The Medicines Optimisation Innovation Centre: a dedicated centre driving innovation in medicines optimisation-impact and sustainability.

BACKGROUND: Sub-optimal medicines use is a challenge globally, contributing to poorer health outcomes, inefficiencies and waste. The Medicines Optimisation Innovation Centre (MOIC) was established in Northern Ireland by the Department of Health (DH) in 2015 to support implementation of the Medicines Optimisation Quality Framework. AIM: To demonstrate how MOIC informs policy and provides support to commissioners to improve population health and wellbeing. SETTING: MOIC is a regional centre with multidisciplinary and multi-sector clinical expertise across Health and Social Care and patient representation. DEVELOPMENT: Core funded by DH, MOIC has a robust governance structure and oversight programme board. An annual business plan is agreed with DH. Rigorous processes have been developed for project adoption and working collaboratively with industry. IMPLEMENTATION: MOIC has established partnerships with academia, industry, healthcare and representative organisations across Europe, participating in research and development projects and testing integrated technology solutions. A hosting programme has been established and evaluation and dissemination strategies have been developed. EVALUATION: MOIC has established numerous agreements, partnered in three large EU projects and strengthened networks globally with extensive publications and conference presentations. Informing pathway redesign, sustainability and COVID response, MOIC has also assisted in the development of clinical pharmacy services and antimicrobial stewardship in Europe and Africa. Northern Ireland has been recognised as a 4-star European Active and Healthy Ageing Reference Site and the Integrated Medicines Management model as an example of best practice in Central and Eastern Europe. CONCLUSION: MOIC has demonstrated considerable success and sustainability and is applicable to health systems globally.

The relationship between tumour dosimetry, response, and overall survival in patients with unresectable Neuroendocrine Neoplasms (NEN) treated with 177Lu DOTATATE (LuTate).

Peptide Receptor Radionuclide Therapy (PRRT) delivers targeted radiation to Somatostatin Receptor (SSR) expressing Neuroendocrine Neoplasms (NEN). We sought to assess the predictive and prognostic implications of tumour dosimetry with respect to response by 68 Ga DOTATATE (GaTate) PET/CT molecular imaging tumour volume of SSR (MITVSSR) change and RECIST 1.1, and overall survival (OS). METHODS: Patients with gastro-entero-pancreatic (GEP) NEN who received LuTate followed by quantitative SPECT/CT (Q-SPECT/CT) the next day (Jul 2010 to Jan 2019) were retrospectively reviewed. Single time-point (STP) lesional dosimetry was performed for each cycle using population-based pharmacokinetic modelling. MITVSSR and RECIST 1.1 were measured at 3-months post PRRT. RESULTS: Median of 4 PRRT cycles were administered to 90 patients (range 2-5 cycles; mean 27.4 GBq cumulative activity; mean 7.6 GBq per cycle). 68% received at least one cycle with radiosensitising chemotherapy (RSC). RECIST 1.1 partial response was 24%, with 70% stable and 7% progressive disease. Cycle 1 radiation dose in measurable lesions was associated with local response (odds ratio 1.5 per 50 Gy [95% CI: 1.1-2.0], p = 0.002) when adjusted by tumour grade and RSC. Median change in MITVSSR was -63% (interquartile range -84 to -29), with no correlation with radiation dose to the most avid lesion on univariable or multivariant analyses (5.6 per 10 Gy [95% CI: -1.6, 12.8], p = 0.133). OS at 5-years was 68% (95% CI: 56-78%). Neither baseline MITVSSR (hazard ratio 1.1 [95% CI: 1.0, 1.2], p = 0.128) nor change in baseline MITVSSR (hazard ratio 1.0 [95% CI: 1.0, 1.1], p = 0.223) were associated with OS when adjusted by tumour grade and RSC but RSC was (95% CI: 0.2, 0.8, p = 0.012). CONCLUSION: Radiation dose to tumour during PRRT was predictive of radiologic response but not survival. Survival outcomes may relate to other biological factors. There was no evidence that MITVSSR change was associated with OS, but a larger study is needed.

Warm Circumpolar Deep Water transport toward Antarctica driven by local dense water export in canyons.

Poleward transport of warm Circumpolar Deep Water (CDW) has been linked to melting of Antarctic ice shelves. However, even the steady-state spatial distribution and mechanisms of CDW transport remain poorly understood. Using a global, eddying ocean model, we explore the relationship between the cross-slope transports of CDW and descending Dense Shelf Water (DSW). We find large spatial variability in CDW heat and volume transport around Antarctica, with substantially enhanced flow where DSW descends in canyons. The CDW and DSW transports are highly spatially correlated within ~20 km and temporally correlated on subdaily time scales. Focusing on the Ross Sea, we show that the relationship is driven by pulses of overflowing DSW lowering sea surface height, leading to net onshore CDW transport. The majority of simulated onshore CDW transport is concentrated in cold-water regions, rather than warm-water regions, with potential implications for ice-ocean interactions and global sea level rise.

FDG PET/CT imaging in detecting and guiding management of invasive fungal infections: a retrospective comparison to conventional CT imaging.

PURPOSE: Invasive fungal infections (IFIs) are common in immunocompromised patients. While early diagnosis can reduce otherwise high morbidity and mortality, conventional CT has suboptimal sensitivity and specificity. Small studies have suggested that the use of FDG PET/CT may improve the ability to detect IFI. The objective of this study was to describe the proven and probable IFIs detected on FDG PET/CT at our centre and compare the performance with that of CT for localization of infection, dissemination and response to therapy. METHODS: FDG PET/CT reports for adults investigated at Peter MacCallum Cancer Centre were searched using keywords suggestive of fungal infection. Chart review was performed to describe the risk factors, type and location of IFIs, indication for FDG PET/CT, and comparison with CT for the detection of infection, and its dissemination and response to treatment. RESULTS: Between 2007 and 2017, 45 patients had 48 proven/probable IFIs diagnosed prior to or following FDG PET/CT. Overall 96% had a known malignancy with 78% being haematological. FDG PET/CT located clinically occult infection or dissemination to another organ in 40% and 38% of IFI patients, respectively. Of 40 patients who had both FDG PET/CT and CT, sites of IFI dissemination were detected in 35% and 5%, respectively (p < 0.001). Of 18 patents who had both FDG PET/CT and CT follow-up imaging, there were discordant findings between the two imaging modalities in 11 (61%), in whom normalization of FDG avidity of a lesion suggested resolution of active infection despite a residual lesion on CT. CONCLUSION: FDG PET/CT was able to localize clinically occult infection and dissemination and was particularly helpful in demonstrating response to antifungal therapy.

FDG-PET metabolic response predicts outcomes in anal cancer managed with chemoradiotherapy.

BACKGROUND: The aim was to investigate the correlation between (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) metabolic response to chemoradiotherapy and clinical outcomes in squamous cell carcinoma (SCC) of the anus. METHODS: A total of 48 patients with biopsy-proven anal SCC underwent FDG-PET scans at baseline and post chemoradiotherapy (54 Gy, concurrent 5-FU/mitomycin). Kaplan-Meier analysis was used to determine survival outcomes according to FDG-PET metabolic response. RESULTS: In all, 79% patients (n=38) had a complete metabolic response (CMR) at all sites of disease, 15% (n=7) had a CMR in regional nodes but only partial response in the primary tumour (overall partial metabolic response (PMR)) and 6% (n=3) had progressive distant disease despite CMR locoregionally (overall no response (NR)). The 2-year progression-free survival (PFS) was 95% for patients with a CMR, 71% for PMR and 0% for NR (P<0.0001). The 5-year overall survival (OS) was 88% in CMR, 69% in PMR and 0% in NR (P<0.0001). Cox proportional hazards regression analyses for PFS and OS found significant associations for incomplete (PMR+NR) vs complete FDG-PET response to treatment only, (HR 4.1 (95% CI: 1.5-11.5, P=0.013) and 6.7 (95% CI: 2.1-21.6, P=0.002), respectively). CONCLUSION: FDG-PET metabolic response to chemoradiotherapy in anal cancer is significantly associated with PFS and OS, and in this cohort incomplete FDG-PET response was a stronger predictor than T or N stage.

Monitoring fusarium crown rot populations in spring wheat residues using quantitative real-time polymerase chain reaction.

Caused by a complex of Fusarium species including F. culmorum, F. graminearum, and F. pseudograminearum, Fusarium crown rot (FCR) is an important cereal disease worldwide. For this study, Fusarium population dynamics were examined in spring wheat residues sampled from dryland field locations near Bozeman and Huntley, MT, using a quantitative real-time polymerase chain reaction (qPCR) Taqman assay that detects F. culmorum, F. graminearum, and F. pseudograminearum. Between August 2005 and June 2007, Fusarium populations and residue decomposition were measured eight times for standing stubble (0 to 20 cm above the soil surface), lower stem (20 to 38 cm), middle stem (38 to 66 cm), and chaff residues. Large Fusarium populations were found in stubble collected in August 2005 from F. pseudograminearum-inoculated plots. These populations declined rapidly over the next 8 months. Remnant Fusarium populations in inoculated stubble were stable relative to residue biomass from April 2006 until June 2007. These two phases of population dynamics were observed at both locations. Relative to inoculated stubble populations, Fusarium populations in other residue fractions and from noninoculated plots were small. In no case were FCR species observed aggressively colonizing noninfested residues based on qPCR data. These results suggest that Fusarium populations are unstable in the first few months after harvest and do not expand into noninfested wheat residues. Fusarium populations remaining after 8 months were stable for at least another 14 months in standing stubble providing significant inoculums for newly sown crops.

Femoral torsion in patients with Blount's disease: a previously unrecognised component.

In 1937 Blount described a series of 28 patients with 'Tibia vara'. Since then, a number of deformities in the tibia and the femur have been described in association with this condition. We analysed 14 children with Blount's disease who were entered into a cross-sectional study. Their mean age was 10 (2 to 18). They underwent a clinical assessment of the rotational profile of their legs and a CT assessment of the angle of anteversion of their hips (femoral version). We compared our results to previously published controls. A statistically significant increase in femoral anteversion was noted in the affected legs, with on average the femurs in patients with Blount's disease being 26 degrees more anteverted than those in previously published controls. We believe this to be a previously unrecognised component of Blount's disease, and that the marked intoeing seen in the disease may be partly caused by internal femoral version, in addition to the well-recognised internal tibial version.

Induction of granulysin in CD8+ T cells by IL-21 and IL-15 is suppressed by human immunodeficiency virus-1.

Immunosuppression following infection with HIV-1 predisposes patients to a myriad of opportunistic pathogens, one of the most important of which is Mtb. Granulysin, expressed by NK cells and CTL, exhibits potent antimicrobial activity against Mtb and several other opportunistic pathogens associated with HIV-1 infection. The immune signals that promote granulysin expression in human CTL are not fully understood. Using primary human CD8+ T cells, in this study, we identify IL-21 as a strong inducer of granulysin, demonstrate that IL-21 and IL-15 activate granulysin expression within CD8+ CD45RO+ T cells, and establish a role for Jak/STAT signaling in the regulation of granulysin within CD8+ T cells. We show that infection of PBMC from healthy donors in vitro with HIV-1 suppresses granulysin expression by CD8+ T cells, concomitant with reduced p-STAT3 and p-STAT5, following activation with IL-15 and IL-21. Of note, simultaneous signaling through IL-15 and IL-21 could partially overcome the immunosuppressive effects of HIV-1 on granulysin expression by CD8+ T cells. These results suggest that HIV-1 infection of PBMC may reduce the antimicrobial profile of activated CD8+ T cells by disrupting signaling events that are critical for the induction of granulysin. Understanding the effects of HIV-1 on CD8+ T cell activation is essential to understanding the physiological basis for inadequate cytotoxic lymphocyte activity in HIV+ patients and for informed guidance of cytokine-based therapy to restore T cell function.

Preclinical efficacy of the bioreductive alkylating agent RH1 against paediatric tumours.

BACKGROUND: Despite substantial improvements in childhood cancer survival, drug resistance remains problematic for several paediatric tumour types. The urgent need to access novel agents to treat drug-resistant disease should be expedited by pre-clinical evaluation of paediatric tumour models during the early stages of drug development in adult cancer patients. METHODS/RESULTS: The novel cytotoxic RH1 (2,5-diaziridinyl-3-[hydroxymethyl]-6-methyl-1,4-benzoquinone) is activated by the obligate two-electron reductase DT-diaphorase (DTD, widely expressed in adult tumour cells) to a potent DNA interstrand cross-linker. In acute viability assays against neuroblastoma, osteosarcoma, and Ewing's sarcoma cell lines RH1 IC(50) values ranged from 1-200 nM and drug potency correlated both with DTD levels and drug-induced apoptosis. However, synergy between RH1 and cisplatin or doxorubicin was only seen in low DTD expressing cell lines. In clonogenic assays RH1 IC(50) values ranged from 1.5-7.5 nM and drug potency did not correlate with DTD level. In A673 Ewing's sarcoma and 791T osteosarcoma tumour xenografts in mice RH1 induced apoptosis 24 h after a single bolus injection (0.4 mg/kg) and daily dosing for 5 days delayed tumour growth relative to control. CONCLUSION: The demonstration of RH1 efficacy against paediatric tumour cell lines, which was performed concurrently with the adult Phase 1 Trial, suggests that this agent may have clinical usefulness in childhood cancer.

The impact of 18-fluorodeoxyglucose positron emission tomography on the staging, management and outcome of anal cancer.

Accurate inguinal and pelvic nodal staging in anal cancer is important for the prognosis and planning of radiation fields. There is evidence for the role of 18-fluorodeoxyglucose positron emission tomography (FDG-PET) in the staging and management of cancer, with early reports of an increasing role in outcome prognostication in a number of tumours. We aimed to determine the effect of FDG-PET on the nodal staging, radiotherapy planning and prognostication of patients with primary anal cancer. Sixty-one consecutive patients with anal cancer who were referred to a tertiary centre between August 1997 and November 2005 were staged with conventional imaging (CIm) (including computed tomography (CT), magnetic resonance imaging, endoscopic ultrasound and chest X-ray) and by FDG-PET. The stage determined by CIm and the proposed management plan were prospectively recorded and changes in stage and management as a result of FDG-PET assessed. Patients were treated with a uniform radiotherapy technique and dose. The accuracy of changes and prognostication of FDG-PET were validated by subsequent clinical follow-up. Kaplan-Meier survival analysis was used to estimate survival for the whole cohort and by FDG-PET and CIm stage. The tumour-stage group was changed in 23% (14 out of 61) as a result of FDG-PET (15% up-staged, 8% down-staged). Fourteen percent of T1 patients (3 out of 22), 42% of T2 patients (10 out of 24) and 40% of T3-4 patients (6 out of 15) assessed using CIm, had a change in their nodal or metastatic stage following FDG-PET. Sensitivity for nodal regional disease by FDG-PET and CIm was 89% and 62%, respectively. The staging FDG-PET scan altered management intent in 3% (2 out of 61) and radiotherapy fields in 13% (8 out of 61). The estimated 5-year overall survival (OS) and progression-free survival (PFS) for the cohort were 77.3% (95% confidence interval (CI): 55.3-90.4%) and 72.2% (95% CI: 51.5-86.4%), respectively. The estimated 5-year PFS for FDG-PET and CIm staged N2-3 disease was 70% (95% CI: 42.8-87.9%) and 55.3% (95% CI: 23.3-83.4%), respectively. FDG-PET shows increased sensitivity over CIm for staging nodal disease in anal cancer and changes treatment intent or radiotherapy prescription in a significant proportion of patients.

Clinical influence of 18F-fluorodeoxyglucose positron emission tomography on the management of primary tumours of the thymus.

The objective of the current study was to evaluate the effect of PET on the management of primary tumours of the thymus. Patients with a primary tumour of the thymus who underwent PET were identified from a prospective database. Forty-three PET scans were carried out on 26 patients with primary thymic tumours. Sensitivity, specificity and accuracy were 79, 100 and 85%, respectively. Conventional imaging and PET findings were discordant in 10 cases (23%). PET appropriately changed patient management in three (7.0%) cases based on accurate results that differed from pre-PET imaging. Most PET scans carried out (88%) did not influence clinical management. Patient comorbidities, limited treatment options and already planned surgery are factors that may hinder the effect of PET in the setting of thymic tumours. The potential for false-negative results, probably because of a combination of low-fluorodeoxyglucose avidity and small volume residual disease, needs to be considered in management planning. However, the positive predictive value of PET is high and enables appropriate modification of management in a small, but potentially important subset of patients.

The impact of 18-fluorodeoxyglucose positron emission tomography-computed tomography on the staging and management of primary rectal cancer.

PURPOSE: 18-Fluorodeoxyglucose positron emission tomography-computed tomography (FDG PET-CT) has a role in recurrent colorectal cancer. This study was designed to assess the impact of PET-CT on management of primary rectal cancer. METHODS: Eighty-three patients with rectal cancer underwent PET-CT scan between 2002 and 2005. Referring physicians prospectively recorded stage and management plan after conventional imaging before PET-CT scan, which were compared to subsequent stage and management after PET-CT. RESULTS: Staging PET-CT caused a change in stage from conventional imaging in 26 patients (31 percent). Twelve (14 percent) were upstaged (7 change in N stage; 4 change in M stage; 1 change in N and M stage), and 14 (17 percent) were downstaged (10 change in N stage; 3 change in M stage; 1 change in N and M stage). PET-CT scan altered management intent in seven patients (8 percent) (curative to palliative 6 patients; palliative to curative 1 patient). Management was altered in ten patients (12 percent). There was no difference in impact with respect to tumor height. CONCLUSIONS: PET-CT scan impacts the management of patients with primary rectal cancer and influences staging/therapy in a third of patients and should be a component of rectal cancer workup.

The effects of gas flow on granular currents.

Currents of particles have been quite successfully modelled using techniques developed for fluid gravity currents. These models require the rheology of the currents to be specified, which is determined by the interaction between particles. For relatively small slow currents, this is determined primarily through friction, which can be controlled and reduced by fluidizing the particles, so that they may become much more mobile. Recent results cannot be predicted using many of the proposed models, and may be defined by the interaction between the particles and the fluid through which they are passing. However, in addition, particles that are only initially fluidized also form currents that are also mobile, but otherwise are different from continuously fluidized currents. The mobility of these currents appears not to be connected to the time taken for them to degas. This suggests that defining the continuous stresses on the particle current may not be sufficient to understand its motion and that a challenge for the future is to understand the structure of these flows and how this affects their motion.

Applying Real-Time Quantitative PCR to Fusarium Crown Rot of Wheat.

Fusarium crown rot (FCR) of wheat is a persistent problem that causes significant losses worldwide. In Montana, FCR is caused primarily by Fusarium culmorum and F. pseudograminearum. Recently, a real-time quantitative PCR (QPCR) assay was developed for FCR using primers and probes specific for a segment of the trichodiene synthase (tri5) gene. The purpose of this study was to determine the utility of QPCR for accessing FCR severity on wheat in field experiments. In 2004 and 2005, plots of spring and durum wheat were inoculated with varying levels of F. pseudograminearum oat inoculum and grown under rain-fed conditions. Two weeks prior to harvest, plants were collected from the plots and assessed for FCR severity and analyzed by QPCR for Fusarium DNA quantities. Disease severity scores (DSS) and Fusarium DNA quantities were positively correlated with each other for all three cultivars in 2004 but for only the durum cultivar in 2005 (P < 0.05). In 2004, grain yields for both spring wheat cultivars were negatively correlated with Fusarium DNA quantities (P > 0.05). When DSS and Fusarium DNA quantities negatively correlated with yield, both measurements were comparable in predicting yield reduction (R = -0.64 and -0.77, respectively). Results indicate that this QPCR assay is effective in measuring FCR severity in wheat.

Wheat puroindolines interact to form friabilin and control wheat grain hardness.

Wheat grain is sold based upon several physiochemical characteristics, one of the most important being grain texture. Grain texture in wheat directly affects many end use qualities such as milling yield, break flour yield, and starch damage. The hardness (Ha) locus located on the short arm of chromosome 5D is known to control grain hardness in wheat. This locus contains the puroindoline A ( pina) and puroindoline B ( pinb) genes. All wheats to date that have mutations in pina or pinb are hard textured, while wheats possessing both the 'soft type' pina-D1a and pinb-D1a sequences are soft. Furthermore, it has been shown that complementation of the pinb-D1b mutation in hard spring wheat can restore a soft phenotype. Here, our objective was to identify and characterize the effect the puroindoline genes have on grain texture independently and together. To accomplish this we transformed a hard red spring wheat possessing a pinb-D1b mutation with 'soft type' pina and pinb, creating transgenic isolines that have added pina, pinb, or pina and pinb. Northern blot analysis of developing control and transgenic lines indicated that grain hardness differences were correlated with the timing of the expression of the native and transgenically added puroindoline genes. The addition of PINA decreased grain hardness less than the reduction seen with added PINB. Seeds from lines having more 'soft type' PINB than PINA were the softest. Friabilin abundance was correlated with the presence of both 'soft type' PINA and PINB and did not correlate well with total puroindoline abundance. The data indicates that PINA and PINB interact to form friabilin and together affect wheat grain texture.

Inhibition of Chk1-dependent G2 DNA damage checkpoint radiosensitizes p53 mutant human cells.

Cell cycle checkpoints are surveillance mechanisms that monitor and coordinate the order and fidelity of cell cycle events. When defects in the division program of a cell are detected, checkpoints prevent the pursuant cell cycle transition through regulation of the relevant cyclin-cdk complex(es). Checkpoints that respond to DNA damage have been described for the G1, S and G2 phases of the cell cycle. The p53 tumour suppressor is a key regulator of G1/S checkpoints, and can promote cell cycle delay or apoptosis in response to DNA damage. The importance of these events to cellular physiology is highlighted by the fact that tumours, in which p53 is frequently mutated, have widespread defects in the G1/S DNA damage checkpoints and a heightened level of genomic instability. G2/M DNA damage checkpoints have been defined by yeast genetics, though the genes in this response are conserved in mammals. We show here using biochemical and physiological assays that p53 is dispensable for a DNA damage checkpoint activated in the G2 phase of the cell cycle. Moreover, upregulation of p53 through serine 20 phosphorylation, does not occur in G2. Conversely, we show that the Chk1 protein kinase is essential for the human G2 DNA damage checkpoint. Importantly, inhibition of Chk1 in p53 deficient cells greatly sensitizes them to radiation, validating the hypothesis of targeting Chk1 in rational drug design and development for anti-cancer therapies.

(18)F-FDG PET provides high-impact and powerful prognostic stratification in staging newly diagnosed non-small cell lung cancer.

UNLABELLED: Survival of lung cancer patients remains poor despite increasingly aggressive treatment. Conventional staging has well-described limitations. (18)F-FDG PET has been shown to stage lung cancer more accurately than does CT scanning, but the impact on patient treatment and outcome is poorly defined. This study evaluated this impact in routine clinical practice within a tertiary oncology facility. METHODS: For 153 consecutive patients with newly diagnosed non-small cell lung cancer, the treatment plan based on conventional staging methods was compared with the treatment plan based on incorporation of PET findings. Survival was analyzed using the Cox proportional hazards regression model. RESULTS: For broad groupings of stage, 10% of cases were downstaged and 33% upstaged by PET. When assessable, the PET stage was confirmed in 89% of patients. PET had a high impact on 54 patients (35%), including 34 whose therapy was changed from curative to palliative, 6 whose therapy was changed from palliative to curative, and 14 whose treatment modality was changed but not the treatment intent. For 39 patients (25%), a previously selected therapy was altered because of the PET findings. The Cox model indicated that the pre-PET stage was significantly associated with survival (P = 0.013) but that the post-PET stage provided much stronger prognostic stratification (P < 0.0001) and remained significant after adjustment for treatment delivered. CONCLUSION: Staging that incorporated PET provided a more accurate prognostic stratification than did staging based on conventional investigations. Further, the additional information provided by PET significantly and appropriately changed management in the majority of patients.

Hypoxia-selective antitumor agents. 16. Nitroarylmethyl quaternary salts as bioreductive prodrugs of the alkylating agent mechlorethamine.

Nitrobenzyl quaternary salts of nitrogen mustards have been previously reported as hypoxia-selective cytotoxins. In this paper we describe the synthesis and evaluation of a series of heterocyclic analogues, including pyrrole, imidazole, thiophene, and pyrazole examples, chosen to cover a range of one-electron reduction potentials (from -277 to -511 mV) and substitution patterns. All quaternary salt compounds were less toxic in vitro than mechlorethamine, and all were more toxic under hypoxic than aerobic conditions, although the differentials were highly variable within the series. The most promising analogue, imidazole 2, demonstrated DNA cross-linking selectively in hypoxic RIF-1 cells, and was active in vivo in combination with radiation or cisplatin. However, 2 also produced unpredictable toxicity in vivo, suggestive of nonspecific nitrogen mustard release, and this has restricted further development of these compounds as hypoxia-selective cytotoxins.