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To compare the chronic ocular manifestations in Stevens–Johnson syndrome and toxic epidermal necrolysis patients from a 15-year cohort. All SJS and TEN patients admitted to our burn intensive care unit between 1999 and 2014 were invited for assessment. Slit-lamp examination was performed, and ocular condition was graded according to the Sotozono scoring System, which depended on the extent of cornea, conjunctiva and lid involvement. Tear osmolarity was also measured. A total of 18 SJS and 4 TEN cases with an average of 92 and 135 months from disease onset were included. The average age of onset was 46.4 ± 16.6 in SJS and 43.5 ± 19.3 in TEN patients. The LogMAR visual acuity was 0.209 ± 0.591 in SJS and 0.489 ± 0.688 in TEN patients (p = 0.048). The average total Sotozono score was 3.75 ± 7.32 in SJS and 6.88 ± 9.49 in TEN (p = 0.358). Neither the age of onset (p = 0.787), length of follow-up (p = 0.256) nor disease type (SJS vs TEN, p = 0.188) predicted the Sotozono score. There was a statistically significant correlation between Sotozono score and LogMAR VA (r s = 0.437, p = 0.003). The average total Sotozono score was higher in the TEN group than in the SJS group, but the difference was not statistically significant. Nevertheless, the score correlated with the visual acuity which was statistically worse in the TEN group.

Purpose Drug-induced agranulocytosis is a rare but life-threatening adverse drug reaction. Its epidemiology in Chinese is largely unknown. This study aimed to estimate the incidence, mortality, and risk of the drugs associated with agranulocytosis in Hong Kong Chinese. Methods A population-based case-control study was conducted using the Clinical Data Analysis and Reporting System, a database managed by the Hong Kong Hospital Authority. Patients with drug-induced agranulocytosis from 1 January 2004 to 31 December 2013 were identified. World Health Organization causality assessment was used to evaluate the possible drug aetiology of each case. Odd ratios (ORs) of the drug exposure were calculated using exact conditional logistic regression. Results 155 cases of drug-induced agranulocytosis were identified. Mean age was 51.4 years and 95 cases were female. Incidence rate was estimated to be 2.2 cases per million person-years and the all-cause mortality of patients with drug-induced agranulocytosis was 3.9%. Among the cases, the most common associated drug groups were antithyroid drugs (41.9%), antimicrobials (20%), anticonvulsants (10.3%), and antipsychotics (6.5%). Carbimazole had the highest risk of agranulocytosis (adjusted OR 416.7, 95% Confidence Interval (CI) 51.5 – 3372.9) with an incidence of 9.2 (95% CI 6.9 - 12.1) per 10,000 users and 3.6 (95% CI 2.7 - 4.8) per 10,000 user-years. Other drugs with significant risk included cephalosporins, clozapine, penicillins, phenytoin, and propyl thiouracil. Conclusions The incidence and mortality in Hong Kong Chinese were relatively low compared to Caucasians. Antithyroid drugs were the most common Its epidemiology in Chinese is largely unknown. This study aimed to estimate the incidence, mortality, and risk of the drugs associated with agranulocytosis in Hong Kong Chinese. Methods A population-based case-control study was conducted using the Clinical Data Analysis and Reporting System, a database managed by the Hong Kong Hospital Authority. Patients with drug-induced agranulocytosis from 1 January 2004 to 31 December 2013 were identified. World Health Organization causality assessment was used to evaluate the possible drug aetiology of each case. Odd ratios (ORs) of the drug exposure were calculated using exact conditional logistic regression. Results 155 cases of drug-induced agranulocytosis were identified. Mean age was 51.4 years and 95 cases were female. Incidence rate was estimated to be 2.2 cases per million person-years and the all-cause mortality of patients with drug-induced agranulocytosis was 3.9%. Among the cases, the most common associated drug groups were antithyroid drugs (41.9%), antimicrobials (20%), anticonvulsants (10.3%), and antipsychotics (6.5%). Carbimazole had the highest risk of agranulocytosis (adjusted OR 416.7, 95% Confidence Interval (CI) 51.5 – 3372.9) with an incidence of 9.2 (95% CI 6.9 - 12.1) per 10,000 users and 3.6 (95% CI 2.7 - 4.8) per 10,000 user-years. Other drugs with significant risk included cephalosporins, clozapine, penicillins, phenytoin, and propyl thiouracil. Conclusions The incidence and mortality in Hong Kong Chinese were relatively low compared to Caucasians. Antithyroid drugs were the most common implicated drug class and carbimazole had the highest risk of agranulocytosis.

Background and objectives Photo-aging in Chinese often presents with benign pigmentary lesions. Q-switched lasers for pigmentary lesions in Asians had reported a risk of post-inflammatory hyperpigmentation (PIH) up to 25%. Longer pulse widths in the millisecond domains were advocated with reduced risk of PIH. Recently, picosecond lasers of various wavelengths were introduced with proven efficacy in tattoo removal. The objective of this study is to assess the efficacy and safety of a novel picosecond 755-nm alexandrite laser for the treatment of benign pigmented lesions in Asians retrospectively. Methods A list of all patients who received picosecond 755-nm alexandrite laser treatment at a private dermatology center in Hong Kong was included. Those who had any other laser or topical treatment during the period of picosecond laser treatment were excluded. The age, skin phototype, type of pigmentary lesion, number of treatments performed was recorded. The baseline and most recent standardized photographs were assessed by trained physicians for comparison. A score of 0–4, representing poor 0–24%, fair 25–49%, good 50–74%, excellent 75–95%, and complete 95%+ improvement was given. Adverse events associated with the laser treatment were also recorded. All patients were followed up until 6 months after the last laser session. Results A total of 13 subjects were included in the present study. The number of treatment sessions received ranged from one to seven. The benign pigmentary lesions consist of Nevus of Ota, cafe-au-lait patches, lentigines, Becker's nevus, Hori's macules, and nevus spilus. Among patients with Nevus of Ota, one patient achieved complete clearance after four treatments and two other patients had excellent clearance after three and four sessions, respectively. Patients with cafe-au-lait had fair to good clearance after one to seven treatment sessions. One patient who has Hori's macules was resistant to laser treatments and a fair response was achieved after eight treatments. In the present series, two patients (4.8%) developed transient hypopigmentation, which had improved upon subsequent follow-up in both cases and none had post-inflammatory hyperpigmentation. Conclusions The novel picosecond 755-nm alexandrine laser is effective for the treatment of benign pigmentary lesions in Chinese, especially for the clearance of Nevus of Ota. Picosecond laser appears to be associated with a much lower risk of PIH for treatment of pigmentary lesions in Asians. Lasers Surg. Med. 48:23–29, 2016. © 2015 Wiley Periodicals, Inc.

Background and Objective Several studies have been published on the first generation non-thermal focused ultrasound with an average improvement of 0–3.95 cm reported [1,2]. We aim to investigate the efficacy of the second-generation non-thermal focused ultrasound device with a combined radiofrequency hand piece. With the addition of radiofrequency energy, the temperature of the adipose tissue is raised before focused ultrasound is applied. This facilitates the mechanical disruption of fat cells by focused ultrasound. Study Design and Methods Twenty subjects were recruited and underwent three treatments biweekly. Caliper reading, abdominal circumference, and standardized photographs were taken with the Vectra® system at all visits. We aim to have the subjects stand and hold the same position and the photograph taken after exhalation. Caliper and circumference measurements carry uncertainty. It is impossible to eliminate all uncertainties but can be improved by having the same trained physician assistant perform the measurement at the same site and taking an average of three readings. Pain score and satisfaction were recorded by means of the visual analogue scale. The efficacy is defined by a statistically significant improvement in circumferential improvement based on intention-to-treat analysis. Results Seventeen subjects completed the treatment schedule. Abdominal circumference showed statistically significant improvement at 2 weeks post-second treatment (P = 0.023) and almost all subsequent follow-ups. Caliper readings were statistically significant at 2 weeks post-second treatment (P = 0.013) and almost all follow-ups. The mean pain score reported was 2.3 on the visual analog scale and 6% were unsatisfied with the overall treatments. Six incidents of wheal formation appeared immediately after treatment all of which subsided spontaneously within several hours. Conclusion The combination non-thermal focused ultrasound and radiofrequency device is effective for improving body contour in Asians. Lasers Surg. Med. 48:203–207, 2016. © 2015 Wiley Periodicals, Inc.

Background Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare but life-threatening conditions that initially affect the skin and mucous membranes. The aim of this study was to compare the acute ocular manifestations between SJS and TEN. Methods The initial presenting ophthalmic records of patients with either SJS ( = 30% involvement), who were treated at one tertiary burn center in Hong Kong between 1999 and 2014, were retrospectively analyzed and compared. Results A total of 20 SJS and 12 TEN cases were included. All were drug-induced. The patient demographics and treatment received were comparable. Overall, 40% of SJS and 75% of TEN patients had acute ocular surface inflammation. When comparing the two groups, there was a significant difference in the number of cases with mild involvement (5% in SJS, 42% in TEN, p = 0.01), while no statistically significant differences were found (p > 0.05) comparing between the moderate (15% in SJS, 0% in TEN) and severe groups (20% in SJS, 33% in TEN). Conclusions Ocular surface inflammation was common during the acute phase in both SJS and TEN. TEN had a significantly higher number of cases with mild ocular involvement when compared with SJS, but no significant difference between the number of moderate and severe cases between the two groups.

Background and Objectives High-intensity focused ultrasound (HIFU) is a noninvasive technology for body contouring. HIFU is focused within the subcutaneous adipose tissue, causing coagulative necrosis and cell death. The objective of this study is to evaluate the effectiveness of a HIFU device for sculpting of the abdomen. Materials and Methods The system has a set focal depth of 1.3 cm. Twelve subjects with adipose thickness no less than 2.5 cm who met the screening criteria were recruited. Each subject received one treatment to the abdomen. The total fluence used per site was 150–165 J/cm2 with a mean of 161 J/cm2. The waist circumference at iliac crest and the point of maximum circumference were recorded at baseline, 4, 8, and 12 weeks post-treatment, as well as their weight and BMI. Subjects' rating on comfort level and satisfaction were collected via questionnaires at every follow-up. Standardized photographs were also taken with the Canfield System® at each visit. Results Seven out of 12 subjects were satisfied with the outcome and 9 out of 12 would recommend this treatment to their friends and family. There was statistically significant improvement in the waist circumference measured at both the iliac crest (P-value 0.013, 0.002, 0.005) and maximum waistline (P-value 0.003, 0.034, 0.023) at 4, 8, 12 weeks post-treatment. Spearman's rho for correlation of energy level versus improvement showed that at 12 weeks post-treatment follow-up, the improvement significantly correlated with the total fluence per treatment (P-value 0.041). The higher the total fluence delivered, the larger the decrease in waist circumference. Conclusions High-intensity focused ultrasound effectively decreases waist circumference in Chinese. The higher the total fluence delivered, the larger the decrease in waist circumference was observed. Lasers Surg. Med. 46:263–269, 2014. © 2014 Wiley Periodicals, Inc.

Immunodeficiency due to anti-interferon-gamma autoantibody (anti-IFN-γ autoAb) is an emerging adult-onset immunodeficiency syndrome predominantly found in Southeast Asians. It is associated with severe or disseminated infections caused by non-tuberculous mycobacteria (NTM) and other opportunistic pathogens. We describe 3 patients with anti-IFN-γ autoAb who developed reactive and infective dermatoses, and thoroughly review the existing literature on dermatoses associated with the immunodeficiency syndrome. Case 1 developed Sweet's syndrome associated with Mycobacterium chelonae lymphadenitis and penicilliosis. Case 2 suffered from multiple episodes of lobular panniculitis during recurrent infections by NTM, Penicillium marneffei and Burkholderia pseudomallei. Both cases responded to immunomodulating agents including corticosteroid and non-steroidal anti-inflammatory drugs. Case 3 had direct skin invasion by M. chelonae and responded to prolonged anti-mycobacterial therapy. A novel working algorithm is proposed for the diagnosis and treatment of these patients who may be encountered by the dermatologist and histopathologist in clinical practice.

Drug-induced agranulocytosis is a rare but life-threatening adverse drug reaction. Its epidemiology in Chinese is largely unknown. This study aimed to estimate the incidence, mortality, and risk of the drugs associated with agranulocytosis in Hong Kong Chinese.A population-based case-control study was conducted using the Clinical Data Analysis and Reporting System, a database managed by the Hong Kong Hospital Authority. Patients with drug-induced agranulocytosis from 1 January 2004 to 31 December 2013 were identified. World Health Organization causality assessment was used to evaluate the possible drug aetiology of each case. Odd ratios (ORs) of the drug exposure were calculated using exact conditional logistic regression.A total of 155 cases of drug-induced agranulocytosis were identified. Mean age was 51.4 years, and 95 cases were female. Incidence rate was estimated to be 2.2 cases per million person-years, and the all-cause mortality of patients with drug-induced agranulocytosis was 3.9%. Among the cases, the most common associated drug groups were antithyroid drugs (41.9%), antimicrobials (20%), anticonvulsants (10.3%), and antipsychotics (6.5%). Carbimazole had the highest risk of agranulocytosis (adjusted OR 416.7, 95% confidence interval (CI) 51.5-3372.9) with an incidence of 9.2 (95%CI 6.9-12.1) per 10 000 users and 3.6 (95%CI 2.7-4.8) per 10 000 user-years. Other drugs with significant risk included cephalosporins, clozapine, penicillins, phenytoin, and propyl thiouracil.The incidence and mortality in Hong Kong Chinese were relatively low compared to Caucasians. Antithyroid drugs were the most common implicated drug class, and carbimazole had the highest risk of agranulocytosis. Copyright © 2017 John WileySons, Ltd.

Summary What is known and objective Hydralazine is an effective antihypertensive drug which acts by vasodilatation. It is well known to cause drug-induced lupus erythematosus. Nevertheless, the overall safety profile is good and cutaneous adverse effects are uncommon. To the best of our knowledge, hydralazine has never been reported to cause Stevens–Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN). Case summary We herein report the first case of hydralazine-induced TEN in a patient with end-staged renal failure. Despite meticulous wound management and intensive medical care, the patient died of a sudden cardiac arrest on day 10 of admission. What is new and conclusion We speculate that patients with renal failure may be predisposed to a higher risk of allergy to drug entities that are rarely associated. Physicians should be aware that hydralazine can be a potential cause for severe allergic reaction such as SJS or TEN, particularly in the setting of poor renal excretory function. Patient education and cautious monitoring by physicians are essential for early diagnosis and hence successful management of the life-threatening condition.

Several studies have been published on the first generation non-thermal focused ultrasound with an average improvement of 0-3.95 cm reported. We aim to investigate the efficacy of the second-generation non-thermal focused ultrasound device with a combined radiofrequency hand piece. With the addition of radiofrequency energy, the temperature of the adipose tissue is raised before focused ultrasound is applied. This facilitates the mechanical disruption of fat cells by focused ultrasound.Twenty subjects were recruited and underwent three treatments biweekly. Caliper reading, abdominal circumference, and standardized photographs were taken with the Vectra(®) system at all visits. We aim to have the subjects stand and hold the same position and the photograph taken after exhalation. Caliper and circumference measurements carry uncertainty. It is impossible to eliminate all uncertainties but can be improved by having the same trained physician assistant perform the measurement at the same site and taking an average of three readings. Pain score and satisfaction were recorded by means of the visual analogue scale. The efficacy is defined by a statistically significant improvement in circumferential improvement based on intention-to-treat analysis.Seventeen subjects completed the treatment schedule. Abdominal circumference showed statistically significant improvement at 2 weeks post-second treatment (P = 0.023) and almost all subsequent follow-ups. Caliper readings were statistically significant at 2 weeks post-second treatment (P = 0.013) and almost all follow-ups. The mean pain score reported was 2.3 on the visual analog scale and 6% were unsatisfied with the overall treatments. Six incidents of wheal formation appeared immediately after treatment all of which subsided spontaneously within several hours.The combination non-thermal focused ultrasound and radiofrequency device is effective for improving body contour in Asians.

High-intensity focused ultrasound (HIFU) is a noninvasive technology for body contouring. HIFU is focused within the subcutaneous adipose tissue, causing coagulative necrosis and cell death. The objective of this study is to evaluate the effectiveness of a HIFU device for sculpting of the abdomen.The system has a set focal depth of 1.3 cm. Twelve subjects with adipose thickness no less than 2.5 cm who met the screening criteria were recruited. Each subject received one treatment to the abdomen. The total fluence used per site was 150-165 J/cm(2) with a mean of 161 J/cm(2) . The waist circumference at iliac crest and the point of maximum circumference were recorded at baseline, 4, 8, and 12 weeks post-treatment, as well as their weight and BMI. Subjects' rating on comfort level and satisfaction were collected via questionnaires at every follow-up. Standardized photographs were also taken with the Canfield System® at each visit.Seven out of 12 subjects were satisfied with the outcome and 9 out of 12 would recommend this treatment to their friends and family. There was statistically significant improvement in the waist circumference measured at both the iliac crest (P-value 0.013, 0.002, 0.005) and maximum waistline (P-value 0.003, 0.034, 0.023) at 4, 8, 12 weeks post-treatment. Spearman's rho for correlation of energy level versus improvement showed that at 12 weeks post-treatment follow-up, the improvement significantly correlated with the total fluence per treatment (P-value 0.041). The higher the total fluence delivered, the larger the decrease in waist circumference.High-intensity focused ultrasound effectively decreases waist circumference in Chinese. The higher the total fluence delivered, the larger the decrease in waist circumference was observed.

Introduction: Toxic Epidermal Necrolysis (TEN) is a rare but potentially life-threatening muco-cutaneous condition associated with idiosyncratic hypersensitivity to certain drugs. Ophthalmic involvement is common, typically affecting the ocular surface and eyelids. Survivors often suffer from resulting bilateral blindness and ocular dryness or pain. Objective: To report the successful management of severe ocular surface disease during the acute stage of toxic epidermal necrolysis using early amniotic membrane transplantation on both eyes in a Chinese paediatric patient. Design: Interventional case report Case report: A 15 year-old Chinese girl was transferred to the intensive care unit of Queen Mary Hospital, Hong Kong with TEN after taking oral cefuroxime and diclofenac. She developed bilateral keratoconjunctivitis, diffuse corneal epithelial defects (80-90% of cornea surface) and later bilateral symblephara. After initial treatment with daily rodding, topical lubricants, steroids and antibiotics, there was no improvement in her condition. Bilateral amniotic membrane transplantation (AMT) was performed over the cornea, fornix, tarsal and bulbar conjunctiva on day 10 of illness. On discharge from the hospital (post-operative week 7), the patient had pinhole visual acuity of 6/7.5 in the right eye and 6/6 the left eye. She was eventually weaned off all topical medication Visual acuity eventually recovered to 6/6 in both eyes by week 20 after surgery. There was mild residual forniceal symblepharon and eyelid margin keratinization. She continues to require regular lubricants for her chronic ocular surface condition. Conclusion: Early use of AMT minimized ocular damage and prevented severe vision loss in a Chinese pediatric patient with severe bilateral ocular surface inflammation secondary to TEN. Effective management is dependent on early and active communication between the patient’s family, pediatricians, intensive care physicians and ophthalmologists.

A 59 year old Chinese man was admitted for a blistering eruption. He had stopped using injected drugs and drinking alcohol three years ago after having previously drunk two cans of beer, equivalent to 2-3 units of alcohol, a week. Two years ago, he had been diagnosed with chronic hepatitis C virus (HCV) infection and had recently been diagnosed with pulmonary tuberculosis, for which he was started on isoniazid 600 mg, rifampicin 600 mg, ethambutol 1.5 g, and pyrazinamide 2 g three times a week. Three days after starting this treatment, he developed a progressive blistering eruption over his neck and both upper limbs, which affected his lateral arms and forearms but spared the oral mucosa and other parts of his body. Nikolsky’s sign was negative. He stopped all the drugs two weeks later because of a suspected drug eruption. He had a normal blood cell count with a haemoglobin of 120 g/L (reference range 124-168). Liver enzymes were raised, with alanine aminotransferase at 65 U/L (7-36), aspartate aminotransferase at 96 U/L (14-30), alkaline phosphatase at 158 U/L (32-93), and γ-glutamyl transferase at 648 U/L (11-62), as was total bilirubin at 63 µmol/L (14-23). Liver ultrasound was normal and his serum α fetoprotein was 2 ng/ml (

A 70-year-old woman presented with a 4-month history of right leg ulcers (upper left panel). Biopsy showed infiltration by abnormal medium to large size lymphoid cells (upper left middle panel, haematoxylin eosin). There was no obvious angiocentricity or angioinvasion. The abnormal lymphoid cells were positive for cytoplasmic CD3 epsilon (upper right middle panel, immunoperoxidase), CD56 (upper right panel), and T-cell intracellular antigen-1. In-situ hybridization for EpsteinBarr virus encoded RNA was positive. Overall features were consistent with extranodal natural killer (NK)/T-cell lymphoma, nasal type. She was treated with chemotherapy. After the second course, blistering skin eruptions occurred over the trunk, buttocks and legs (lower left panel). A skin biopsy revealed erythema multiforme-like areas with scattered cytoid bodies (white arrow) throughout all levels of the epidermis, and areas with pemphigus vulgaris-like changes showing early suprabasal acantholysis (black arrow) (lower right panel). Direct immunofluorescence studies showed weak intercellular and basement membrane staining with both C3 and IgG, confirming the diagnosis of paraneoplastic pemphigus (PNP). She deteriorated progressively and died 3 months after presentation despite immunosuppression and further chemotherapy. Paraneoplastic pemphigus characteristically presents as painful oral and mucosal ulcerations, with concomitant skin involvement simulating pemphigus vulgaris or erythema multiforme. Bronchiolitis obliterans may occur and can be fatal. PNP is caused by serum autoantibodies against epithelial proteins, particularly the plakin family, leading to epithelial injury in the skin, and mucosal and bronchial linings. Therefore, the underlying neoplasms are almost exclusively of B-cell lineage. However, T-cells and CD56+ NK cells have also been postulated to be effectors of PNP. This case illustrated the rare association between NK cell lymphoma and PNP, suggesting therefore that NK cells might be involved in the pathogenesis of PNP. Clinicians should also be alert to the possibility of PNP in lymphomas not of B-cell lineage.

To analyse the association between body mass index (BMI) and breast cancer risk among Chinese women in Hong Kong. Methods: We conducted a population-based case control study of breast cancer in June 2002. Standardized questionnaires concerning BMI and other anthropometric data were completed by patients at the Queen Mary Hospital (QMH). The cases were 198 women aged 24-85 years who had documented breast cancer in 1995-2000 by triple assessment criteria, and the controls were 353 women who were followed up at QMH for benign breast disease after breast cancer had been excluded by triple assessment. The controls were frequency-matched to the cases by age. Results: BMI at diagnosis was positively correlated with the risk of breast cancer among postmenopausal women (p < 0.001 for trend). Also, when compared with women with a low BMI (< 19), women with a BMI of 23-27 and 27-31 had a 1.73-fold (95% confidence interval, CI, 1.04-2.86) and 2.06-fold (95% CI, 1.08-3.93) increased risk of breast cancer, respectively, after adjustment for non-anthropometric risk factors. BMI at diagnosis, however, was not related to the risk of breast cancer among premenopausal women. The odds ratios for premenopausal women with a BMI of 23-27 and 27-31 were 1.5 (95% CI, 0.82-2.71) and 1.32 (95% CI, 0.39-4.43), respectively. Furthermore, present BMI and BMI 5 years before diagnosis were poorly associated with breast cancer risk among both pre- and postmenopausal women. Conclusion: Weight control in obese women may be an effective measure for breast cancer prevention in postmenopausal women.