Glycated matrix up-regulates inflammatory signaling similarly to Porphyromonas gingivalis lipopolysaccharide.

BACKGROUND AND OBJECTIVE: Hyperglycemia and advanced glycation end-products (AGEs) have been hypothesized as the etiologic factors of diabetic periodontitis. The aim of this study was to clarify in greater detail the patterns of AGE-mediated periodontal inflammation under various physiological conditions. MATERIAL AND METHODS: The deposition of AGEs and expression of the receptor for AGEs (RAGE) were identified by immunohistochemistry in Sprague-Dawley rats with experimentally induced periodontitis or diabetes. Human periodontal ligament cells (PDLCs) and mesenchymal stem cells (MSCs) were cultured under simulated conditions of hyperglycemia, Porphyromonas gingivalis lipopolysaccharide (LPS) stimulation and matrix glycation. Cell viability and expression of toll-like receptors (TLRs), Rage, an inflammatory signaling initiator (nuclear factor kappa light chain enhancer of activator ß cells), an oxidative stressor (heme oxygenase-1) and collagen synthesis (type I and type IV) genes were evaluated. RESULTS: The deposition of AGEs and the expression of Rage were evident in the inflamed periodontal tissues in all rats and appeared to be enhanced in rats with diabetes. Matrix glycation augmented cytotoxicity, up-regulated RAGE and TLRs in both PDLCs and MSCs, and significantly activated downstream inflammatory signaling in MSCs. Oxidative stress was significantly increased under matrix glycation in both PDLCs and MSCs and was significantly increased at a high-glucose concentration in MSCs. A consistent decrease in expression of type I and type IV collagens was observed in MSCs, but a delayed reduction was noted in PDLCs. CONCLUSIONS: Matrix glycation modulated cell behavior to induce inflammation equivalent to that produced by incubation with P. gingivalis LPS. Periodontal inflammation also led to matrix glycation, thus demonstrating a definite interaction between diabetes and periodontitis.

Asymptomatic urethral infection in male sexually transmitted disease clinic attendees.

The purpose of this study is to determine the prevalence of asymptomatic male patients with urethral infections attending a government sexually transmitted infection clinic in Hong Kong and their microbiological profile. A total of 274 consecutive male patients without any symptoms for urethral infections were recruited. A questionnaire was used to record the symptoms, sexual history and demographics. Further assessment, including urethral smear for Gram stain, gonococcal culture and polymerase chain reaction (PCR) for Chlamydia trachomatis (CT), Mycoplasma genitalium (MG) and Ureaplasma urealyticum (UU) were performed. In 274 asymptomatic patients, 36 patients had non-gonococcal urethritis (NGU) and two patients had positive gonococcal culture. Among the asymptomatic patients with NGU, there were 6 (16.6%), 10 (22.8%) and five (13.9%) patients with positive PCR for CT, UU and MG, respectively. In addition, there were 14 asymptomatic patients with positive PCR for CT but without evidence of NGU. In conclusion, urethral infections were identified in a significant number of asymptomatic male patients and therefore, routine screening for this group is warranted.

Role of Mycoplasma genitalium and Ureaplasma urealyticum in non-gonococcal urethritis in Hong Kong.

OBJECTIVE: To determine the association of Mycoplasma genitalium and Ureaplasma urealyticum in symptomatic male patients presenting with non-gonococcal urethritis in a sexually transmitted infection clinic in Hong Kong. DESIGN: Cross-sectional study. SETTING: A sexually transmitted infection clinic, Department of Health, Centre for Health Protection, Hong Kong. PATIENTS: A cohort of consecutive new male patients attending the government sexually transmitted infection clinic. MAIN OUTCOME MEASURES: Prevalence of Mycoplasma genitalium and Ureaplasma urealyticum among symptomatic male patients with non-gonococcal urethritis and asymptomatic patients without non-gonococcal urethritis. RESULTS: Specimens of 22 and 10 patients tested positive by polymerase chain reaction for Ureaplasma urealyticum and Mycoplasma genitalium respectively, among the symptomatic non-gonococcal urethritis group (n=98). In the asymptomatic control group (n=236), corresponding patient numbers whose specimens tested positive were 47 and 5. There was no statistically significant difference between the two groups, in terms of the proportion of patients infected with Mycoplasma genitalium (P=0.799) or Ureaplasma urealyticum (P=0.535). CONCLUSIONS: In our study, demonstration of Mycoplasma genitalium and Ureaplasma urealyticum by polymerase chain reaction was not associated with symptomatic non-gonococcal urethritis in male patients attending a Hong Kong government clinic for sexually transmitted infections.

Management of asthma in adults in primary care.

Asthma is a chronic inflammatory disease of the airway which is often misdiagnosed and undertreated. Early diagnosis and vigilant asthma control are crucial to preventing permanent airway damage, improving quality of life and reducing healthcare burdens. The key approaches to asthma management should include patient empowerment through health education and self-management and, an effective patient-healthcare provider partnership.

A recalcitrant case of cicatricial pemphigoid.

A 57-year-old woman presented with a 1-year history of blisters and erosions on her oral mucosa with bilateral conjunctivitis and symblephara formation. A diagnosis of cicatricial pemphigoid was made based on the clinical features and immunohistological findings. A multidisciplinary team managed her with different topical and systemic immunosuppressive agents but she finally succumbed due to multi-organ failure secondary to sepsis.

Cutaneous tuberculosis in Hong Kong: an update.

OBJECTIVE: To provide an update on cutaneous tuberculosis in Hong Kong. DESIGN: Retrospective study. SETTING: Social Hygiene Service (Dermatology Division), the largest dermatological referral centre in Hong Kong. PATIENTS: Patients presented with cutaneous tuberculosis between 1993 and 2002 inclusive. Case notes, histology reports, and microbiological reports were reviewed with particular reference to the epidemiology, duration of illness, history of contact with tuberculosis, culture results, and response to treatment. RESULTS: There were 147 patients with cutaneous tuberculosis; among these a few had true cutaneous tuberculosis (n = 16) and the remainder were tuberculids (n = 131). In all they accounted for 0.04% of new dermatology cases diagnosed. Cases of cutaneous tuberculosis were distributed as follows: lupus vulgaris (n = 6, 4%), tuberculosis verrucosa cutis (n = 6, 4%), tuberculosis of the skin unclassified (n = 2, 1%), and orificial tuberculosis (n = 2, 1%). Culture and polymerase chain reaction was positive in less than half of the latter cases. All responded well to anti-tuberculosis therapy. Erythema induratum was the most common form (n = 127, 86%), but papulonecrotic tuberculids (n = 4, 3%) were uncommon. Erythema induratum affected the lower limb in all patients, with a female predominance, and responded to isoniazid monotherapy, multidrug anti-tuberculosis therapy, or doxycycline. CONCLUSION: Lupus vulgaris and tuberculosis verrucosa cutis remain the commonest forms of true cutaneous tuberculosis, and erythema induratum is the most common tuberculid. Culture and polymerase chain reaction are positive in a small proportion of patients.

Atypical mycobacterial cutaneous infections in Hong Kong: 10-year retrospective study.

OBJECTIVE: To review the epidemiology of atypical mycobacterial cutaneous infection in Hong Kong. DESIGN: Retrospective study. SETTING: Social Hygiene Service (Dermatology Division), the largest dermatological referral centre in Hong Kong. PATIENTS: Patients with a diagnosis of atypical mycobacterial cutaneous infection based on clinical features, histopathology, with or without a positive culture during the period 1993 to 2002. MAIN OUTCOME MEASURES: Epidemiological data, clinical features, histology, microbiological investigation, and treatment response. RESULTS: Of 345,394 dermatological cases presented over the 10-year period, 33 (0.0096%) cases (19 male, 14 female) of atypical mycobacterial cutaneous infection were diagnosed. The most common type of infection was caused by Mycobacterium marinum (n=17, 51.5%), followed by Mycobacterium avium-intracellulare (n=3, 9.1%) and Mycobacterium chelonae (n=2, 6.1%). The upper limb, especially the hands and fingers, was the most common (69.7%) site of involvement. Tissue culture was positive in 18 (54.5%) cases. All biopsies showed granulomatous histology. Thirty-two patients received treatment and 31 responded. Twenty-six were treated with oral tetracycline group of antibiotics (minocycline, doxycycline, tetracycline). The duration of treatment ranged from 8 to 54 weeks (mean, 24 weeks). Mild transient adverse effects to treatment were reported in six cases. CONCLUSION: Atypical mycobacterial infection is rare in Hong Kong. Because of the low sensitivity of traditional culture techniques, atypical mycobacterial infection may be underdiagnosed if only culture-confirmed cases are included. Polymerase chain reaction provides a rapid and sensitive method to improve diagnostic accuracy. Tissue culture is crucial to determine antimicrobial susceptibility. In our study, tetracycline group of antibiotics, especially minocycline, was an effective treatment, particularly in cases caused by Mycobacterium marinum.

Metastatic Crohn's disease in a Chinese girl.

Metastatic Crohn's disease, in which non-caseating granulomatous infiltration of the skin occurs at sites separated from the gastro-intestinal tract by normal tissue, is the least common dermatologic manifestation of Crohn's disease. We report a 15-year-old girl with metastatic Crohn's disease presenting as granulomatous vulvar papules and nodules with typical histopathologic features. To the best of our knowledge, this is the first case of metastatic Crohn's disease in Chinese children reported in the English medical literature.

HIV-associated eosinophilic folliculitis in a Chinese woman: a case report and a survey in Hong Kong.

This is the first survey of eosinophilic folliculitis (EF) in patients infected with the human immunodeficiency virus (HIV) in Hong Kong. The present report provides the local data on HIV-associated eosinophilic folliculitis (HIV-EF) and includes the first Chinese, heterosexual female patient with this condition. This is a retrospective study on all HIV-positive patients (n = 451) attending the outpatient clinic of the AIDS Unit in Hong Kong. Patients diagnosed as having EF with histological support were included for analysis. The data were presented by descriptive method. Three patients were identified, all of them had skin biopsies done which confirmed the diagnosis; including the female case. Recognition of HIV-EF is important because it is indicative of significant immunosuppression with risk of opportunistic infection. We concluded that HIV-EF is no longer an exclusive male disease in homosexual patients only. We expect more female patients or heterosexual subjects who are HIV positive developing this disease in the future.

PIP: A retrospective record review of HIV-associated eosinophilic pustular folliculitis (EF) cases in 451 HIV-positive patients attending an outpatient AIDS clinic in Hong Kong revealed the first female case of HIV-EF in a Chinese heterosexual woman. A 45-year-old HIV-positive woman presented with a 2-week history of pruritic papulopustular eruption on the face. Clinical examination revealed multiple erythematous follicular papules and pustules on her face and neck. Histologic examination of a skin biopsy indicated spongiosis and exocytosis in the epidermis involving infundibulum and sebaceous glands with micropustule formation. This patient's EF responded well to treatment with ultraviolet B phototherapy. This record review also revealed 2 HIV-EF cases in Chinese men (1 homosexual and 1 heterosexual). In previous series, HIV-EF has been found only in homosexual men.

Poikiloderma-like cutaneous amyloidosis in an ethnic Chinese girl.

Primary cutaneous amyloidosis is the deposition of amyloid in the skin without involvement of internal organs. It is easily diagnosed when presented in its typical manifestation. Atypical or rare clinical presentations can pose diagnostic difficulties. Poikiloderma-like cutaneous amyloidosis (PCA), a rare variant of primary cutaneous amyloidosis, was first reported in the literature in 1936 (1). It is characterised by: 1) poikilodermatous skin lesions; 2) lichenoid papules; 3) cutaneous amyloid deposit in the pigmented and lichenoid lesions; 4) light sensitivity; 5) short stature; and 6) other features such as blister formation or palmoplantar keratosis. Ogino coined the term PCA syndrome when these unusual features present early in life (2). We report a 26-year-old Chinese woman who presented with poikilodermatous skin lesions and was misdiagnosed as poikiloderma atrophica vasculare (PAV) on the basis of clinical appearance without any histological proof. The diagnosis of PCA was made after skin biopsy which showed amyloid deposits in the skin. This condition can easily be confused with other true poikiloderma skin diseases. Histology is important in confirming the diagnosis.

Lipodystrophia centrifugalis abdominalis infantilis: two cases from China.

We report the first two Chinese patients with lipodystrophia centrifugalis abdominalis infantilis in China. The first patient was a 3-year-old girl who developed an area of hyperpigmented skin depression on the right groin which spread centrifugally to the abdomen and right lower chest. Later, another lesion developed on the neck. The second patient was a 4-year-old girl who developed multiple areas of skin depression on her bilateral groin, periumbilical region, right axilla, and chest. The lesions also extended centrifugally. Erythematous margins and lymphadenopathy were present in both cases. Inflammatory changes were found in the subcutaneous fat. The clinical pictures and histologic features supported the diagnosis of LCAI in both cases.

Necrolytic migratory erythema in glucagonoma syndrome.

A 32-year-old female Chinese presenting with typical features of necrolytic migratory erythema due to glucagonoma syndrome is reported. The clinical, biochemical, histopathological, and electron-microscopic findings are described. Various different aspects of this rare entity are discussed.

Scleredema in Chinese patients: a local retrospective study and general review.

The records from 12 Chinese adult patients with scleredema, who had attended the Social Hygiene Service of the Hong Kong Department of Health between 22 January 1990 and 19 March 1996, were retrieved and analysed. The neck was the commonest site of involvement (75%), followed by the back (42%), and the shoulder (17%). The vast majority (83%) of scleredema cases were associated with diabetes mellitus; half of these were insulin-dependent. Most of the patients (92%) had hypertension for which medical treatment was needed. No cases of skin disease were preceded by acute infection, and none had any associated paraproteinaemia. The degree of skin involvement did not affect the daily activities of most of the patients. This study revealed differences between the disease in our locality and those described in the western literature.

Special features of non-melanoma skin cancer in Hong Kong Chinese patients: 10-year retrospective study.

OBJECTIVE: To determine the incidence and clinical characteristics of non-melanoma skin cancer in Hong Kong Chinese patients. DESIGN: Retrospective study. SETTING: Social Hygiene Services, Hong Kong. PATIENTS: Records of 528 Chinese patients with a histological diagnosis of non-melanoma skin cancer from 1990 to 1999 were reviewed. MAIN OUTCOME MEASURES: Demographic data, site and clinical type of cancer, predisposing factors, history, recurrence, and the development of new skin cancers. RESULTS: Non-melanoma skin cancer is uncommon but not rare among the Chinese population in Hong Kong. The incidence of newly diagnosed basal cell carcinoma in 1990 was 16.0 per 10,000 new skin case attendances and, in 1999, the incidence was 31.8 per 10,000 new skin case attendances. The corresponding figures for squamous cell carcinoma in 1990 and 1999 were 6.9 and 11.6 per 10,000 new skin case attendances. The incidence of basal cell carcinoma among the Hong Kong Chinese population in 1990 and 1999 was 0.32 and 0.92 per 100,000, respectively, whereas that of squamous cell carcinoma was 0.16 and 0.34 per 100,000, respectively. Demographic data and the site distribution of non-melanoma skin cancer were comparable to those reported in Caucasians living in North America and Europe, but different from those in Caucasians living in Australia and Hawaii. Pigmented basal cell carcinoma was the most common type of non-melanoma skin cancer (60.1%) in Chinese patients, in contrast with rodent ulceration in Caucasian. Multiple skin cancers, recurrence, and subsequent new skin cancers were less frequently observed than in studies of Caucasians. CONCLUSION: When compared with reported findings in Caucasians, Chinese patients show differences in the clinical type and multiplicity of lesions, predisposing factors, recurrence, and subsequent new skin cancer rates for non-melanoma skin cancer. Pigmented basal cell carcinoma seems to be an important differential diagnosis with regard to pigmented lesions in the Chinese population.

PDGF-simvastatin delivery stimulates osteogenesis in heat-induced osteonecrosis.

Heat generated during implant osteotomy might lead to osteonecrosis and delayed bone repair, thus resulting in impaired early osseointegration and fixation of bone-anchoring devices. In this study, we proposed to overcome heat-induced injury to bone by fabricating core-shell polymeric biodegradable microspheres encapsulating a mitogenic factor, platelet-derived growth factor (PDGF), and a differentiation factor, simvastatin, in a simultaneous or sequential release profile. Microspheres encapsulating bovine serum albumin (BSA), PDGF, simvastatin, PDGF-in-core with simvastatin-in-shell, and simvastatin-in-core with PDGF-in-shell were delivered to fill standardized osteotomy sites on edentulous ridges of rat maxillae under irrigated or non-irrigated conditions. In the absence of irrigation, significant reduction of cell viability and increase in inflammation and sequestrum formation without evidence of osteogenesis were observed. Both PDGF and simvastatin deliveries facilitated cell viability and reduced osteonecrosis. Localized osteogenesis was seen under simvastatin treatment, while generalized but primitive osteogenesis was noted in PDGF-treated osteotomy sites. In addition, sequential PDGF-simvastatin delivery further augmented osteogenesis and promoted bone maturation. The results suggested that sequential PDGF-simvastatin delivery was an effective modality to prevent heat-induced complications and facilitate bone apposition after implant osteotomy, potentially favoring the early fixation of bone-anchoring devices and oral implant osseointegration.

Developing guidelines for venous thromboembolism for The National Institute for Clinical Excellence: involvement of the orthopaedic surgical panel.

Following the publication in 2007 of the guidelines from the National Institute for Health and Clinical Excellence (NICE) for prophylaxis against venous thromboembolism (VTE) for patients undergoing surgery, concerns were raised by British orthopaedic surgeons as to the appropriateness of the recommendations for their clinical practice. In order to address these concerns NICE and the British Orthopaedic Association agreed to engage a representative panel of orthopaedic surgeons in the process of developing expanded VTE guidelines applicable to all patients admitted to hospital. The functions of this panel were to review the evidence and to consider the applicability and implications in orthopaedic practice in order to advise the main Guideline Development Group in framing recommendations. The panel considered both direct and indirect evidence of the safety and efficacy, the cost-effectiveness of prophylaxis and its implication in clinical practice for orthopaedic patients. We describe the process of selection of the orthopaedic panel, the evidence considered and the contribution of the panel to the latest guidelines from NICE on the prophylaxis against VTE, published in January 2010.

Cutaneous melanoma: a population-based epidemiology report with 989 patients in Hong Kong.

Studies in white populations have confirmed advanced age as a risk factor for cutaneous melanoma, but in nonwhite populations, its role is less clear. To clarify a possible association in our local population, comprising 94.9% Chinese, a retrospective epidemiological study of 20 years of data on cutaneous melanoma between 1983 and 2002 from a central cancer registry in Hong Kong was conducted. There were 989 new cases and 378 death cases registered, and analysis showed that both the incidence and mortality rate of cutaneous melanoma increase with increasing age. Advanced age is thus confirmed as a risk factor for cutaneous melanoma in our local population. In an ageing population, the estimated future incidence and mortality rate of cutaneous melanoma are likely to increase.

Glomeruloid haemangioma with cerebriform morphology in a patient with POEMS syndrome.

A 40-year-old Chinese man presented with sensorimotor polyneuropathy, IgAlambda paraprotein, osteosclerotic bone lesions, hypertrichosis, and impotence with decreased testosterone and raised prolactin level. POEMS (polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy and skin changes) syndrome was diagnosed and he was treated with melphalan and prednisolone. After chemotherapy, other manifestations of POEMS syndrome developed, such as multiple haemangiomas over the chest and neck region, splenomegaly and generalized oedema. One haemangioma had a peculiar clinical morphology, similar to the appearance of cerebral gyri. Skin biopsy confirmed the diagnosis of glomeruloid haemangioma. Chemotherapy was then switched to cyclophosphamide and prednisolone, resulting in further improvement in muscle power and hypertrichosis. To our knowledge, this is the first report on a clinically distinctive morphology of glomeruloid haemangioma, and its recognition may increase the index of suspicion for early skin biopsy.

Cutaneous tuberculosis in Hong Kong: a 10-year retrospective study.

BACKGROUND: Cutaneous tuberculosis was once a relatively common skin disease in Hong Kong. Tuberculosis verrucosa cutis was the commonest type. Because the last survey was carried out 25 years ago, it was thought necessary to find out the new incidence and pattern of this important disease in this locality. METHODS: A 10-year (1983-1992) retrospective survey on the epidemiologic and clinicobacteriologic aspects of cutaneous tuberculosis had been done in the public sector of Hong Kong. The records of the confirmed cases were retrieved for statistical analysis. RESULTS: A total of 176 cases are included in the final analysis. This represents 0.066% of all new skin cases seen during the 10-year period. Among these, 79.5% are erythema induratum, 6.3% lupus vulgaris, and 4.5% tuberculosis verrucosa cutis. They are further divided into true cutaneous tuberculosis (14.8%, n = 26) and the tuberculide (85.2%, n = 150). Among the patients with true tuberculosis, 42.3% had lupus vulgaris, 30.8% had tuberculosis verrucosa cutis, and 26.9% had scrofuloderma. Among the tuberculides, erythema induratum accounted for 93.3%. CONCLUSIONS: Cutaneous tuberculosis is now uncommon in Hong Kong. Tuberculosis verrucosa cutis is no longer the commonest type in Hong Kong as described in some textbooks. Erythema induratum is now the most common among the total cases and lupus vulgaris is the most common among the true cutaneous forms of tuberculosis.

Three patients with orbital xanthogranuloma and non-progressive haematological abnormalities.

Orbital xanthogranuloma is a rare dermatological condition characterized by its bilateral and rather symmetrical subcutaneous granulomatous infiltration around the eyes. It shares morphological similarities with other xanthogranulomatous diseases such as juvenile or adult type xanthogranuloma, necrobiotic xanthogranuloma and cutaneous infiltration in Erdheim-Chester disease, and should be differentiated from them. Three elderly Chinese patients with this condition were found to have underlying haematological abnormalities: normochromic normocytic anaemia, thrombocytopenia or eosinophilia. Their skin lesions remained localized and associated haematological abnormalities stable for up to 7 years. Haematological abnormalities were also reported in previous cases and this finding is unlikely to be coincidental; however, its clinical significance remains unknown.