2009

Tan KK, Yan ZY, Vijayan A, Chiu MT
Correspondence: Dr Ker-Kan Tan, kerkan@gmail.com

ABSTRACT
Introduction Diagnosis of diaphragmatic rupture is difficult, and delays could result in a catastrophic outcome. We reviewed our institution’s management of patients with diaphragmatic rupture after blunt trauma.
Methods All patients in this study were treated at Tan Tock Seng Hospital, Singapore, from March 2002 to October 2008. Patients with penetrating injuries were excluded. The parameters included age, mechanism of injury, haemodynamic status at admission, Glasgow coma scale (GCS) score, injury severity score (ISS), imaging studies, location of diaphragmatic injuries, associated injuries and outcome.
Results 14 patients with a median age of 38 years formed the study group. Vehicular-related incidents accounted for 71.4 percent of the injuries. The median GCS score on admission was 14 (range 3–15), while the median systolic blood pressure and heart rate were 94 (range 50–164) mmHg and 110 (range 76–140) beats per minute, respectively. The median ISS was 41 (range 14–66). All had chest radiographs performed in the emergency department, six (42.9 percent) had computed tomography performed before surgery, while the remaining eight (57.1 percent) were sent straight to the operating theatre from the emergency department. There were five (35.7 percent) right-sided and nine (64.3 percent) left-sided diaphragmatic ruptures. The mortality rate was 35.7 percent. Some of the associated injuries included eight (57.1 percent) splenic lacerations, five (35.7 percent) haemothorax and lung injuries, four (28.6 percent) bone fractures and three (21.4 percent) liver lacerations. 12 (85.7 percent) patients underwent repair of the diaphragmatic rupture using interrupted polypropylene suture, while the remaining two (14.3 percent) were too haemodynamically unstable to undergo definitive treatment. Advanced age, haemodynamic instability and raised ISS were associated with mortality.
Conclusion An accurate diagnosis of diaphragmatic rupture in trauma patients is difficult, and a thorough examination of both the hemidiaphragms is mandatory during emergency laparotomy for these patients. Those with more severe injuries and decreased physiological reserves usually fare worse.

Keywords: blunt abdominal injuries, diaphragm, diaphragmatic rupture, emergency laparotomy, surgical emergency
Singapore Med J 2009; 50(12): 1150-1153

Hussain A, Mahmood H, Singhal T, Balakrishnan S, El-Hasani S
Correspondence: Mr Abdulzahra Hussain, azahrahussain@yahoo.com

ABSTRACT 
Introduction The correlation between clinical and histopathology findings in appendicitis has been highlighted by many studies. However, the impact of this correlation on the surgical decision to remove a normal-looking appendix is still vague, with no clear definition of positive appendicitis. The aim of this study was to correlate the histological, operative and clinical diagnoses of acute appendicitis (AA). 
Methods 200 patients with a preoperative diagnosis of AA underwent laparoscopic appendectomy. A single consultant surgeon performed all the procedures. The clinical, macroscopical and microscopical outcomes were reported and analysed. Follow-up assessment was performed as an outpatient appointment. 
Results 112 women and 88 men were included in this study. The mean age was 18.8 (range 8–83) years. Macroscopical appendicitis was confirmed in 139 (69.5 percent) patients, while microscopical appendicitis was reported in 147 (73.5 percent) specimens of the appendix. Ten (7.2 percent) out of 139 patients who were macroscopically positive were found to have a normal appendix on microscopical examination. Different pathologies were found in 21 (10.5 percent) patients, and all underwent appendectomy. Microscopical appendicitis was confirmed in10 (25percent) out of 40 patients who had a normal-looking appendix. 
Conclusion The correlation of the clinical, microscopical and macroscopical findings in AA is important in order to understand the natural history of appendicitis, and this may help to formulate a sound surgical decision. These findings are supportive of justifying appendectomy for normal-looking appendices, if no other pathology is found.

Wong TH, Tan YM
Correspondence: Dr Wong Ting Hway, wong.th@iname.com

Ng KH, Peh WCG
Correspondence: Prof Ng Kwan Hoong, dwlng@tm.net.my

ABSTRACT
After submission and acceptance of a scientific paper by a journal, the final stages in the publishing process are copy-editing and proofreading. The primary purpose of this step is to ensure accurate and quality production of scientific papers. Authors are responsible for checking their proofs properly and in detail, ensuring that everything is correct as this is their last chance to make any changes before their work is set in print forever.

Chang KTE
Correspondence: Dr Kenneth TE Chang, kenneth.chang.te@kkh.com.sg

ABSTRACT 
Formal pathological examination of the placenta provides valuable information to the obstetrician, neonatologist, paediatrician and family. This article aims to provide the clinician with an overview of the significance of placental examination in relation to common or important pathological processes, and the utility of information obtained therein in explaining adverse outcomes, management of subsequent pregnancies, and assessment of newborn risk for the development of short-or long-term sequelae. General guidelines for placental examination, and logistical and practical issues are also discussed. Finally, the role of the placenta in the defence of obstetricians and other healthcare workers in cases of poor neonatal outcome is described. 

Lapeña JF
Correspondence: Dr José F Lapeña Jr, lapenajf@upm.edu.ph

ABSTRACT
The concept of editorial freedom or independence is examined in the light of the editor-owner relationship. Like individual and national freedom or independence, it is a rhetorical concept whose realisation flows from internal achievement as much as it depends on external validation. This freedom entails roles and responsibilities embodied in specific codes of practice for editors, such as the guidelines espoused by the International Committee of Medical Journal Editors and the World Association of Medical Editors. The calling to embody these guidelines makes editing a vocation that demands isolation and distancing, separation and solitude. It involves bracketing one’s biases, prejudgments and preconceptions. With such detachment comes real freedom; one that requires a moral fibre and trustworthiness that uphold truth and right, whether in full view of public scrutiny, or in the aloneness of private secrecy. The stereotypical tension between academic and commercial concerns highlights the editor-owner relationship, and bears directly on editorial independence. In practice, journal owners overstep their prerogatives. The absence of clear contracts defining editorial independence and the lack of established mechanisms governing the editor-owner relationship affect many small-to medium-sized journals in developing countries. Even large journals in developed and democratic nations or totalitarian states and societies are not spared. At the end of the day, editorial freedom exists only insofar as it is tolerated, or until editors cross the line.

Keywords: editorial freedom, editorial independence, editorial policies, editor-owner relationship
Singapore Med J 2009; 50(12): 1120-1122

Loukas M, Tubbs S, Louis Jr RG, Apaydin N
Correspondence: Dr Marios Loukas, mloukas@sgu.edu 

ABSTRACT
We present a 48-year-old male cadaver in which the right superficial palmar arterial arch had no contribution from the radial artery and terminated by giving rise to a common trunk for the princeps pollicis and radialis indicis arteries. The dorsal radial artery of the thumb was absent and no arterial supply was provided by the radial artery. Accordingly, the entire arterial supply to the right thumb was provided by the superficial palmar arterial arch, which was composed solely of the ulnar artery, which received no collateral supply from the radial artery system. Considering that the arterial supply of the thumb in the present case was solely provided by the superficial palmar arch, a potential hazard could exist in the event of traumatic injury to the ulnar artery.

Singh AP, Mahajan S, Singh AP
Correspondence: Dr Arun Pal Singh, singh_arunpal@hotmail.com

ABSTRACT
A 52-year-old Indian woman presented with a progressively increasing swelling and pain in the right elbow for the past eight months, which was not associated with trauma or constitutional symptoms. The patient was diagnosed to have Campanacci grade III giant cell tumour of the proximal radius, and was treated with above-elbow amputation. The patient has not shown any recurrence after five years of follow-up. The case was reported because of its rarity and the unusual site of occurrence of the tumour. 

Basu S, Ansari M, Gupta S, Kumar A 
Correspondence: Dr Anand Kumar, profanandkumar52@gmail.com

ABSTRACT
We report a retroperitoneal transitional cell carcinoma arising from the primitive urogenital remnants of a 56-year-old married Indian woman. She presented with a huge cystic mass in the hypogastrium and right iliac fossa, which extended into the right thigh as a massive dumb-bell tumour. On exploration, it was found not to be arising from any known retroperitoneal structure. The mass was excised, and the histopathology confirmed transitional cell carcinoma with positive margins. Though she received postoperative chemotherapy with cyclophosphamide, adriamycin and cisplatin, she developed extensive local recurrence and hepatic secondaries, and succumbed to the disease after ten months of follow-up. We highlight the rarity of the disease, its atypical presentation as a cystic dumb-bell lump, its diagnostic challenges and aggressive behaviour, and review the literature on primary retroperitoneal transitional cell carcinomas.

Ho FLW, Cunanan EC, Wang SC, Mukherjee JJ
Correspondence: Dr Jagat J Mukherjee, jjmukh@nuh.com.sg 

ABSTRACT 
When performed properly, bilateral inferior petrosal sinus sampling (BIPSS) for adrenocorticotropic hormone (ACTH) is rarely associated with complications. Major complications reported to date include thromboembolism, brain stem infarction, pontine haemorrhage, isolated sixth nerve palsy and venous subarachnoid haemorrhage. We describe a rare case where a predominant contrast extravasation into the subarachnoid space, admixed with a small quantity of venous blood, occurring during BIPSS in a 58-yearold woman with ACTH-dependent Cushing’s syndrome, was misinterpreted as venous subarachnoid haemorrhage.