GCF Chan

This issues we have several articles on some relatively common paediatric problems. The studies either directly touched on the latest advance in management or provided us some background information so new therapeutics can be applied in the future.

Ventricular septal defect (VSD) and patent ductal arteriosus are the 2 most common types of congenital heart problems. Since a proportion of VSD can close spontaneously, the prediction of which lesions may close remains a topic of repeated debate. The closure rate does not only depend on the type of the lesion, but also the size and the underlying hemodynamic conditions. It will be hard to draw a definite conclusion. In addition, the length of time for the observation is another important determinant as well, as shown in the single centre longitudinal cohort review by Law TY et al, a much higher spontaneously closure rate was observed if we extend the observation period from 2 years to 6 years. Of interest, more than half of the peri-membranous VSD can close spontaneously. For the muscular VSD, if the size is big, the chance of spontaneous closure will drop significantly. The main limitation of this study is that the more sever VSD might be referred out for surgical treatment so only the milder form of lesions were allowed to be observed over a longer period. In recent years, with the advance in relative less invasive approach, more patients can undergo hybrid method of VSD closure using minimal invasive technique. This can reduce the surgical risk and hasten recovery. As a result, more parents may select earlier intervention and this may affect the proportion of those choosing observation as well.

The incidence of both type 1 and type 2 diabetes mellitus (DM) have been increasing significantly over the past decade. The sad fact about type 1 DM is that once it is established, patients require lifelong insulin injection, frequent blood monitoring and diet restriction. Therefore, depression can occur not only during the acute phase but can run in a chronic course then it may lead to problem in compliance and disease control. Chan CSY et al utilised a validated questionnaire, Patient Health Questionnaire-9 (PHQ-9), on a cohort of mixed DM (type 1 & 2) patients and found that almost 18% of them have depression. The risk factors included high body mass index, presence of diabetic-related complications, more frequent hospital admissions, poor family dynamics and parent-child relationship problems, known psychological or behavioural problems. Of interest, the use of continuous glucose monitoring system was associated with lower risk in developing depressive symptoms. Therefore, for high-risk patients the transcutaneous monitoring system should be used. The monitoring system provides real time glucose assessment, and the data can be shown and stored in patient's mobile phone. Since it does not require daily multiple punctures for glucose monitoring, the compliance is far better so less depression is expected. Due to the instant feedback, for example after eating, the glucose control is also found to be better.

Advance in medical technology also affecting the surgical practice and one of such examples is Da Vinci robotic surgical system. Robot-assisted surgery is considered to have better accuracy and stability as compared to conventional laparoscopic-assisted surgery. In the study by Yang B et al they showed robotic surgery had less blood loss and shorter hospital stay for Meckel's diverticulum in children. But there was no significant difference in operative time, fasting time, or postoperative complications between the two approaches. However, one of the major drawbacks is the cost, robot-assisted surgery is significantly more expensive than laparoscopic-assisted surgery. We expect with time, especially in terms of rapid advancement in artificial intelligence (AI) and robotic technique, the application of robotic surgery will further increase. As more experts are using robotic surgery, we expect the cost will eventually come down due the higher utilisation rate.

Saliva drooling is an embarrassing functional defect socially. However, it does not generate enough attention from the clinicians because it is not a "life and death" situation. It is common among physical or mental retarded children, of whom many other comorbid condition already caught the attention of the healthcare providers. Dr Hau SY et al reviewed the result of their Sialorrhea Improvement Program in a local hospital. The program involves both paediatric neurologists and occupational therapists. Affected children received a pre-designed set of treatments including occupational therapy, transdermal scopolamine and/or botulinum toxin injection. Different assessment protocols were adopted for anterior drooling group and posterior drooling group. Analysis demonstrated significant improvements in patients who were given transdermal scopolamine and botulinum toxin injection. Botulinum toxin A injection significantly decreased the aspiration pneumonia rate of patients suffering from posterior drooling. Mild side effects in terms of allergy and transient tiredness were reported in some patients who received transdermal scopolamine. None of the patient with botulinum injection developed clinically significant side effects. Of note, a new promising agent known as dihydroergotoxine mesylate has a longer duration of action and lesser side effects. It is currently approved for use in adult population which may replace scopolamine in the future for both adult and children.

From time to time, we must review the practice of old and common paediatric problems. There may be new development that can minimise the surgical risks, improve the efficacy, and enhance the disease control.