use and misuse.

Keywords: impact factor, Institute for Scientific Information, Journal Citation Report, Science Citation Index
Singapore Med J 2009; 50(8): 752-755

Singh P, Khaira A, Sharma A, Dinda AK, Tiwari SC
Correspondence: Dr Ambar Khaira, ambarkhaira@gmail.com

ABSTRACT
A 34-year-old man presented with polymerase chain reaction-positive pleuropulmonary tuberculosis with asymptomatic subnephrotic proteinuria and microscopic haematuria. He was diagnosed to have IgA nephropathy on renal biopsy. The patient was started on a four-drug anti-tuberculous therapy. Healing of the pleuropulmonary lesions along with disappearance of proteinuria and haematuria were seen both at one month and six months posttreatment, with no relapse of renal symptoms at one-year follow-up.

Keywords: anti-tuberculous treatment, IgA nephropathy, kidney disease, Mycobacterium tuberculosis, pleuropulmonary tuberculosis, primary glomerulopathies, tuberculosis
Singapore Med J 2009; 50(7): e268-e269

Sin IL, Tan TYT
Correspondence: Dr Tony Tan, tan_tony@rafflesmedical.com

ABSTRACT
Down syndrome in monochorionic twins has rarely been reported. We report such a case diagnosed prenatally. Maternal serum screening was performed at 15 weeks for a twin pregnancy which indicated a risk of greater than 1:50 for Down syndrome. The review of early ultrasonography confirmed monochorionic twins. Amniocentesis at 17 weeks’ gestation was performed on one of the twin sacs, which confirmed Down syndrome. A screening scan at 19 weeks’ gestation showed isolated absent nasal bones in both twins. Termination of pregnancy was performed subsequently.

Keywords: amniocentesis, Down syndrome, nasal bone, maternal serum screening, monochorionic twins, twins
Singapore Med J 2009; 50(7): e264-e267