Though Apparently Minor, Yet Significant
In medical practice, we often pay attention to the "chief compliant" and the "cardinal signs" and then plan our investigations and management. However, there may be some relatively minor symptoms or disease processes that we inadvertently ignore. The original articles of this issue focus on some apparently "minor" aspects of common disorders or even minor illnesses but they are in fact significant for our patients.
Different aspects of daily activity are affected in children with Autism Spectrum Disorder (ASD). The commonly mentioned problems are poor social interacting skill, repetitive behaviour, hyperactivity and poor attention span. Disrupted sleeping pattern is also frequently encountered in these children but it is often ignored. Yu XT et al provided us an insight in applying non-invasive mean to intervene the abnormal sleeping habit of children with ASD by using extended parent-based behavioural education training. In fact, sleeping disorders affects one's learning process significantly and may impact on the mental development of the affected children. Aberrant sleeping habits do not confine to children with ASD, it also affects many non-ASD children and adolescents nowadays. Similar training can potentially apply to "normal" children with abnormal sleeping pattern.
When we talk about growth hormone therapy, we tend to think of its application on short stature and suboptimal physical growth. From the paper by Lee JY, et al, it illustrated the multi-tasks of growth hormone. Using a Mouse Model of Parder-Willi syndrome, it demonstrated that growth hormone can modulate the expression of GABABR1 and GH/IGH axis of genes in the cerebellum. It provides us some scientific evidence that the function of growth hormone is far beyond just controlling physical growth but also plays an important role in neurological development. In fact, growth hormone has been shown to improve cognitive function in both children and adults with Parder-Willi syndrome. Growing evidence suggests that growth hormone replacement in adults with growth hormone deficiency, even after they achieve their final height, can improve their bodily function in many aspects including acquired metabolic syndrome. A recent systematic review suggests that growth hormone replacement in elderly subjects with growth hormone deficiency can decrease their LDL cholesterol levels and improves their quality of life.1
The report of Zheng YB gave us a very good background data on the prevalence and effects of primary nocturnal enuresis in Chinese children. This is a common but often neglected topic since it appears to have little impact on the physical health. Some may not consider it as a disease process. However, it does have an impact on the psychosocial aspect of the affected children and their families. In this study, it showed that the prevalence of bed wetting at least once a month occurred in 4% of children and is higher in younger children (7.6% in children <8 years) with a decreasing trend over the older age group (1.2% in children >10 years). It also found that the prevalence of primary nocturnal enuresis was quite similar in the 2 districts of Shanghai City. These 2 districts have different demographic characteristics and one is more remote with a large migrant population. In addition to provide us the basic epidemiological data, it reflected that such condition annoys the parents more than the children. For the management, most of the children were just given advice to adopt a regular life style to promote self healing, 17.5% were given medications but only 6.5% were given alerter or alarms for bladder training. This reflects that despite 1/3 of them sought medical advice, only a very small proportion was presribed the current recommended approach. We believe that the prevalence of children with primary nocturnal enuresis will be quite similar in Hong Kong and how our primary health care physicians and paediatricians manage this condition remains to be investigated.
The invited article by Prof J Neu illustrated another "minor" and yet significant factor in our life: our own body microbes. Ever since the perinatal period, human host starts to have intimate relationship with the microbes within our body system. It is getting more evidence that they present as commensals and symbionts rather than pathogens. We learnt that in the past that the production of vitamin K and the formation of blood group antibodies are dependent on the gut microbes. Now we know that the change in the microbes profile has been implicated in disease process ranging from necrotising enterocolitis to subsequent autoimmune diseases. There are distinctly different microbial patterns between healthy individuals and patients who suffer from inflammatory bowel diseases. While we still have to verify whether such microbial pattern plays the role in either etiology or consequence of various diseases, the "commensals" within our body may not be just bystander as we used to think. They are important contributory factors of our health and we have to pay attention to such changing pattern in the future.2 The commensals profile may help us in either diagnosis or even management of some autoimmune diseases in the future.
Therefore, apparently minor manifestation, hormone, disease or even microbials can play a significant role in our diagnosis and management algorithm. Only if we pay attention to details, we can grip the holistic view of what our patients really need.
1. Kokshoorn NE, Biermasz NR, Roelfsema F, Smit JW, Pereira AM, Romijn JA. GH replacement therapy in elderly GH-deficient patients: a systematic review. Eur J Endocrinol 2011;164:657-65.
2. Ho JT, Chan GCF, Li JC. Systemic effects of gut microbiota and its relationship with disease and modulation. BMC Immunol 2015;16:21.