Table of Contents

HK J Paediatr (New Series)
Vol 20. No. 3, 2015

HK J Paediatr (New Series) 2015;20:135-136


Back to the Basic: Have We Missed the Diagnosis or Complications of Our Patients?

GCF Chan

We are proud of our local heath care standard and we always quote that our practice is comparable to the standard of developed countries. However, the medical knowledge and practice have been progressing very rapidly in recent years, are we still keeping up with the pace of the advancement? In this issue, the original articles gave us some insight to this aspect.

Dr. Pang GSW, et al. reported the prevalence of adrenal insufficiency in a cohort of thalassaemia patients managed by a local regional hospital. Although such condition has been reported in the literature, local data remains lacking. Based on the data obtained from this study cohort, 36% of them have either primary or secondary adrenal insufficiency. This is a relatively high figure and all patients with this complication were under 20-year-old. Whether this data reflected the phenomenon of a bias sample remains to be confirmed. The traditional belief quoted that hypogonadism, diabetes mellitus and hypothyroidism are the 3 most common endocrine deficient states caused by iron overload. The current study suggested that adrenal insufficiency might in fact more common than diabetes and hypothyroidism. It also implies that most of these patients might have been under-diagnosed previously. It appeared that serum ferritin level failed to predict the occurrence of this condition. Even most of these patients have relatively benign outcome but we know that adrenal insufficiency can be aggravated by stress such as infection. Therefore, we should not take it lightly and include the screening of fasting cortisol in the regular monitoring regimen for our thalassaemia patients may have to be considered.

Another article described a condition known as benign acute childhood myositis. It is supposed to be a common but often under-diagnosed condition. Shum CO et al. analyzed their case cohort in a regional hospital of Hong Kong and found that around 2 to 5 new cases were diagnosed annually. The diagnosis has to follow a list of pre-set criteria including: 1) acute onset of pain over the calf muscle; 2) preceding febrile illness within 2 weeks from the onset of the symptoms; and 3) elevated serum CPK. Some borderline conditions might have been overlooked and the association with either influenza A (50%) or influenza B (17%) can serve as a hint. While most of the children with this condition can achieve spontaneous remission without any long term sequelae, knowing this condition and its natural course can help us to avoid unnecessary investigations and treatments.

In the report of Zhou HQ et al. related to the experience in using extracorporeal membrane oxygenation therapy (ECMO) in a tertiary referral centre in Zhejiang, the outcome of a group of children with acute fulminant myocarditis has been studied. ECMO has become a standard practice for children who suffer from acute fulminant myocarditis since 90's. With timely implementation of ECMO, many children who suffered from severe form of myocarditis can be salvaged nowadays. Interestingly, more than 40% of the reported cohort (3 out of 7 patients) actually suffered from cardiac arrest and required cardiac pulmonary resuscitation prior to ECMO. Whether such suboptimal clinical state was due to the delay of ICU referral has to be clarified. Currently, only one hospital in Hong Kong can provide such service and we noticed a learning curve in the referral pattern. For such specialised service involving only a handful of patients each year, we have to concentrate the patients to centre with cardiac surgery service readily available. In the future Children Hospital of Hong Kong, one has to pay attention to this limitation under the new setting.

Finally, acute pharyngitis is a common childhood problem and is considered the "bread and butter" for the private paediatricians in their daily practice. However, when should we start antibiotic treatment for this group of children remains a highly controversial clinical practice issue. It is because antibiotics are only effective for around 30% of patients mainly for those who suffered from Group A streptococcal infection. Chan JYC and his colleagues of the HKCP suggested the usage of rapid antigen detection test to achieve early diagnosis of Group A streptococcal infection. This can guide us on subsequent antibiotic usage. Although we aware of the limited access to this test currently, even in the pubic hospital setting, establishing the rapid test should be a relatively easy task if paediatricians working in both public and private sectors are committed to this approach. This practice recommendation will greatly reduce unnecessary antibiotics usage and can potentially minimise the emergence of antibiotic resistant bacterial strain.

The current issue also captures the essence of the 2nd Annual Scientific Meeting of HKCP held in December 2014. Reader can use it as a reminder of what they learnt in the last meeting by going through the Proceeding which recorded not only the abstracts of the oral and poster presentations but also the synopsis of the 3 interesting symposia. The case scenario and the key discussion points of the symposia were vividly summarised. Our journal will continue to serve as an archive of this important meeting in the future.

From the awareness of the diagnosis of benign acute childhood myositis, availability of the rapid test for acute pharyngitis, the life saving option of ECMO for acute fulminant myocarditis, and finally the need of monitoring adrenal complications in thalassaemia patients, all of these are current basic practicing skills for a paediatrician and we should pay attention to. The HKJP and the Annual Scientific Meeting of the HKCP will continue to serve as an accessible media to facilitate the information dissemination of up-to-date paediatric practice in the future.

GCF Chan
Chief Editor

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