Novel health systems service design checklist to improve healthcare access for marginalised, underserved communities in Europe.

BACKGROUND: Marginalised communities such as homeless people, people who use drugs (PWUD), lesbian, gay, bisexual, transgender and intersex people (LGBTI), prisoners, sex workers and undocumented migrants are at high risk of poor health and yet face substantial barriers in accessing health and support services. The Nobody Left Outside (NLO) Service Design Checklist aims to promote a collaborative, evidence-based approach to service design and monitoring based on equity, non-discrimination and community engagement. METHODS: The Checklist was a collaborative project involving nine community advocacy organisations, with a focus on homeless people, PWUD, LGBTI people, prisoners, sex workers, and undocumented migrants. The Checklist was devised via a literature review; two NLO platform meetings; a multistakeholder policy workshop and an associated published concept paper; two conference presentations; and stakeholder consultation via a European Commission-led Thematic Network (including webinar). RESULTS: The NLO Checklist has six sections in line with the WHO Health Systems Framework. These are: (1) service delivery, comprising design stage (6 items), services provided (2 items), accessibility and adaptation (16 items), peer support (2 items); (2) health workforce (12 items); (3) health information systems (7 items); (4) medical products and technologies (1 item); (5) financing (3 items); and (6) leadership and governance (7 items). It promotes the implementation of integrated (colocated or linked) healthcare services that are community based and people centred. These should provide a continuum of needs-based health promotion, disease prevention, diagnosis, treatment and management, together with housing, legal and social support services, in alignment with the goals of universal health coverage and the WHO frameworks on integrated, people-centred healthcare. CONCLUSIONS: The Checklist is offered as a practical tool to help overcome inequalities in access to health and support services. Policymakers, public health bodies, healthcare authorities, practitioner bodies, peer support workers and non-governmental organisations can use it when developing, updating or monitoring services for target groups. It may also assist civil society in wider advocacy efforts to improve access for underserved communities.

The Role of Pharmacists in Travel Medicine in South Africa.

Worldwide, pharmacists, who are the most accessible health-care providers, are playing an ever increasing role in travel medicine, assisting travelers in taking the necessary precautions to ensure safe and healthy travel. This article looks at the situation in South Africa, and how pharmacists are performing these functions within the legal constraints of the Medicines and Related Substances Act 101 of 1965, which prevents pharmacists from prescribing many of the travel vaccines and medications. The scope of practice in community pharmacies increased since the successful down-scheduling of some of the antimalarials, allowing pharmacists to supply the many travelers who frequently travel to neighboring countries. As in many other countries, travel medicine in South Africa is currently thwart with products that are out of stock, and a number of temporary guidelines were put in place to deal with these. Ways to facilitate expanding the role of pharmacists in travel medicine in South Africa need to be further explored.

Diagnostic accuracy of image-guided biopsies in small (<4 cm) renal masses with implications for active surveillance: a systematic review of the evidence.

OBJECTIVE:: To determine the safety and diagnostic accuracy of renal tumour biopsies in a defined population of small renal masses (SRMs) only <4 cm using 3 × 2 table, intention to diagnose approach. 3 × 2 table approach examines indeterminate results as a separate category rather than pushing these through traditional 2 × 2 table (four-cell matrix) approach. METHODS:: A highly sensitive search was performed in the Cochrane Library, Database of Abstracts of Reviews of Effects; MEDLINE and MEDLINE in Process, EMBASE and conference proceedings (1966-2016) for the acquisition of data on the diagnostic accuracy and complications of RTB in patients with SRM <4 cm. Methodological quality and risk of bias was assessed using QUADAS-2. Test characteristics were calculated using conventional 2 × 2 contingency table analysis excluding non-diagnostic biopsies, and an intention-to-diagnose approach with a 3 × 2 table for pooled estimates of the sensitivity and specificity. RESULTS:: A total of 20 studies were included with a total sample size of 974. The pooled estimates for sensitivity and specificity of RTB based upon univariate analysis using 2 × 2 table observed sensitivity 0.952 [confidence interval (CI) 0.908-0.979] and specificity 0.824 (CI 0.566-0.962). Using the 3 × 2 table and intention-to-diagnose principle, sensitivity 0.947 (CI 0.925-0.965) and specificity 0.609 (CI 0.385-0.803) decreased. CONCLUSION:: RTB in SRMs (<4 cm) is associated with a high diagnostic sensitivity but poor specificity when non-diagnostic results are included by a 3 × 2 table for analysis (intention to diagnose approach). Risk of non-diagnostic results and poor quality of research need addressing through future studies, preferably by a well-designed prospective study appropriately powered for diagnostic accuracy using valid reference standards. ADVANCES IN KNOWLEDGE:: A comprehensive synthesis of literature on image-guided biopsies in SRMs using a different methodology and study design.

Antibody-conjugated drug assay for protease-cleavable antibody-drug conjugates.

BACKGROUND: Antibody-drug conjugates (ADCs) require multiple assays to characterize their PK. These assays can separately evaluate the ADC by quantifying the antibody or the conjugated drug and may give different answers due to assay measurement differences, heterogeneous nature of ADCs and potential biotransformations that occur in vivo. RESULTS: We present a new version of the antibody-conjugated drug assay for valine-citrulline-linked monomethylauristatin E (vcMMAE) ADCs. A stable isotope-labeled internal standard, protein A affinity capture and solid-phase cleavage of MMAE using papain was used prior to LC-MS/MS analysis. CONCLUSION: The assay was used to assess the difference in ex vivo drug-linker stability of native-cysteine versus engineered cysteine ADCs and to determine the number of drugs per antibody of a native-cysteine ADC in vivo.

Lentiviral and targeted cellular barcoding reveals ongoing clonal dynamics of cell lines in vitro and in vivo.

BACKGROUND: Cell lines are often regarded as clonal, even though this simplifies what is known about mutagenesis, transformation and other processes that destabilize them over time. Monitoring these clonal dynamics is important for multiple areas of biomedical research, including stem cell and cancer biology. Tracking the contributions of individual cells to large populations, however, has been constrained by limitations in sensitivity and complexity. RESULTS: We utilize cellular barcoding methods to simultaneously track the clonal contributions of tens of thousands of cells. We demonstrate that even with optimal culturing conditions, common cell lines including HeLa, K562 and HEK-293 T exhibit ongoing clonal dynamics. Starting a population with a single clone diminishes but does not eradicate this phenomenon. Next, we compare lentiviral and zinc-finger nuclease barcode insertion approaches, finding that the zinc-finger nuclease protocol surprisingly results in reduced clonal diversity. We also document the expected reduction in clonal complexity when cells are challenged with genotoxic stress. Finally, we demonstrate that xenografts maintain clonal diversity to a greater extent than in vitro culturing of the human non-small-cell lung cancer cell line HCC827. CONCLUSIONS: We demonstrate the feasibility of tracking and quantifying the clonal dynamics of entire cell populations within multiple cultured cell lines. Our results suggest that cell heterogeneity should be considered in the design and interpretation of in vitro culture experiments. Aside from clonal cell lines, we propose that cellular barcoding could prove valuable in modeling the clonal behavior of heterogeneous cell populations over time, including tumor populations treated with chemotherapeutic agents.

Measurement of in vivo therapeutic mAb concentrations: comparison of conventional serum/plasma collection and analysis to dried blood spot sampling.

BACKGROUND: Development of an alternative sampling method that uses small amounts of whole blood, such as dried blood spots (DBS), would be an advance in the quantitative assay field. Previously, we assessed the ability to quantitate therapeutic monoclonal antibodies present in DBS compared with a typical serum sample-based method, and concluded that measurements in DBS were reproducible and yielded methods that met requirements for precision, accuracy and sensitivity. The goal herein was to assess the measurement of therapeutic antibodies in DBS compared with serum and plasma in vivo. RESULTS: Comparison of DBS versus serum in Sprague-Dawley rats and DBS versus plasma in cynomolgus monkeys for measurement of antibody concentrations revealed a two- to three-fold difference in exposure between the samples. CONCLUSION: Overall, there was good correlation between DBS versus serum and DBS versus plasma, but there was a discrepancy in DBS exposures, presumably attributable to hematocrit and recovery effects.

Invasive breast cancer: relationship between shear-wave elastographic findings and histologic prognostic factors.

PURPOSE: To compare the histologic prognostic feature of invasive breast cancer with mean stiffness as measured with shear-wave elastography. MATERIALS AND METHODS: This retrospective study was exempted from ethical committee review. Patient consent for use of images for research was obtained. The study group comprised 101 consecutive women (age range, 38-91 years) with solid lesions identified during routine breast ultrasonography (US) performed between April 2010 and March 2011 and subsequently confirmed at histologic examination to be invasive cancers. Four elastographic images in two orthogonal planes were obtained of each lesion, and mean stiffness values were obtained from each image. Histologic findings following surgery were used for comparison, namely histologic grade, tumor type, invasive size, vascular invasion status, and lymph node status. Relationship between mean stiffness and histologic parameters was investigated by using a general linear model and multiple regression analysis. RESULTS: High histologic grade (P < .0001), large invasive size (P < .0001), lymph node involvement (P < .0001), tumor type (P < .0001), and vascular invasion (P = .0077) all showed statistically significant positive association with high mean stiffness values. Multiple linear regression indicated that invasive size is the strongest pathologic determinant of mean stiffness (P < .0001), with histologic grade also having significant influence (P = .022). CONCLUSION: In this study, breast cancers with higher mean stiffness values at shear-wave elastography had poorer prognostic features.

Type and maturational status of dendritic cells in cutaneous B cell lymphoproliferative disorders.

AIMS: B cell cutaneous lymphoid hyperplasia (B-CLH) and cutaneous mucosa-associated lymphoid tissue (MALT) lymphoma represent opposite poles of the same disease spectrum. We explored the hypothesis that dendritic cells (DCs) are central in the generation and regulation of such lesions. METHODS AND RESULTS: Immunohistochemistry was used to identify Langerhan cells (LCs), dermal DCs (DDCs) and plasmacytoid DCs (PDCs), as well as mature and alternatively activated DCs, in B-CLH (n = 14) and cutaneous MALT lymphoma (n = 18). PDCs were most numerous in both types of lesion, but there were significantly more PDCs and DDCs and greater numbers of mature DCs in B-CLH. Nevertheless, DCs were still present in cutaneous MALT lymphoma and there were also proportionately more alternatively activated cells. CONCLUSION: Mature DDCs are prime activators of naive T cells and our results suggest that they are likely to be largely responsible for driving the initial proliferation in B-CLH. The results also suggest that PDCs play a central role, and we hypothesize that they dictate the magnitude, duration and direction of the response. In cutaneous MALT lymphoma PDCs are the dominant DC subtype, and may act by damping down the antitumour host immune response, as well as directly stimulating the growth and differentiation of the neoplastic lymphocytes.

Evidence for biological effects of metformin in operable breast cancer: a pre-operative, window-of-opportunity, randomized trial.

Metformin may reduce the incidence of breast cancer and enhance response to neoadjuvant chemotherapy in diabetic women. This trial examined the effects of metformin on Ki67 and gene expression in primary breast cancer. Non-diabetic women with operable invasive breast cancer received pre-operative metformin. A pilot cohort of eight patients had core biopsy of the cancer at presentation, a week later (without treatment; internal control), then following metformin 500-mg o.d. for 1 week increased to 1-g b.d. for a further week continued to surgery. A further 47 patients had core biopsy at diagnosis were randomized to metformin (the same dose regimen) or no drug, and 2 weeks later had core biopsy at surgery. Ki67 immunohistochemistry, transcriptome analysis on formalin-fixed paraffin-embedded cores and serum insulin determination were performed blinded to treatment. Seven patients (7/32, 21.9%) receiving metformin withdrew because of gastrointestinal upset. The mean percentage of cells staining for Ki67 fell significantly following metformin treatment in both the pilot cohort (P = 0.041, paired t-test) and in the metformin arm (P = 0.027, Wilcoxon rank test) but was unchanged in the internal control or metformin control arms. Messenger RNA expression was significantly downregulated by metformin for PDE3B (phosphodiesterase 3B, cGMP-inhibited; a critical regulator of cAMP levels that affect activation of AMP-activated protein kinase, AMPK), confirmed by immunohistochemistry, SSR3, TP53 and CCDC14. By ingenuity pathway analysis, the tumour necrosis factor receptor 1 (TNFR1) signaling pathway was most affected by metformin: TGFB and MEKK were upregulated and cdc42 downregulated; mTOR and AMPK pathways were also affected. Gene set analysis additionally revealed that p53, BRCA1 and cell cycle pathways also had reduced expression following metformin. Mean serum insulin remained stable in patients receiving metformin but rose in control patients. This trial presents biomarker evidence for anti-proliferative effects of metformin in women with breast cancer and provides support for therapeutic trials of metformin.

Long-term oncologic outcomes of laparoscopic radical nephrectomy for kidney cancer resection: Dundee cohort and metaanalysis of observational studies.

BACKGROUND: The long-term oncologic outcome of laparoscopic radical nephrectomy compared with that of open radical nephrectomy remains unclear. A few case series with follow-up periods longer than 5 years are reported in the literature. The existing literature is focused primarily on early and intermediate outcomes of laparoscopic radical nephrectomy. This study aimed to assess the outcome of laparoscopic radical nephrectomy for localized disease compared with open surgery. METHODS: The search strategy was designed to identify observational and experimental studies conducted in any country that investigated the long-term oncologic outcomes of laparoscopic radical nephrectomy compared with open surgical resection, published in any language. We searched the MEDLINE (1996 to May 2010), EMBASE (1996 to May 2010), and Cochrane databases using the OVID interrogation software. The study included 77 men from the Dundee cohort referred for clinically localized renal cell carcinoma who underwent open or laparoscopic radical nephrectomy between January 1998 and 2004, with at least 5 years of follow-up evaluation for each. These men were included in a metaanalysis of observational studies reporting on 438 patients with a mean or median follow-up period of 5 years. The data was analyzed using Minitab statistical software and Cochrane RevMan 5.4 using the random model. RESULTS: The five studies (including the Dundee cohort) investigating the effects of the laparoscopic approach on renal cancer management showed no significant differences in 5 years survival between laparoscopic and open surgical approaches for the resection of kidney cancer. The resulting pooled odds ratio (OR) did not differ markedly between the two groups (pooled OR, 0.82; 95% confidence interval [CI], 0.48-1.39). Similar to overall survival, the laparoscopic and open surgical approaches for renal cancer surgery did not differ significantly (Figs. 4, 5). The pooled ORs for the two outcomes were 0.76 (955 CI, 0.36-1.56) for laparoscopic surgery and 0.73 (95% CI, 0.32-1.69) for open surgery. The quality of the studies was poor. The reported designs of the studies were prone to selection, confounding, and reporting biases. CONCLUSIONS: The current retrospective data (observational studies) comparing long-term oncologic outcomes between laparoscopic and open radical nephrectomy did not demonstrate any significant differences during a follow-up period of 5 years.

Factors influencing a second myeloid malignancy in patients with Philadelphia-negative -7 or del(7q) clones during tyrosine kinase inhibitor therapy for chronic myeloid leukemia.

The detection of Philadelphia-negative (Ph(neg)) cells with non-random karyotypic abnormalities after tyrosine kinase inhibitor (TKI) therapy of chronic myeloid leukaemia (CML) can be associated with myelodysplastic syndrome (MDS) or acute myeloid leukemia (AML). To our knowledge, however, there have been no studies on variables influencing the risk of MDS/AML in patients with specific Ph(neg) karyotypes. We systematically examined studies reporting -7 or del(7q) within Ph(neg) cells in TKI-treated CML patients, and abstracted clinical and cytogenetic data from individual reports into a standardized format for further analysis. Of 53 patients, 43 had Ph(neg) -7 clones [as the sole abnormality (-7(sole)) in 29, or with other clones (-7(dual)) in 14], and del(7q) was present in 10. A total of 16/51 evaluable patients, all with -7, transformed to MDS/AML. Transformation was more frequent (15/16 patients) within 6 months of Ph(neg) -7 detection rather than subsequently (P < 0.0001). At first detection after TKI therapy, Ph(neg) abnormal clones comprised ≥50% of Ph(neg) cells in a greater proportion of patients with -7 than del(7q) (P = 0.035). Upon comparing -7(sole) and -7(dual), the latter was likely to be transient (P = 0.004), and AML was frequently observed with persistent -7 clones (P = 0.03). By logistic regression analysis (n = 36), clone size (P = 0.017), time-to-detection longer than 15 months (P = 0.02), and CML response (P = 0.085) were associated with MDS/AML. Validation of these novel associations in registry-based studies will help develop predictive criteria that define the MDS/AML risk in individual patients.

FGFR2 protein expression in breast cancer: nuclear localisation and correlation with patient genotype.

BACKGROUND: Single Nucleotide Polymorphisms (SNPs) in intron 2 of the Fibroblast Growth Factor Receptor Type 2 (FGFR2) gene, including rs2981582, contribute to multifactorial breast cancer susceptibility. The high risk polymorphism haplotype in the FGFR2 gene has been associated with increased mRNA transcription and altered transcription factor binding but the effect on FGFR2 protein expression is unknown. 40 breast tumours were identified from individuals with known rs2981582 genotype. Tumour sections were stained for FGFR2 protein expression, and scored for nuclear and cytoplasmic staining in tumour and surrounding normal tissue. FINDINGS: FGFR2 immunohistochemistry demonstrated variable nuclear staining in normal tissue and tumour tissue, as well as consistent cytoplasmic staining. We did not find an association between nuclear staining for FGFR2 and genotype, and there was no association between FGFR2 staining and estrogen or progestogen receptor status. There was an association between presence of nuclear staining for FGFR2 in normal tissue and presence of nuclear staining in the adjacent tumour (Fishers exact test, p = 0.002). CONCLUSIONS: Variable nuclear staining for FGFR2 in breast cancer, but an absence of correlation with rs2981582 genotype suggests that the mechanism of action of polymorphisms at the FGFR2 locus may be more complex than a direct effect on mRNA expression levels in the final cancer. The effect may relate to FGFR2 function or localisation during breast development or tumourigenesis. Nuclear localisation of FGFR2 suggests an important additional role for this protein in breast development and breast cancer, in addition to its function as a classical cell surface receptor.

p53 mutant breast cancer patients expressing p53γ have as good a prognosis as wild-type p53 breast cancer patients.

INTRODUCTION: Normal function of the p53 network is lost in most cancers, often through p53 mutation. The clinical impact of p53 mutations in breast cancer remains uncertain, especially where p53 isoforms may modify the effects of these p53 mutations. METHODS: Expression of p53ß and p53γ isoforms, the isoforms identified in normal breast tissue, was detected by reverse transcription polymerase chain reaction from a cohort of 127 primary breast tumours. Expression of p53ß and p53γ isoforms was analysed in relation to clinical markers and clinical outcomes (5 years) by binary logistic regression, Cox proportional hazards regression and Kaplan-Meier survival analyses. RESULTS: p53ß and p53γ were not randomly expressed in breast cancer. p53ß was associated with tumour oestrogen receptor (ER) expression, and p53γ was associated with mutation of the p53 gene. The patient group with the mutant p53 breast tumour-expressing p53γ isoform had low cancer recurrence and an overall survival as good as that of patients with wild-type p53 breast cancer. Conversely, patients expressing only mutant p53, without p53γ isoform expression, had a particularly poor prognosis. CONCLUSIONS: The determination of p53γ expression may allow the identification, independently of the ER status, of two subpopulations of mutant p53 breast cancer patients, one expressing p53γ with a prognosis as good as the wild-type p53 breast cancer patients and a second one not expressing p53γ with a particularly poor prognosis. The p53γ isoform may provide an explanation of the hitherto inconsistent relationship between p53 mutation, treatment response and outcome in breast cancer.

Quantitative shear wave ultrasound elastography: initial experience in solid breast masses.

INTRODUCTION: Shear wave elastography is a new method of obtaining quantitative tissue elasticity data during breast ultrasound examinations. The aims of this study were (1) to determine the reproducibility of shear wave elastography (2) to correlate the elasticity values of a series of solid breast masses with histological findings and (3) to compare shear wave elastography with greyscale ultrasound for benign/malignant classification. METHODS: Using the Aixplorer® ultrasound system (SuperSonic Imagine, Aix en Provence, France), 53 solid breast lesions were identified in 52 consecutive patients. Two orthogonal elastography images were obtained of each lesion. Observers noted the mean elasticity values in regions of interest (ROI) placed over the stiffest areas on the two elastography images and a mean value was calculated for each lesion. A sub-set of 15 patients had two elastography images obtained by an additional operator. Reproducibility of observations was assessed between (1) two observers analysing the same pair of images and (2) findings from two pairs of images of the same lesion taken by two different operators. All lesions were subjected to percutaneous biopsy. Elastography measurements were correlated with histology results. After preliminary experience with 10 patients a mean elasticity cut off value of 50 kilopascals (kPa) was selected for benign/malignant differentiation. Greyscale images were classified according to the American College of Radiology (ACR) Breast Imaging Reporting and Data System (BI-RADS). BI-RADS categories 1-3 were taken as benign while BI-RADS categories 4 and 5 were classified as malignant. RESULTS: Twenty-three benign lesions and 30 cancers were diagnosed on histology. Measurement of mean elasticity yielded an intraclass correlation coefficient of 0.99 for two observers assessing the same pairs of elastography images. Analysis of images taken by two independent operators gave an intraclass correlation coefficient of 0.80. Shear wave elastography versus greyscale BI-RADS performance figures were sensitivity: 97% vs 87%, specificity: 83% vs 78%, positive predictive value (PPV): 88% vs 84%, negative predictive value (NPV): 95% vs 82% and accuracy: 91% vs 83% respectively. These differences were not statistically significant. CONCLUSIONS: Shear wave elastography gives quantitative and reproducible information on solid breast lesions with diagnostic accuracy at least as good as greyscale ultrasound with BI-RADS classification.

DNA polymerase theta up-regulation is associated with poor survival in breast cancer, perturbs DNA replication, and promotes genetic instability.

"Replicative stress" is one of the main factors underlying neoplasia from its early stages. Genes involved in DNA synthesis may therefore represent an underexplored source of potential prognostic markers for cancer. To this aim, we generated gene expression profiles from two independent cohorts (France, n=206; United Kingdom, n=117) of patients with previously untreated primary breast cancers. We report here that among the 13 human nuclear DNA polymerase genes, DNA Polymerase (POLQ) is the only one significantly up-regulated in breast cancer compared with normal breast tissues. Importantly, POLQ up-regulation significantly correlates with poor clinical outcome (4.3-fold increased risk of death in patients with high POLQ expression), and this correlation is independent of Cyclin E expression or the number of positive nodes, which are currently considered as markers for poor outcome. POLQ expression provides thus an additional indicator for the survival outcome of patients with high Cyclin E tumor expression or high number of positive lymph nodes. Furthermore, to decipher the molecular consequences of POLQ up-regulation in breast cancer, we generated human MRC5-SV cell lines that stably overexpress POLQ. Strong POLQ expression was directly associated with defective DNA replication fork progression and chromosomal damage. Therefore, POLQ overexpression may be a promising genetic instability and prognostic marker for breast cancer.

The burden of imported malaria in Gauteng Province.

OBJECTIVES: To describe the burden of malaria in Gauteng Province, and to identify potential risk factors for severe disease. DESIGN: We conducted a prospective survey of malaria cases diagnosed in hospitals throughout Gauteng from December 2005 to end November 2006. OUTCOME MEASURES: Malaria frequency, severity, and treatment. Results. We identified 1 701 malaria cases; 1 548 (91%) were seen at public sector hospitals and 153 (9%) at private hospitals; 1 149 (68%) patients were male. Median age was 27 years (range 1 month - 89 years). Most (84%) infections were acquired in Mozambique. Disease severity did not differ by age or sex. Patients who were South African-born were more likely to have severe disease (OR=1.43 (1.08 - 1.91)), as were patients who experienced a delay >48 hours between onset of symptoms and diagnosis or treatment (OR=1.98 (1.48 - 2.65)). While most patients appropriately received quinine, only 9% of severe malaria cases received the recommended loading dose. CONCLUSIONS: The incidence of malaria in Gauteng was higher than previously reported, emphasising the need to prevent malaria in travellers by correct use of non-drug measures and, when indicated, malaria chemoprophylaxis. Disease severity was increased by delays between onset and treatment and lack of partial immunity. Providers should consult the latest guidelines for treatment of malaria in South Africa, particularly about treatment of severe malaria. A change in drug policy to artemisinin combination therapy for imported uncomplicated malaria in non-malaria risk provinces should be strongly considered.

Dose-intensified treatment of Burkitt lymphoma and B-cell lymphoma unclassifiable, (with features intermediate between diffuse large B-cell lymphoma and Burkitt lymphoma) in young adults (<50 years): a comparison of two adapted BFM protocols.

The chemotherapy dose-intensity in two adapted German BFM paediatric protocols (BFM 90 and NHL 86) was compared in contemporaneously treated adults <50 years with Burkitt lymphoma and B-cell lymphoma unclassifiable, with features intermediate between diffuse large B-cell lymphoma and Burkitt lymphoma (collectively referred to as BL). In BFM 90, primary prophylaxis with Granulocyte-colony-stimulating factor was used, postinduction treatment was started at granulocytes > or =0.5 x 10(9)/L (> or =1.0 x 10(9)/L in NHL 86) with a higher mean methotrexate dose (2.9 g/m(2)/cycle, n = 23; 1.6 g/m(2)/cycle in NHL 86, n = 22, P < 0.001). Intervals between consecutive treatment-cycles were shorter in BFM 90 (P < 0.001) with no additional toxicity. However, the two-year failure-free survival with BFM 90 (82%) was similar to that achieved with NHL 86 (72%, P = 0.33). We conclude that BFM 90 enables safe intensification of therapy in young adults with BL compared to NHL 86, but registry-based studies are required to further evaluate the antineoplastic effects and cost-effectiveness of the two therapeutic approaches.

Effect of incomplete removal of the tert-butoxycarbonyl protecting group during synthesis of a pharmaceutical drug substance on the residual solvent analysis.

During development of the residual solvent method using headspace-GC for a drug substance, an unexpected peak was observed in the chromatography. GC-MS analysis confirmed the unknown peak identity as isobutylene. An understanding of the source of the isobutylene was required in order to develop appropriate impurity and residual solvent control strategies for the drug substance. The experiments performed to determine the source of the isobutylene peak observed in the headspace-GC chromatography and how the tert-butoxycarbonyl (BOC) de-protection step used in the drug substance synthesis contributes to its observation are discussed.