Bendamustine: Safety and Efficacy in the Management of Indolent Non-Hodgkins Lymphoma

Bendamustine (Treanda, Ribomustin) was recently approved by the US Food and Drug Administration (FDA) for treatment of patients with rituximab refractory indolent lymphoma and is expected to turn into a frontline therapy option for indolent lymphoma. This compound with amphoteric properties was designed in the former Germany Democratic Republic in 1960s and re-discovered in 1990s with multiple successive well-designed studies. Bendamustine possesses a unique mechanism of action with potential antimetabolite properties, and only partial cross-resistance with other alkylators. Used in combination with rituximab in vitro, bendamustine shows synergistic effects against various leukemia and lymphoma cell lines. In clinical studies, bendamustine plus rituximab is highly effective in patients with relapsed-refractory indolent lymphoma, inducing remissions in 90% or more and a median progression-free survival of 23–24 months. The optimal dosing and schedule of bendamustine administration is largely undecided and varies among studies. Results of ongoing trials and dose-finding studies will help to further help ascertain the optimal place of bendamustine in the management of indolent NHL

Heterozygous Variants in KMT2E Cause a Spectrum of Neurodevelopmental Disorders and Epilepsy.

We delineate a KMT2E-related neurodevelopmental disorder on the basis of 38 individuals in 36 families. This study includes 31 distinct heterozygous variants in KMT2E (28 ascertained from Matchmaker Exchange and three previously reported), and four individuals with chromosome 7q22.2-22.23 microdeletions encompassing KMT2E (one previously reported). Almost all variants occurred de novo, and most were truncating. Most affected individuals with protein-truncating variants presented with mild intellectual disability. One-quarter of individuals met criteria for autism. Additional common features include macrocephaly, hypotonia, functional gastrointestinal abnormalities, and a subtle facial gestalt. Epilepsy was present in about one-fifth of individuals with truncating variants and was responsive to treatment with anti-epileptic medications in almost all. More than 70% of the individuals were male, and expressivity was variable by sex; epilepsy was more common in females and autism more common in males. The four individuals with microdeletions encompassing KMT2E generally presented similarly to those with truncating variants, but the degree of developmental delay was greater. The group of four individuals with missense variants in KMT2E presented with the most severe developmental delays. Epilepsy was present in all individuals with missense variants, often manifesting as treatment-resistant infantile epileptic encephalopathy. Microcephaly was also common in this group. Haploinsufficiency versus gain-of-function or dominant-negative effects specific to these missense variants in KMT2E might explain this divergence in phenotype, but requires independent validation. Disruptive variants in KMT2E are an under-recognized cause of neurodevelopmental abnormalities

Recognising the challenges of collaborative, multi-site research

Background: Collaborative multi-site research is gaining recognition. In particular, across stakeholders in the health and social care professions, there has been an increase in the documentation of such approaches, with the majority acknowledging the strengths and few identifying the pitfalls. Four universities in the south west of England collaborated on the design, analysis and implementation of a project scoping the staff development needs of nursing and midwifery academics to meet the National Health Service Modernisation Agenda in the United Kingdom. Aim: This paper highlights the challenges and the lessons learned from each stage of the process of this large multi-site collaborative study. Consideration has been given to addressing the site-specific differences as well as the politics of the processes and power relations across the research team. Discussion: From an analytical reflection across the team, there were a number of lessons learned from the process of collaboration. Initially, the main challenge was the selection of the team and lead researcher and these were its greatest success. Nevertheless, managing each individual's competing roles within the organisation remained problematic. Particular challenges included gaining consensus on the research design, the chosen sample and data collection to reflect the site-specific differences and were overcome through discussion and effective leadership. Towards the end of the study, adequately representing each institution in the findings, as well as dissemination have remained the greatest challenges. Conclusions: While collaboration has been lauded as a way forward, this analysis of the process highlights some of the difficulties of working as a multi-site virtual team who are widely spread geographically and who have no previous connection. At different stages of the process there has been acknowledgement of the political dimensions affecting such an approach and a need to avoid the pitfalls of collaborative working in order to harness the potential of all team members, if success is to be achieved

Thermodynamic properties of B2-AlFeNi alloys. Part I: Investigation by Knudsen effusion mass Spectrometry

The vaporization of Al-Fe-Ni alloys has been investigated in the temperature range 1180 to 1508 K by Knudsen effusion mass spectrometry (KEMS). Fourteen different compositions were examined in the B2 region: 10 compositions at two fixed Al concentrations, X-Al = 0.45 and X-Al = 0.50 plus four extra compositions at constant X-Ni/X-Fe = 1. For the first time, reliable partial pressures and thermodynamic activities of Al, Fe, and Ni have been evaluated from the measured ion intensities for both the alloy and the pure element. Gibbs energies, partial molar enthalpies, and entropies of formation for all the components have also been obtained. The relative partial molar enthalpies and entropies were found to be nearly temperature independent over the wide temperature ranges investigated. At 1400 K, the Gibbs energy of formation of Al0.50Fe0.25Ni0.25 and Al0.45Fe0.275Ni0.275, with Al(liq), Fe(fcc), and completely paramagnetic Ni(fcc,cpm) as reference states, are -37.9 +/- 0.42 kJ/mol and -38.1 +/- 0.42 kJ/mol, respectively. At the same temperature, the enthalpies of formation of Al0.50Fe0.25Ni0.25 and Al0.45Fe0.275Ni0.275, with the same reference states, are -51.5 +/- 1.7 kJ/mol and -49.2 +/- 1.7 kJ/mol, respectively

Effects of antiplatelet therapy on stroke risk by brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases:subgroup analyses of the RESTART randomised, open-label trial

Background: Findings from the RESTART trial suggest that starting antiplatelet therapy might reduce the risk of recurrent symptomatic intracerebral haemorrhage compared with avoiding antiplatelet therapy. Brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases (such as cerebral microbleeds) are associated with greater risks of recurrent intracerebral haemorrhage. We did subgroup analyses of the RESTART trial to explore whether these brain imaging features modify the effects of antiplatelet therapy. Methods: RESTART was a prospective, randomised, open-label, blinded-endpoint, parallel-group trial at 122 hospitals in the UK that assessed whether starting antiplatelet therapy might reduce the risk of recurrent symptomatic intracerebral haemorrhage compared with avoiding antiplatelet therapy. For this prespecified subgroup analysis, consultant neuroradiologists masked to treatment allocation reviewed brain CT or MRI scans performed before randomisation to confirm participant eligibility and rate features of the intracerebral haemorrhage and surrounding brain. We followed participants for primary (recurrent symptomatic intracerebral haemorrhage) and secondary (ischaemic stroke) outcomes for up to 5 years (reported elsewhere). For this report, we analysed eligible participants with intracerebral haemorrhage according to their treatment allocation in primary subgroup analyses of cerebral microbleeds on MRI and in exploratory subgroup analyses of other features on CT or MRI. The trial is registered with the ISRCTN registry, number ISRCTN71907627. Findings: Between May 22, 2013, and May 31, 2018, 537 participants were enrolled, of whom 525 (98%) had intracerebral haemorrhage: 507 (97%) were diagnosed on CT (252 assigned to start antiplatelet therapy and 255 assigned to avoid antiplatelet therapy, of whom one withdrew and was not analysed) and 254 (48%) underwent the required brain MRI protocol (122 in the start antiplatelet therapy group and 132 in the avoid antiplatelet therapy group). There were no clinically or statistically significant hazards of antiplatelet therapy on recurrent intracerebral haemorrhage in primary subgroup analyses of cerebral microbleed presence (2 or more) versus absence (0 or 1) (adjusted hazard ratio [HR] 0·30 [95% CI 0·08–1·13] vs 0·77 [0·13–4·61]; pinteraction=0·41), cerebral microbleed number 0–1 versus 2–4 versus 5 or more (HR 0·77 [0·13–4·62] vs 0·32 [0·03–3·66] vs 0·33 [0·07–1·60]; pinteraction=0·75), or cerebral microbleed strictly lobar versus other location (HR 0·52 [0·004–6·79] vs 0·37 [0·09–1·28]; pinteraction=0·85). There was no evidence of heterogeneity in the effects of antiplatelet therapy in any exploratory subgroup analyses (all pinteraction>0·05). Interpretation: Our findings exclude all but a very modest harmful effect of antiplatelet therapy on recurrent intracerebral haemorrhage in the presence of cerebral microbleeds. Further randomised trials are needed to replicate these findings and investigate them with greater precision. Funding: British Heart Foundation