Pan-Asian adapted ESMO Clinical Practice Guidelines for the management of patients with locally-advanced unresectable non-small-cell lung cancer: a KSMO-ESMO initiative endorsed by CSCO, ISMPO, JSMO, MOS, SSO and TOS.

The most recent version of the European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, treatment and follow-up of early and locally-advanced non-small-cell lung cancer (NSCLC) was published in 2017, and covered the diagnosis, staging, management and treatment of both early stage I and II disease and locally-advanced stage III disease. At the ESMO Asia Meeting in November 2018, it was decided by both the ESMO and the Korean Society of Medical Oncology (KSMO) to convene a special face-to-face guidelines meeting in 2019 in Seoul. The aim was to adapt the ESMO 2017 guidelines to take into account potential differences related to ethnicity, cancer biology and standard practices associated with the treatment of locally-advanced, unresectable NSCLC in Asian patients. These guidelines represent the consensus opinions reached by those experts in the treatment of patients with lung cancer who represented the oncology societies of Korea (KSMO), China (CSCO), India (ISMPO), Japan (JSMO), Malaysia (MOS), Singapore (SSO) and Taiwan (TOS). The voting was based on scientific evidence, and it was independent of both local current treatment practices and the treatment availability and reimbursement situations in the individual participating Asian countries.

Efflux in Acinetobacter baumannii can be determined by measuring accumulation of H33342 (bis-benzamide).

OBJECTIVES: Overexpression of efflux pumps in Acinetobacter baumannii is a common mechanism of multidrug resistance in this nosocomial pathogen. Increased efflux pump expression is often assumed from MICs of antibiotics and dyes, without measurement of efflux levels. This study describes a safe, rapid and simple 96-well plate assay that measures the accumulation of a fluorescent dye, Hoechst (H) 33342. METHODS: The growth kinetics of three resistant and three susceptible Singaporean clinical isolates of A. baumannii in the presence of carbonyl cyanide-m-chlorophenylhydrazone (CCCP) and phenylalanine-arginine-ß-naphthylamide (PAßN) were studied to determine non-inhibitory concentrations for use in the assay. Accumulation of H33342 was measured in these clinical isolates with and without efflux inhibitors. Accumulation was also measured in an adeB efflux pump deletion mutant and its parental strain to assess the ability of the assay to identify altered efflux in strains lacking efflux pumps. Results were compared with data from accumulation assays with ethidium bromide and norfloxacin. RESULTS: Increased accumulation, indicative of reduced efflux, was observed in AB211ΔadeB compared with parental strain AB211. Clinical isolates demonstrated different levels of accumulation of H33342. The addition of both CCCP and PAßN significantly increased the accumulation of H33342. The pattern of norfloxacin accumulation broadly reflected H33342 accumulation. Ethidium bromide showed a different pattern of accumulation in clinical isolates. CONCLUSIONS: The measurement of the intracellular accumulation of H33342 in real time allowed a comparison of efflux activity between strains of A. baumannii.

Students' tripartite efficacy beliefs in high school physical education: within- and cross-domain relations with motivational processes and leisure-time physical activity.

Within instructional settings, individuals form relational efficacy appraisals that complement their self-efficacy beliefs. In high school physical education (PE), for instance, students develop a level of confidence in their teacher's capabilities, as well as estimating how confident they think their teacher is in their (i.e., the students') ability. Grounded in existing transcontextual work, we examined the motivational pathways through which students' relational efficacy and self-efficacy beliefs in PE were predictive of their leisure-time physical activity. Singaporean students (N = 990; age M = 13.95, SD = 1.02) completed instruments assessing efficacy beliefs, perceptions of teacher relatedness support, and autonomous motivation toward PE, and 2 weeks later they reported their motivation toward, and engagement in, leisure-time physical activity. Structural equation modeling revealed that students reported stronger other-efficacy and RISE beliefs when they felt that their teacher created a highly relatedness-supportive environment. In turn, their relational efficacy beliefs (a) supported their confidence in their own ability, (b) directly and indirectly predicted more autonomous motives for participation in PE, and (c) displayed prospective transcontextual effects in relation to leisure-time variables. By emphasizing the adaptive motivational effects associated with the tripartite constructs, these findings highlight novel pathways linking students' efficacy perceptions with leisure-time outcomes.

Repurposing Proton Beam Therapy through Novel Insights into Tumour Radioresistance.

Despite improvements in radiotherapy, radioresistance remains an important clinical challenge. Radioresistance can be mediated through enhanced DNA damage response mechanisms within the tumour or through selective pressures exerted by the tumour microenvironment (TME). The effects of the TME have in recent times gained increased attention, in part due to the success of immune modulating strategies, but also through improved understanding of the downstream effects of hypoxia and dysregulated wound healing processes on mediating radioresistance. Although we have a better appreciation of these molecular mechanisms, efforts to address them through novel combination approaches have been scarce, owing to limitations of photon therapy and concerns over toxicity. At the same time, proton beam therapy (PBT) represents an advancement in radiotherapy technologies. However, early clinical results have been mixed and the clinical strategies around optimal use and patient selection for PBT remain unclear. Here we highlight the role that PBT can play in addressing radioresistance, through better patient selection, and by providing an improved toxicity profile for integration with novel agents. We will also describe the developments around FLASH PBT. Through close examination of its normal tissue-sparing effects, we will highlight how FLASH PBT can facilitate combination strategies to tackle radioresistance by further improving toxicity profiles and by directly mediating the mechanisms of radioresistance.

A new cytolysin from the sea anemone, Heteractis magnifica: isolation, cDNA cloning and functional expression.

We purified a new cytolysin (HMgIII) from the sea anemone, Heteractis magnifica. HMgIII, which has a molecular mass of approximately 19 kDa, functions as both a cytolysin and a hemolysin. The full-length HMg III cDNA was obtained by reverse transcriptase-polymerase chain reaction, using primers designed from its N-terminal amino acid sequence and an internal conserved region of two other sea anemone cytolysins: equinatoxin II (EqT II) and cytolysin III. The cDNA contained an open reading frame of 633 bp, which encodes a protein of 211 amino acids. The nascent HMg III protein contained a prepropeptide of 34 amino acids, which includes a signal peptide of 19 amino acids. The mature HMg III has a predicted molecular mass of 19 kDa and a pI of 9.1, and shares 91%, 89%, 65% and 63% amino acid sequence similarity with cytolysin III, cytolysin ST I, tenebrosin-C and equinatoxin (EqT II), respectively. The predicted secondary structure of the mature HMg III comprises 16% alpha-helix, 23% extended strand and 60% random coils. The characteristic amphiphilic alpha-helix of cytolysins is located at the N-terminus of the processed HMg III. Recombinant HMg III (rHMg III) was expressed in Escherichia coli as a fusion protein containing a 6xHisTag at the N-terminus. The hemolytic and cytotoxic activities of the purified rHMg III were comparable to those of the native HMg III. The hemolytic activities of both proteins were similarly potentiated with 8-anilino-1-naphthalenesulfonate (ANS). Increasing the length of the peptide tag on the N-terminal of rHMg III correlated with decreasing hemolytic activity, thus confirming the importance of the N-terminal amphiphilic alpha-helix for its cytolytic activity.

Expression of the recA gene in recombination-deficient (rec-) strains of Escherichia coli.

Basal and induced levels of recA expression in wild-type and isogenic derivatives of Escherichia coli carrying various rec mutations were measured using a low-copy number recApo-lacZ fusion, pKLC3.2. Basal recA expression in wild-type and isogenic derivatives containing single rec- mutations, as well as in the recBCsbcA strain and isogenic recA, recF and recJ derivatives, ranged from 1000 to 3900 units. In the recBCsbcBC strain and isogenic recL and recN derivatives basal recA expressions were 3- to 5-fold higher than that of wild-type cells and were inducible by mitomycin C. Except for the recA and lexA3(lnd-) mutants, recA expression was induced by mitomycin C in wild-type cells and its isogenic recB, recD, recF, recG, recJ, recL, recN, recO and ruv derivatives. RecF was required for induction of recA expression by mitomycin C, but not by naladixic acid in the recBCsbcA and recBCsbcBC genetic backgrounds. In wild-type cells, induction of recA expression by naladixic acid required the recBC, but not the recD function of the RecBCD enzyme. This requirement is suppressed by either an additional sbcA or sbcC mutation, but not by an sbcB mutation.

Detection of human papillomavirus (HPV) using dot blot and Southern blot, hybridizing with a mixture of seven probes.

A previously presented method for the detection and typing of human papillomavirus (HPV) DNA has been modified for the simultaneous analysis of HPV types 6, 11, 16, 18, 31, 33 and 35. The method has two steps, where a dot blot test is used to exclude cases that do not hybridize with HPV-DNA. The remaining cases are then analysed by a Southern blot procedure, using a mixture of subgenomic probes for the simple and accurate analysis of HPV types. When the procedure was used for the analysis of clinical samples, patient groups at varying risk were found to differ with regard to the prevalence of HPV infections. Thus, the virus was detected in only 8.8% of otherwise healthy young women - i.e. women without clinical signs of HPV-related disease - as compared to 48% of women who also had cervical intraepithelial neoplasia (CIN). A similarly high prevalence was found in patients in whom CIN persisted (42%) as compared to those in whom the morphological lesion regressed to normal (8%).

Detection of the BC 24 transforming fragment of the herpes simplex virus type 2 (HSV-2) DNA in cervical carcinoma tissue by polymerase chain reaction (PCR).

The polymerase chain reaction (PCR) was used to investigate samples from Indonesian and Swedish patients with cervical intraepithelial neoplasia grade III (CIN III), squamous cell carcinoma or adenocarcinoma of the cervix for the presence of a transforming fragment (BC 24) of herpes simplex virus type 2 (HSV-2) DNA. The PCR test for HSV-2 DNA was more sensitive than the infectivity endpoint titer in a cell culture system and no cross reactivity was found with either varicella-zoster virus, cytomegalovirus, Epstein-Barr virus, human papillomavirus 16 or 18, or human genomic DNA. Using this PCR test, 2 out of 5 cases with CIN III, 10 of 71 squamous cell carcinomas, and 3 of 11 adenocarcinomas of the uterine cervix were found to contain DNA sequences homologous to the BC 24 fragment of the HSV-2 genome. Only two of the samples containing this transforming region of the HSV-2 DNA were positive in a PCR assay for the HSV-2 DNA polymerase gene. The great majority of the HSV-2 BC 24 DNA positive (12 of 15) came from the Indonesian group of patients. All 15 CIN III or cancer samples positive for the HSV-2 BC 24 fragment were also positive for papillomavirus DNA. In line with observations made by others, our data support the hypothesis that HSV infection could represent one of several possible oncogenic cofactors leading to cervical carcinoma. The HSV cofactor might be more important in the Indonesian than in the Swedish population.

Complete androgen insensitivity due to a splice-site mutation in the androgen receptor gene and genetic screening with single-stranded conformation polymorphism.

OBJECTIVE: To characterize the genetic defect in a family with complete androgen insensitivity syndrome and to determine whether single-stranded conformation polymorphism (SSCP) can be used to detect subtle mutations in the androgen receptor (AR) gene. DESIGN: Amplification, subcloning where appropriate, and sequencing of the AR gene in members of the affected family and to use SSCP to differentiate rapidly mutant from normal alleles. SETTING: Reproductive endocrinology clinic and laboratory in a university hospital. PATIENTS: A family of which two sisters (46XY) have complete androgen insensitivity syndrome. RESULTS: A novel single base (G --> A) mutation in the exon G-intron 7 junction of the AR gene caused an abnormal donor splice site leading to complete androgen insensitivity in both affected siblings. Their mother was demonstrated to be the heterozygous carrier of this mutation while the other two males in the family carried the normal allele. Single-stranded conformation polymorphism proved useful for defining the normal, mutant, and heterozygous carrier status of each member of this family. CONCLUSIONS: This new mutation of the human AR gene illustrates the importance of exon G in receptor function. Single-stranded conformation polymorphism is a simple and rapid screening technique that can be used to detect unknown subtle mutations in the AR gene.

Molecular fingerprinting of Riemerella anatipestifer by repetitive sequence PCR.

Riemerella anatipestifer is a gram-negative rod-shaped bacterium associated with epizootic infections in poultry. A total of 35 R. anatipestifer isolates including the type strain ATCC11845T, reference and field strains for 18 different serotypes were characterized by repetitive sequence based-PCR (rep-PCR) with outwardly-directed primers based on the repetitive extragenic palindromic (REP) consensus sequence. This technique was applied by using either extracted genomic DNA or preparation of whole bacterial cells harvested directly from plate cultures. Rep-PCR discriminated the R. anatipestifer isolates into 19 electrophoretic types. DNA fingerprints obtained from rep-PCR of extracted genomic DNA or from preparations of whole cells yielded comparable patterns. Substantial variation was seen among the rep-PCR fingerprints of different serotypes. Moreover, different polymorphisms of the rep-PCR fingerprints were evident among epidemiologically unrelated isolates of the same serotype. These results suggest the presence of repetitive extragenic palindromic-like elements within the genome of R. anatipestifer that can be used in some isolates to discriminate between different strains belonging to the same serotype. Rep-PCR may serve as a useful molecular tool for subtyping R. anatipestifer isolates for epidemiologic investigations. The whole cell procedure offers the advantage of ease of performance requiring only small quantities of cells.

RAPD analysis: an efficient method of DNA fingerprinting in fishes.

Random Amplified Polymorphic DNA (RAPD) generated using arbitrary primers of 9, 10, 16 and 20 nucleotide lengths by Polymerase Chain Reaction (PCR) was investigated in 12 species of fishes. We found that the amplification products were best resolved by Urea-SDS-PAGE and detected by silver staining. The amplification products ranged from 25 to 75 depending on the primer and template combination. The random primers generated unique fingerprints for each species of fish in terms of number and position of RAPDs. Our results showed that the fish species can be distinguished from each other by RAPDs. The complexity of the RAPDs in the fingerprints may be manipulated to suit the requirement of the study. The use of RAPD in taxonomy, fishery management and fish culture is discussed.

Echocardiographic detection of mobile right atrial thrombus.

Mobile right atrial thrombus is a rare echocardiographic diagnosis with important implications on further management. We report a case of 50-year-old woman with deep vein thrombosis of her left lower limb, who was found to have a large mobile serpiginous right atrial thrombus on both two-dimensional echocardiography (2DE) and transoesophageal echocardiography (TEE). She developed acute pulmonary embolism within thirty-six hours of diagnosis and subsequently underwent successful pulmonary embolectomy. This case demonstrates the usefulness of echocardiography as a non-invasive tool in the investigation of suspected pulmonary thromboembolism. The detection of right atrial thrombus mandates serious consideration for prompt surgical action.

Hepatitis B virus infection in patients with systemic lupus erythematosus.

Sera from 76 patients with systemic lupus erythematosus (SLE) were examined for HBsAg, anti-HBsAb and total anti-HBcAB by radioimmunoassay. Fifteen patients (19.7%) had one or more of these serological markers of HBV infection. This is comparable to the sero-prevalence in 100 sex- and age-matched healthy individuals (19%). There was no significant difference in the prevalence of HBV infection in patients who had received immunosuppressants compared with those who had not. Patients who had received transfusion of blood or blood products had a higher prevalence of serological markers but this was not statistically significant.

Recent advances in upper gastrointestinal endoscopy.

During the past decade considerable advances have been made in the field of gastrointestinal endoscopy. Newer and narrower-bodied endoscopes are now available for more comprehensive examination of the upper gastrointestinal tract. More lengthy instruments have made feasible the examination of most parts of the small intestine in children. The introduction of multivariate accessory equipment has given operative endoscopy a new burst of life, and the 1980s have seen renewed activity in such therapeutic modalities as endoscopic sphincterotomy and its various recent modifications. Similarly, endoscopic oesophageal sclerotherapy has been gaining momentum since interest was revived in the technique about five years ago. A brief review is made of these recent developments, including the less well-known subject of dye indicators. An attempt is made to assess their relative significance in the light of recent trends.

Legionnaires' disease--report of Singapore's first local case.

A previously healthy 27 year-old male plumber presented with six days of fever, nausea, vomiting, malaise and headache. The subsequent development of cough, dyspnoea and pleuritic pain coincided with the simultaneous development of progressive bilateral cavitary pneumonia with pleural effusion. Leucocytosis, thrombocytopenia, hyponatraemia, hypoalbuminaemia, hypophosphataemia and hypoxaemia were the main laboratory abnormalities. Clinical suspicion of Legionnaires' disease was confirmed by the presence of serum antibody to Legionella pneumophila (titre 1:512) by an indirect fluorescent antibody test. Treatment with erythromycin and rifampicin resulted in clinical recovery with minimal residual bilateral pleural effusion six months after presentation. This patient is the first to acquire Legionnaires' disease in Singapore.

Prevalence of antibody to hepatitis C in patients with liver disease.

We studied the seroprevalence of antibody to hepatitis C virus (HCV) in patients with liver disease using the Abbott HCV EIA. Twenty-four patients with acute sporadic nonA nonB hepatitis, 19 patients with chronic hepatitis, 28 patients with cirrhosis and 47 patients with hepatocellular carcinoma (HCC) were assayed. The seroprevalence was 8.3% (2/24) in acute hepatitis; 10.5% (2/19) in chronic hepatitis; 3.6% (1/28) in cirrhosis and 14.9% (7/47) in hepatocellular carcinoma. The seroprevalence rates were lower in all categories of liver disease compared to figures reported in developed countries. Possible reasons included a delayed or missed seroconversion in the acute hepatitis group. Other etiologies like hepatitis B and alcohol may play a more important role in chronic liver disease. On the other hand, the seroprevalence locally may actually be low. Sporadic, non-blood transfusion appears to be a common method of acquiring the infection.

Zollinger-Ellison syndrome--report of four cases and review of literature.

Four patients with Zollinger-Ellison Syndrome (ZES) are presented to highlight the difficulties in the recognition, diagnosis and management of this rare disease. The presentation of ZES is usually indistinguishable from ordinary peptic ulcer disease and in those patients with symptoms not related to peptic ulcer, i.e., diarrhoea, as their main complaint, the diagnosis is often not even considered. A high index of suspicion is required, however, in patients with recurrent ulcers, multiple ulcers and in those with resistant or rapidly relapsing ulcers after conventional therapy. A presumptive diagnosis can be made by the demonstration of grossly elevated fasting serum gastrin levels combined with a secretin stimulation test in doubtful cases. The main problem is the location of the gastrin-secreting tumour which is usually pancreatic but often too small to be detected by currently available techniques. Histamine H2-receptor antagonists in high doses are effective in controlling the gastric acid hypersecretion which is chiefly responsible for the morbidity and mortality in ZES. They provide the treatment of choice in patients where the tumour cannot be located, though every attempt should be made to do this as surgery is the treatment of choice for this invariably malignant tumour. Total gastrectomy is now reserved for those patients in whom medical therapy has failed. The role of chemotherapy in metastatic disease has yet to be established.

Primary hepatocellular carcinoma developing in a female patient on long term oral contraceptives--a case report.

The association between hepatic tumours and oestrogen and progestogen therapy is well established. The risk of developing primary hepatocellular carcinoma (PHC) is small. In Africa and Asia where hepatitis B virus (HBV) infections are common, the development of PHC is also high. The presence of Hepatitis B core antibody indicates previous exposure to HBV and carries a risk of developing PHC by more than 34 times of non-infected normal. A Chinese female 29 years who had been on oral oestrogen and progestogen contraceptives continuously for 8 years developed PHC. She had no known illness due to HBV but was found to have concomitantly positive Hepatitis B core antibody in her sera. The presence of this HB core antibody and the long term consumption of oestrogen/progesterone derivatives may have been responsible for the early presentation of PHC in this patient. It is the first report in this country of PHC developing in a pill consumer since the introduction of oral contraceptives a decade ago In view of the prevalence of Hepatitis B in the region, this case finding warrants further study to determine whether (a) there is a higher frequency in pill consumers (b) an earlier age of presentation of hepatic malignancy. Meanwhile, it may be prudent to recommend alternative methods of birth control in individuals known to have been previously exposed to HBV infection, clinically or otherwise.

Prevalence in Sweden of human papillomavirus type 16 infection in CIN II-III cases assessed by a PCR method.

The presence of human papillomavirus (HPV) 16 in cervical intraepithelial neoplasia (CIN)II-III cases was studied by means of a polymerase chain reaction (PCR)-based method applied to paraffin-embedded tissues. Twenty-two of 45 (49%) cases showed a positive signal determined by direct visualization on gel stained with ethidium bromide. Fourteen of these cases were confirmed by dot blot hybridization, which accords with a prevalence of HPV 16 infection in 31% of Stockholm patients with CIN II-III. The latter value is lower than that published elsewhere (Young et al. 1989; Maki et al. 1991; Skydberg et al. 1991).