 Okay, here's the laser point, but I don't see the laser point, so, so, I would like to thank energy inviting me to give a talk about the basic science of the Stephen Johnson and TN. At the beginning, I would like to outline my talk. They will include drug antigen and environmental factor and the host factor that include genetic or non-engin genetic, actually retreated or non-retreated, and also the immune mechanism involving the pathogenesis of Stephen Johnson syndrome, and also the downstream cell death mechanism, and also the potential therapeutic target. So this is in the latest decade, the scientists did make significant progress in this Stephen Johnson research, such like the pathogenesis of the PI concept, the T-serchrone identified from the drug sensitivity, and also identify the CT95 as a potential target that can inhibit by IVIG applied to clinical therapy, and also the drug-specific HRA association, such as Kappa Zanpin, associated with the B-1502, and also the RAPU, you know, Stephen Johnson associated with the B-5801, and also the cytotoxic protein, when I think they find to explain why the extensive epitomonic process involving Stephen Johnson syndrome, and also we have done lots of functional genomic studies, such like HRA B-1502, they have a functional low interact with the drug. So considered the mechanism, I would like to brief the concept by this slide. The pathogenesis could involve many factors, many elements, including now pharmacology elements, chemistry, drug itself, drug antigen also very important, and also some factors, especially the patient factor, that some patients have underlying diseases, or some genetic diversity, or contribute to the pathogenesis, and also in the end, the T-cell will be activated by the drug, then have the trigger, the T-cell attacks the skin, and also the organ. So this is the several elements involved in the pathogenesis, including genomic and immunology, and also the cytotoxic T-cell. So the first element, first factor is the drug antigen, of course, is very important because not all the drug can trigger such a severe skin reaction, like Stephen Johnson syndrome. Only, of course, the population only has a certain kind of drug, such like alpinocapazine, phenytoin, and Saffa mesazol, and Lomotrigin can have such kind, can, is potentially induce this kind of severe skin reaction. And although this is being labeled by FDA, so I think near 100 drugs are potentially related to Stephen Johnson, but in clinical, and in academic database, only a few of them, only certain of them are notorious and potentially to cause such kind of skin reaction. So, so taking an example for the endoconversal drug, only, in clinical only, the endoconversal drug with aromatic structure, the common thing to relate to Stephen Johnson syndrome, such as campazine, phenytoin, Lomotrigin, and phenylbapidone. But the aromatic drug without the aromatic ruin, such like a dopamine, Bapriacid, and at the level, just like 10, is really to observe, to relate to Stephen Johnson syndrome. So meaning the drug antigen is very important to trigger the immune reaction to our host, to immune, to immune system. So another factor is environmental factor. There have been some pathogens, such like a mycoplasma, herpesin virus can trigger the same reaction induced by drug of Stephen Johnson syndrome. And also about 10 to 20 percent is still unknown, so-called idiopathic. But considering idiopathic, sometimes we don't know what the factor is. Not necessarily, it's really, it's unknown. So for example, we recently identified some virus in Taiwan, antivirus, A6, A6 virus, there's a new variant that the virus cause antigen shift. Then we have observed many children develop very severe generalized skin reaction. They are mimicking the Stephen Johnson syndrome. So meaning there are, some of virus can have a similar antigen. They are able to trigger our immune system to, to, to, like, like, like Stephen Johnson syndrome. Okay. So, and, and another factor is the host factor, I think the, the, the, the, the, the genetic factor, genetic factor of course is very important, and especially in the HRA, RD have been found to strongly associate with many drugs, such like a cup of MP in our, our puenal and the apacabia, and also in, in, in the, in recent year, the, the depsone, the on, on kind of antibiotics can treat the, the, the leprosy. I find to strongly associate with HRAB 3, 3, 1, 0, 1. So there are several very good example of HRA, strong HRA association, specifically earlier to specifically drug that, and in 2004, we first, first identified the strongly association of HRAB 15-2 with cup, cup of MP induced Stephen Johnson or toxic epitomaniacalysis. And, and the, the, the findings are further validated by many other population, especially in, in South Asian country, but in non-South Asian country, such like in Japan or Korea, this kind of association is not, is, is there no association was, was observed. And, and if we look at the earlier frequency of B 15-2, this kind of strong association only present in, in population or region with the high frequency of B 15-2. And also in, in European country or Western country, without the high frequency of B 15-2, this kind of, this kind of strong association was not observed. So we further follow up the, with more and more side to look at the phenotype and the genotype correlation. We found HRAB 15-2 is only strongly association with the phenotype of Stephen Johnson or TEN, especially with the clinical presentation, more, more extensive of epitomaniacal treatment, more than 5 percent, 10 percent, this kind of genetic association will become nearly 100 percent. But with patient with the limit skin involvement, such like less than 1 percent or patient without this kind of a bristerine reaction, such like hypersensitized syndrome, this, this kind of a different phenotype, then the genetic association will disappear, will, will not, not, cannot be observed, this kind of strong, strong association. Okay. So what is the gene associated with H-Covid-19 induced non-Steven-John syndrome in terms of hypersensitized syndrome or macular-propyl rush? And we have found the HRA3101 is a secondive or socialized, this kind of non-Steven-John syndrome phenotype. And the HRA associated is sometimes more complicated than we saw because in the study from Japan and the Europe, the group, they found that 3101 can be secondive or socialized in Japanese or European population, either the Steven-John syndrome or hypersensitized syndrome caused by Covid-19. So our further study by using the patient from the Euroscopes group, we find that the HRA3101 indeed shows strong association with Covid-19 induced hypersensitized syndrome or called the DRACE. But when further look at this earlier with the non-Steven-John syndrome, with the Covid-19 induced Steven-John syndrome in European patient, then the association become weaker. So meaning that the one area of HRA could be, that is, as an initiative specific, also the phenotype association. So it's very complicated than we saw. So this is the Covid-19 transnational law made in Taiwan. We first identified the strong gene association and then validated by many other South Asian Asian countries. And then the earlier was labeled by US FDA and as well as other in Taiwan as a country health organization to... And then I think in 2010 in Taiwan, our national health instruments decided to cover the gene test. So now this kind of test is an obligation, not just a research in many countries. So in Taiwan, we have an electronic medical record system. So the committee will remind the doctor to perform this kind of test before Dr. Prescribe the drug. So in the recent two years, because the system are the more and more doctors, now their X2 have the gene test. So in recent two years or recent three years, we really find one patient, although they still have some patients are induced by... Have students induced by carousel pain, but they are rare patient died from carousel pain. And in the 10 years ago, they are... Every year we have saw on many... Some patients died from carousel pain and more than 50 patients. You cannot imagine how so many patients got still induced by carousel pain, more than 50 cases. But now this patient I can observe. But ironically you can observe here, the new user of carousel pain also decreased in recent years. So meaning the awareness of doctor to prescribe carousel pain and also the gene test came, most can prevent the disease happen. Okay. The similar observation was just published by Hong Kong group. They saw that before the policy of the gene test, the incidence is higher in Asian country, about a point to four percent. But now after the gene test have been performed in Hong Kong, it's rarely to find any case of a stimulant caused by carousel pain now. Okay. So this is a typical tragedy in Taiwan that happened every year in the past 10 years. This 40 years female, they just have the carousel pain also. After awfully reused the carousel pain to relieve her carousel syndrome. And then unfortunately the lady has a genetic susceptibility to carousel pain. So one week after taking the drug, it developed a generalized skin region. At the beginning it's not just severe, but one or two days later when I visit the woman, when the data began to use the corticosteroids, so many breast regions began to develop and also on the face and from everywhere. And one week later the lady had 100% skin detachment and died from multiple organ failure and sepsis. So the skin is just the beginning from skin, but in the end the immune system can attack all the organs, not just skin. And the woman had positive B-physioin too, but it's too late. So now this kind of tragedy is a significant decrease, it never happened again. Another successful pharmacological study in Stephen John syndrome, I think, not just also the hypersonal syndrome is the aropyrinome. And we also find the B-15A01 that is strongly associated with aropyrin due to Stephen John syndrome and also the hypersonal syndrome. And this kind of association is more universal, not like camasampin, can in different preparation, also Japanese or European preparation also show very strong association with aropyrinome, hypersensitivity or severe skin reactions. And when we extend our symbol side, of course, nothing is 100%, so we extend our symbol side we found, although the sensitivity, not 100% present in our opinion of hypersensitivity patient, but still very high percentage, especially with patients with the most severe skin reaction, such as Stephen John syndrome or hypersensitivity syndrome, more than 90% of patients carry B-15A01 a year. But for patients with mild skin reactions, such as macular papillosis, then the strength of the association decrease, only 65% patient carry B-15A01. So even if you perform the genetic test, B-15A01 is not guaranteed to 100% prevent patient from the hypersensitivity reaction. So what's the role of HRA in drug hypersensitivity? For the HRA-retricity model, I think that such like B-15A02 or B-15A01 with carbazepine or aropyrinome or Bacavir in that with B-15A01, this kind of HRA-retricity model, the HRA protein have a different affinity to the drug peptide or drug or peptide complex. So meaning the drug peptide antigen have a direct interaction with the HRA molecule and the different HRA molecules have a different affinity to drug antigen. So taking example by carbazepine, the drug can directly find into the HRA-B-15A02 or B-15A01 and then can be recognized by the T-cell receptor of the specific T-cell and then the T-cell will activate, release some danger signal to attack the calcium side. So this is a working hypothesis that has been realized in recent years. We transfect the start to show a transfection of the specific HRA-R-DL such like B-15A02 and then the cytotor T-cell of carbazepine-stimulogenome only can recognize and cure the cell, the transfectic cell which is placed the B-15A02 but not other HRA-R-DL. So meaning only HRA-B or B-15A02 is a functional can interact with the drug then can present antigen to the T-cell. And also other HRA-B-R-DL are similar with the structure similar to B-15A02 such like B-15A01, B-15A01, they are belong to the same serotype of HRA-B-15A05. So with the similar HRA-structure also can, when the cell transfects with the similar HRA-B-R-DL can also present the carbazepine to the T-cell and the T-cell can recognize this similar structure similar earlier. And this B-75 serotype of the structure is similar earlier with the B-15A02 can also be found in patients with carbazepine, steunium, in different populations such as B-15A01 and B-15A08 have been found in other populations. The patient of carbazepine, steunium, they are not necessarily carry always carry B-15A02 but also B-15A01 or other HRA earlier can have the same reaction. Okay, so how HRA and the T-cell, T-cell are recognize the drug in drug have a sensitivity. Now there are three models to explain the complicates as a mechanism. The one is the haptam concept that is the drug, it was peptide, it will have a conveyor binding and the example is the penicillin, another theory is the PI concept that is the drug and the immune molecule they don't have the covalent binding and the carbazepine can fit this kind of this model and the endogen do not have, they are not necessarily for the endogen to have endogen procession by the APC. The third theory is the L-cell peptide repertoire, the theory of the drug such like apocryphae they can have non-common binding but they can change the peptide binding to the HRA earlier. Okay, so this is the new theory of the drug have a sensitivity, the drug such like apocryphae can bind into the F packet of the B-7001 and then at a specific position, at the nigh position of the F pocket, the amino acid, the binding peptide will be changed about 20% of the peptide will be changed. So this kind of theory, but this kind of theory cannot explain, can fit other drug into Stephen John's syndrome such like a carbazepine, we only observe they are not changing of the peptide binding if we we see the present of drug or without the drug. So we also find that the specific T-cell can recognize the HRAB fitting or two in a drug complex. So I mean when compared to the T-cell crown, the T-cell receptor compared to the HRAB fitting or two tolerance control then only the carbazepine Stephen John's syndrome show very unique the T-cell receptor. So this kind of T-cell receptor cannot be detected in other drug induced Stephen John's syndrome such like phenytoin or apulino, meaning the T-cell receptor is another piece of link to the pathogenesis, actually important in the drug and also the T-cell receptor. So and many people are wondering whether that because the phenytoin has showed the similar chemical structure with the carbazepine, so many people think that maybe the phenytoin, Stephen John's syndrome also are associated with the B-7002, indeed it's still significant but the strength is it's weaker, much weaker than the carbazepine because only one cell of the patient can be B-5002. So by come to the general wide association, we found that the significant also associated with the outside of HRAB, HRAB is within the metapolarizing enzyme is in the COP2C9 or 2C19. So the gene link to phenytoin Stephen John's syndrome actually is the metapolarizing enzyme for phenytoin itself. So the 2C9-3 is the enzyme, it's a different enzyme that can affect the enzyme activity for the to metabolize the phenytoin. So when we look at the serine level of phenytoin, indeed we found that the patient with phenytoin induced Stephen John's syndrome or trace, they have a higher drug concentration even before or even stop the phenytoin, then the patient have a poor metabolizer, the drug. So this kind of association you also find not just in Chinese but also in Japanese or also Malaysia, they also have show the the significant association with the phenytoin induced Stephen John's or HRAB. Okay, so it's the mechanism that goes back to the old theory, the metapolarism. It's a metapolarism that they also involved in the pathogenesis of drug habitantivity. For taking example, we also find that in our opinion, the pathogenesis is pretty low because even the patient with B15-01 is not necessary to develop the severe skin reaction even taking our opinion. We found that if the patient with poor retina function, then the metabolized osteopulinary will be delayed metabolism, even the patient stop taking the drug. And if the patient with poor retina function with the CCR less than 30, we found the mortality rate will largely increase. So meaning the not just B15-02 but also retina function, if we combine the two factors together, we found with poor retina function and B15-02, the risk of the the patient develop our opinion habitantivity will largely increase. So this theory has been proved by the dose-dependent osteopulinary specificity response at the study of comptoblac blood doctor picture. So meaning the not just the genetic but also non-genetic factor can affect the pathogenesis. So this is very complicated. The drug antigen entails HRA and also the drug concentration metabolism can play some role. And then the TCO recognize the drug and HRA compress. So meaning considering the eradication of the Sting-John genome, we so-called this is low-hanging fruit to be achieved in the future. We can prevent the disease but actually very complicated. We need to look at more factors, more genetic or non-genetic factors combined together that can be successfully to reach the goal. So the last piece of the mechanism is what is the downstream immune molecule participate in the to to the skin damage. Whether some specific signal or some kind involved in the pathogenesis. So in the past there are two mechanisms to explain the carotene site death. One is the proffering, traditional proffering enzyme, V-interacrisis from the tachycele to attack the tachycele. The another one is the phas ligand and the intangible phas resetting phas ligand, they can from the cytotorothicel can affect the cell death. And we found another another important protein that it called granulicine. We found that from the bristle cell, the Sting-John genome, bristle cell of Sting-John genome, they are highly expressed granulicine in from the t-cell. And then the granulicine also present very high concentration in the bristle free. And if we use the recombinant granulicine into the minus skin also show can induce the skin necrosis in the minus skin. So the granulicine is expressed by CTA and CT 56 cytotothicel, the cytotothicel T-cell, NK T-cell. So there are some research shows that granulicine can be detected in the very early stage of Sting-John genome, but not can be detected in in in general skin minus drug reaction. So now they have been a repeated diagnosed kid. I can rapidly diagnose the Sting-John genome by using the kid. So the other scientific work we can do to help the Sting-John genome is how can we define the drug in addition to clinical assessment. If there's some way in visual tests that we can use a specific marker, we can do. And virtually the traditional in visual tests is the sensitivity for Sting-John genome is very low. Only less than 20 percent of patient can detect by by the in visual test. By using the appropriate biomarker, such like the granulicine, now we found the granulicine is a very good biomarker for the in in visual assay. So if you look at it in granulicine, our opinion is the most difficult drug to have the positive in visual test, even the the X-V or the skin patch test. So we use our opinion of the T-cell and incubate with the metabolite entrepreneurial can successfully get as a positive result. The sensitivity can as high as more than 80 percent. So meaning if we get the right biomarker, then we can improve the sensitivity and the diagnosis in the future. There are other scientific or chemical involved the Sting-John genome, such as IO2, IO5, IO6. There are many scientific or chemical involved in the positive analysis. So this is the complex immune mechanism. The drug entire with the saturated T-cell, then the T-cell immigrate to the skin. Then there are several saturated protein. Monalizing granulicine, we prefer in fast ligand, can be released by T-cell, or T-cell can also release the fast ligand. And then thus the granulicine itself is the aromine, meaning it can stimulate the the dendritic cell or monocyte to spray more chemokine to attract the leukocyte or inform the cell to the skin. So this is a circle of immune system that's specific to attack the skin. So also the cell death mechanism, they are in recent two years, there are many publications to explain in addition to granulicine fast ligand, also anacin A1 and also the microRNA 18A5P also find sure to can participate some, play some role to attack this, to induce the skin death. So the final goal is to have, we know the pathogenism, then we can, we should have the appropriate therapeutic strategy to prevent student joints. You know, we now we have several projects to ongoing to, to, to, to, to treatment of the patient, anti-granulicine or anti-TM for alpha clinical trial, they have to show some efficacy, although this is not a grant of my control study. Okay. I would thank many of my, my colleagues from Taiwan, my hospital, Chang'e-meirah hospital, Akademia Sinica, and also the National Armenian University, and then my international group, Riji Scar or Z Scar or C Scar group, thank you, thank you for your attention. Okay, we don't have a lot of time, but maybe you have questions. I have one, oh yeah, Steve, sorry. When you, when you inject the granulicine into animal skin, is it, does it work with recombinant granulicin, number one, and number two, does it induce a cellular infiltrate, or does the granulicin just bind and cause necrosis of the epidermal cells? I think the both, the granulicine is have, its cell has a cytotoxic ability to induce the cell death. It, it, it, it, it don't need receptors. The granulicin can freely penetrate through the cell membrane and cause induced apoptosis. And, but also the granulicin can attract many, it can, can act like, as an element, it can induce the monocytitis to release the chemokine, then can attract more. To get the blister formation, do you need the cells, or can you just use granulicin? You, but, to get the blister, do you, do you need the cellular infiltrate, or can you just get it without the cellular infiltrate? Yes, just, yeah, if you look at the pathology, there are only few cell infiltrate into the, the blister. That, that's the answer. Then, then, then, I, I think there's the, the truth is the, the, in stem germ, you know, we don't need so many cells to, to, to consider and to, to attack, to, to cause the skin damage. Instead, they can express many, the cytotosis signal, fast like granulicin, everything. Then, compared to the hypocentric syndrome, although there are many cell infiltrate into the skin, but it did not cause the skin encroach, it did not cause the blisters reaction. So, I think there are some specific signal, so-called sick, dangerous signal, can induce the blister and expanses the skin encroaches. I think this, this is the unique part of the stem germ syndrome comes in, in the immune reaction. Another question. In autoimmunity, there are HLA's that are associated with autoimmunity, and then there are also protective HLA's. With your analysis, are you able to detect if there are any protective HLA's? What, what counts? So, in autoimmunity, you have MHC molecules that predispose you to autoimmunity, and you have MHC molecules that protect you from auto, autoimmunity. In your analysis of MHCs that are associated with drug reactions, are you, are you able to also detect MHCs that are protective? I know that there's nothing that's been published, but I'm just wondering, in terms of the type of analysis that you do, would there, would the type of analysis be able to detect protective MHC molecules? Yes, we, we, we did find some HLA mea, they have, as ratio such as 0.01, that's, that's a layer is very popular in our population. So some HLA layer, they, they, they are possible to have some protective effect in the immune system to against the drug. So you think you, you might have protective MHC that? Yes, yes. Because that, that would, that would play into the role of the mechanism of, of how you think the diseases is being caused, because the protective MHC has to be doing something to protect the individual. The protective HLA layer, I don't know if it is so protective or not, because, because it fails some HLA, HLA is being 15.02, this layer have a stronger affinity to the drug or the metabolite, but other HLA, HLA is being 15.01, they are not so strong binding to, to the drug. So the protective allele doesn't have to bind to the drug, it can protect some other, other mechanism. Yes, yes. Single data home answers the question for me. If you look at our, our data in public nature, you can find the HLA B400, 4001, this is the protective, so-called particular layer, meaning in, in torrential patient, there are more, more torrential patient carrying B15 or 4001, but we don't know that whether this kind of idea have functional role compared to the B1502. Okay, but it's a good question to consider about that. Can you disclose your name and affiliation, please? By the way, the last one was Dr. Marverakis. David Margolos from the University of Pennsylvania. Thank you for the nice presentation. Early on in your talk, you showed a nice secular trend study looking at the rate of decline of carbamazine-induced Stevens-Johnson TEN, and it was markedly decreased after you started your 1502 testing. But you had a decrease almost every year in what you showed prior to the mandatory testing and prior to even when the testing became available. So are there other things that are going on in Taiwan in terms of public health to try to diminish the carbamazine-induced TEN or have there just been changes over time in the population in terms of susceptibility? Yes, thank you for your question. In reality, I think most of the data, they don't like to prescribe drugs. They have obligations. They don't need to have to generate tests. So many data now, they are more aware about that, and they would like to shift the behavior, they prescribe other alternative anti-carbamazine drugs. So the change over the incident of carbamazine now, they have several issues. One is the genetic test. Another one is the doctor. They have decreased the prescription of the drug. I think most of the two can explain why the incident of carbamazine now in Taiwan is look like successful eradication, but there are some factors, not just the genetic test. Thank you. We have one more minute. Please, Dr. Wang. Just to follow on from that, you showed Patrick Kwan's paper from Hong Kong. In fact, what was happening was that doctors were moving away from carbamazine using other drugs, which had a higher incidence of SJSTN. So the overall burden of SJSTN, according to his paper, hasn't decreased even though the carbamazine induced SJSTN has decreased, suggesting that because it's a genetic test, they're not familiar with it, or it's a disruptive technology, they're just not using it. So I just want to know whether that's also going on in other parts of Southeast Asia, what the uptake is of 1502, and whether the overall prescribing of carbamazines has gone down. I think the trend in Taiwan is similar to the paper published by the Hong Kong group. The trend is that the doctors now in Taiwan, they prescribe more phenytoin than carbazine than before. So overall, the incidence of SJSTN didn't change. But I think it's very important for the health administrators, the FDA or the government needs to consider when they want to label one of the genetic markers to push the doctor to do the genetic test. Then the doctor will move to another drug. And you need to consider what kind of the drugs is still very dangerous in the marketing. So if there are still many other genetic drugs, they are very dangerous. So we need to have more comprehensive policy, not just consider one drug. We need to think, if the doctor changes to another drug, they could also induce SJSTN. Then overall, the SJSTN could not be changed. So I think the policy, the political policy, is also very important for the clinical implication of carbamazines study. Thank you, Dr. Chang. So our next speaker is Elizabeth Phillips, which is a director of scientists and director of personalized immunology at Ward Oats Institute for Experimental Therapeutics and Vulnerable University. 20-25 minutes, please, and some minutes for question and answers. Thank you.