Laboratory tests are frequently ordered by general practitioners (GPs), but little is known about time trends and between-GP variation of their use. In this retrospective longitudinal study, we analyzed over six million consultations by Swiss GPs during the decade 2009–2018. For 15 commonly used test types, we defined specific laboratory testing rates (sLTR) as the percentage of consultations involving corresponding laboratory testing requests. Patient age- and sex-adjusted time trends of sLTR were modeled with mixed-effect logistic regression accounting for clustering of patients within GPs. We quantified between-GP variation by means of intraclass correlation coefficients (ICC). Nine out of the 15 laboratory test types considered showed significant temporal increases, most eminently vitamin D (ten-year odds ratio (OR) 1.88, 95% confidence interval (CI) 1.71–2.06) and glycated hemoglobin . Test types both subject to substantial increase and high between-GP variation of sLTR were vitamin D (ICC 0.075), glycated hemoglobin (ICC 0.101), C-reactive protein (ICC 0.202), and vitamin B12 (ICC 0.166). Increasing testing frequencies and large between-GP variation of specific test type use pointed at inconsistencies of medical practice and potential overuse. Laboratory testing is one of the most frequently used diagnostic modalities in health care and influences up to 70% of all critical decisions . During Ideally, the use of laboratory tests should depend exclusively on patient factors that determine a clear indication. However, physician factors are also associated with the decision to order laboratory tests ,10. PhysEven though the majority of laboratory tests in Switzerland are ordered in general practice , requestThis study is a retrospective longitudinal database analysis in Swiss general practice using data from the Family Medicine ICPC  Research using Electronic Medical Records (FIRE) project, which comprises of a network of GPs in German-speaking Switzerland exporting anonymized routine data from their electronic medical records to a central database. Among other information such as demographic patient characteristics, ICPC diagnostic codes, and drug prescriptions, GPs also contribute laboratory testing requests. We assessed data over one decade, ranging from the initiation of the FIRE project on 1 January 2009 to 31 December 2018. During this period, 389 GPs exported information on more than 6 million consultations of over 570,000 individual patients.The local ethics committee of the canton of Zurich waived approval, as the project lay outside the scope of the Federal Act on Research involving Human Beings (BASEC-Nr. Req-2017-00797) .We validated laboratory test data by checking all exported labels, units, and distributions of test results for plausibility as well as for database errors . The test panels complete blood count (CBC), urinalysis, liver enzymes, lipid profile, and electrolytes  were aggregated and considered as single tests. We approached data from all GPs in the FIRE project who exported at least 1000 consultations over the study period. Exclusion criteria were defined for the elimination of rare test types to increase the relevance of results and ensure sample sizes were sufficient for meaningful trend analyses and comparisons. Specifically, we excluded test types requested by less than 10% of all GPs over the observation period or requested by less than 10 GPs during any specific year. In addition, we excluded test types occurring with an among-GP median request rate below 1% of consultations over the study period. For each consultation, we extracted date, presence and type of laboratory test requests, (anonymized) IDs of patients and GPs as well as patient age and sex. Depending on the medical record software, some test types had not been exported by all GPs since their registration in the FIRE project, but export was enabled later during the study period after software updates. To assess testing behavior and frequencies, we therefore defined GP-specific observation starting points for counting both consultations and laboratory requests to fit the dates after which GPs actually started exporting respective test types.We aimed to determine GPs’ test type-specific usage frequencies of selected laboratory tests in terms of requesting rates per consultation and defined specific laboratory testing rates (sLTR) as the percentage of consultations by one single GP in which a specific laboratory test type was requested. Analyses of sLTR comprised of assessment of among-GP distribution, time trends, association with patients’ demographic factors, and measures of between-GP variation by extraction of the sLTR variance component attributable to within-GP clustering. For investigation of general testing variability and general association of testing with patient demographic factors, an overall laboratory testing rate (oLTR) was defined as the percentage of consultations in which at least one of the specific test types ultimately included in our analysis was requested.We approached sLTR analysis on the level of single consultations by definition of test type-specific binary variables denoting whether that particular laboratory test type was requested during a consultation. For oLTR, in an analogous manner, we introduced a binary variable encoding request during a consultation of at least one of the test types considered. For each test type separately, mixed-effect logistic regression was used to model the annual time trend with adjustment for patient sex and age (in years) as fixed factors. Random intercepts on the GP- and patient-level were introduced to account for repeated observations and clustering of patients within GPs. We determined odds ratios (OR) and corresponding 95% confidence intervals (95% CI) to report the effect of fixed factors on sLTR. Null models including time as the only fixed factor, but using the same random factor structure, provided a way to quantify the proportion of sLTR variance attributable to between-GP factors by assessing the corresponding intraclass correlation coefficients (ICC).For analysis of oLTR, we fitted a mixed-effect model with hierarchical random intercepts on the GP- and patient-level with adjustments for patient age and sex as fixed factors to our data. A null random intercept-only model was used for computation of the GP-level ICC. As an additional measure of oLTR variation, we computed the central 90% range of GP-level OR for overall testing from the central 90% range of the GP-level random effect distribution as predicted by the null regression model. This quantity can be interpreted as the OR for requesting any laboratory test during a consultation of a given patient between a GP of relatively high oLTR (95th percentile) and a GP of relatively low oLTR (5th percentile) as predicted by the regression model.p-values using a significance threshold of 0.05.We used R 3.6.3  for data cleaning and statistical analyses with the library lme4 for mixed-effect model fitting ,20. We rn = 3,840,762 requests) out of which 21 were excluded  as they were requested by less than 10% of all GPs over the observation period or by less than 10 GPs during one specific year. Additionally, 54 test types  were excluded for occurring with an among-GP median sLTR below 1% of consultations. To enable meaningful time trend assessment, only test types present for at least five years in the database were considered, leading to exclusion of one test type . In total, 6,116,587 consultations from 574,803 patients  28–61 years) were analyzed after the exclusion of 221 patients  due to missing information about age and/or sex  originated from 389 GPs working in 164 practices. Patients were followed over a median of 206 days (IQR 1–703 days) and were observed in a median number of four consultations (IQR 1–11 consultations). During the observation period (1 January 2009–31 December 2018), we approached 91 test types , associations with patient age in panel (b), associations with patient sex in panel (c), and GP-level ICCs in panel (d)). Numerical results can be found in the Test type-specific mixed-effect regression results are displayed graphically in Of the 15 test types analyzed, 12 were requested more frequently for increasing patient age, with the strongest effect for PT/INR  and electrolytes . On the other side, ferritin , CRP  and CBC  were the only test types showing an increase of sLTR for decreasing patient age. Requesting of 14 test types was associated with patient sex. The strongest association with male sex was seen for lipid profile  and PT/INR , while the test types with strongest female sex association were ferritin  and vitamin D .Concerning between-GP variation, we found the highest GP-level ICC for fasting glucose (0.231), CRP (0.202), and vitamin B12 (0.166), and the lowest for PT/INR (0.000), ferritin (0.018), and lipid profile (0.044).Non-adjusted among-GP median oLTR was 20.2% (IQR 16.9–24.0%) over the study period. In mixed-effect analysis, male patients were found to be tested less frequently than female patients , while increasing patient age was associated with higher oLTR . The GP-level ICC was obtained as 0.032, the central 90% GP-level OR range as 4.2 . In this study, we analyzed more than three million single laboratory tests ordered by almost 400 Swiss GPs during the past decade. The most frequently requested test types were CBC, CRP, and renal function tests. Overall, the among-GP median testing rate amounted to 20% of consultations, but odds spanned over a four-fold ratio between low- and high-frequency testing GPs. Time trend analysis showed an increase of testing rates in two thirds of the included test types, especially vitamin D and HbA1c, which were subject to an almost two-fold increase over the past decade. Laboratory test types ranking high simultaneously in temporal increase and in between-GP variation were CRP, HbA1c, and vitamin B12.We found increasing testing frequencies for most of the test types included in our study. Interestingly, our results mirrored findings from a comparable analysis by O’Sullivan et al. based on data from UK general practice gathered between the years 2000 and 2015 . In bothVitamin D and HbA1c testing rates, however, almost doubled within the past decade and the extent of their increase sets them apart from other test types. Increases and potential overuse of vitamin D and HbA1c tests have been identified in other healthcare settings as well. The rise in HbA1c testing might be linked to its adoption for diagnosis of type 2 diabetes replacing blood glucose testing . While wVariation in laboratory testing was moderate on the level of overall testing. Most of the specific test types, however, were subject to variation exceeding an ICC of 0.05, which is unusual for measures in general practice . Test tyWe used demographic variables primarily to adjust time trends, which was necessary to account for age and sex differences in individual GPs’ patient populations. However, several associations appeared and merit discussion. Increasing patient age was associated with higher requesting frequencies of most test types. This was unsurprising, as conditions requiring laboratory testing accumulate with increasing age . Sex difA major strength of this study is its comprehensiveness in including 89% of single laboratory tests requested by GPs in a large and representative database from Swiss general practice. Trends, associations, and between-GP variation seem plausible and closely match results from comparable studies in the UK, adding to external validity of our research ,29. LastOur study presents several limitations. Firstly, we excluded rarely requested laboratory test types (those with <1% median among-physician sLTR) because they would have led to overdispersion and small sample sizes that would have been difficult to manage statistically and to interpret meaningfully. Secondly, younger GPs employed in urban and sub-urban areas are slightly over-represented in the FIRE database compared to national census . ThirdlyThere is considerable between-GP variation of requesting laboratory tests, in part pointing at potential overuse. Laboratory test types associated with both high temporal increase and high between-GP variation were vitamin D, HbA1c, CRP, and vitamin B12. Our findings highlight the roadmap for initiatives aiming to better understand and ultimately reduce unwarranted variation and potential overuse of laboratory testing in general practice.


Background: Development of effective strategies to reduce sedentary time among older adults necessitates understanding of its determinants but longitudinal studies of this utilising objective measures are scarce.Methods: Among 1536 older adults (≥60 years) in the EPIC-Norfolk study, sedentary time was assessed for seven days at two time-points using accelerometers. We assessed associations of change in total and prolonged bouts of sedentary time (≥ 30 minutes) with change in demographic and behavioural factors using multi-level regression.Results: Over follow-up (5.3±1.9 years), greater increases in total sedentary time were associated with older age, being male, higher rate of increase in BMI, lower rate of increase in gardening , a lower rate of increase in walking  and a higher rate of increase in television viewing. Correlates of change in prolonged sedentary bouts were similar.Conclusion: Individuals in specific sub-groups  and who differentially participate in certain behaviours  but not others increase their sedentary time at a higher rate than others; utilising this information could inform successful intervention content and targeting. Excess sedentary time increases adults’ risk of type 2 diabetes, cardiovascular disease, cancer, poor physical function, poor quality of life, and premature mortality. –3 Time aImportantly, no prospective studies have quantified associations of baseline values and changes in behavioural correlates with changes in sedentary time. As interventions increasingly target both reducing sitting activities and replacing this with physical activities, it is important to have an evidence-base for the choice of activity to target.  If changStudies of sociodemographic correlates have also been neglected, despite the fact they may help us specify who we might most usefully target. This type of studies has been limited by mostly cross-sectional study designs and the use of self-reported measures of sedentary time –17, withIt is particularly important to examine these associations in the neglected group of older adults. Previously observed associations in other groups may not apply given that older adults exhibit different physiology and anthropometry   to theirWe aimed to estimate, in a population-based sample of older English adults, five-year changes in objectively-assessed sedentary time and prolonged sedentary bouts. Further, we sought to be the first study to identify whether these changes were associated with baseline socio-demographic and behavioural factors and changes in these factors over time.Of the 1,587 participants who had accelerometer data at both baseline and follow-up health checks, 51 were excluded due to having <4 valid days of data (42 excluded) or having >19 hr/day average wear-time (9 excluded), leaving a total of 1,536 (96.8%) participants. Sensitivity analyses utilising complete case analysis included 953 and 856 participants for baseline and change in correlate analyses, respectively. All results referred to in the text relate to maximally adjusted models unless otherwise stated.Participants were on average 68.6 years old (SD=6.2) . At base2, 95% CI 0.2, 0.5) and higher rate of increase in BMI . Greater rate of increase in total sedentary time was associated with urban versus rural living  and with higher rate of increase in BMI .Greater rate of increase in prolonged sedentary bout time was associated with older age  . FurtherThis is the first study to examine whether change in accelerometer-assessed sedentary time is associated with baseline behavioural factors and changes in these factors over time. Very few studies have examined these associations with socio-demographic factors. In a US cohort (n=962) of middle-aged adults (45.0±3.5 year at baseline), Gabriel et al.  found thStrengths of our study include utilisation of data from EPIC-Norfolk, a large population-based cohort of older adults in which objective measures of sedentary time were available at two time points. These data allowed us to overcome the two main criticisms of research in this area, namely subjective measure use and cross-sectional design. Some limitations should also be noted. Participants who wore accelerometers may have changed their behaviour as a result of being measured, though changes are unlikely to be sustained over five days. , 31 SecoWe found that older English adults spent significant amounts of their waking hours sedentary, and this sedentary time increased as participants aged. While existing interventions have aimed to reduce total sedentary time, we found that time in prolonged sedentary bouts also increased. Therefore, preventing increases in bouted sedentary time may also be important. We found that specific sub-groups  and particular behaviours  were associated with greater increases in sedentary time. This information should inform the development and targeting of future interventions aimed at reducing total sedentary time and time spent in prolonged sedentary bouts in older adults.We utilised data from the EPIC-Norfolk study, a large prospective cohort of adults living in Norfolk (UK) recruited between 1993-1997 from 35 general practices.  ParticipA total of 8,623 and 5,696 participants ≥60 years old attended the baseline and follow-up assessments, respectively. A sub-sample were invited to wear accelerometers at baseline  and follow-up . We utilised data from individuals who wore accelerometers at both health-checks. Participants were asked to wear accelerometers  on the right hip for 7 days during waking hours and remove them while showering, bathing or swimming. Participants wore a uniaxial accelerometer (GT1M) at baseline and a triaxial accelerometer (GT3X+) at follow-up. Uniaxial monitors were initialised to record activity and step frequency in five-second epochs and triaxial accelerometers were initialised to collect raw acceleration in 100 Hz; both data sources were integrated into 60-second epochs in this analysis.  These twNon-wear time was defined as continuous zero counts of ≥90 minutes . Total sRegistrar-General's Social Classification), job status, highest educational level, and urban/rural status were assessed via a self-completed health questionnaire (2) was calculated based on weight and height measurements taken by trained research staff following standard operating procedures. Change in employment status was derived based on change in self-reported job status from baseline to follow-up. Rate of change in BMI was calculated as the difference between baseline and follow-up values divided by time in years between the baseline and follow-up visits (kg/m2/yr).Age, sex, smoking status, body mass index (BMI), occupational classification  were used to account for missing data. [Descriptive statistics were calculated for change in sedentary time and time in prolonged sedentary bouts. Multiple imputation analyses by chained equations , and then summer and winter time variables separately. For computer use, we assessed associations with total use and then evening and daytime use. We then assessed the association between change in correlates and change in sedentary variables.We examined associations across three models. Model 1 was adjusted for wear-time and season (since season can affect activity levels ) at baseComplete-case and multiple imputation analyses were compared to examine how the missing data may have affected the results. We also used the alternative threshold of ≥5 days of valid wear-time to examine how our inclusion criteria (≥4 days) affected the results.Supplementary Tables


Combining results from multiple imaging techniques  through image registration can result in the better characterization of joint tissue characteristics. In the context of inflammatory arthritis conditions, high-resolution peripheral quantitative computed tomography (HR-pQCT) provides excellent bone contrast while magnetic resonance imaging (MRI) provides superior contrast and resolution of soft tissue and inflammatory characteristics. Superimposing these imaging results upon each other provides a robust characterization of the joint. In a preliminary study of nine rheumatoid arthritis (RA) participants in clinical remission, we acquired HR-pQCT and MR images of their 2nd and 3rd metacarpophalangeal (MCP) joints at two timepoints 6 months apart. We present the benefits of a multi-modal imaging approach, in which we demonstrate the ability to localize regions of inflammation with subtle changes in bone erosion volume. Using HR-pQCT and MRI to visualize bone damage and inflammation, respectively, will improve our understanding of the impact that subclinical inflammation has on bone damage progression, and demonstrating if bone repair occurs where inflammation is resolved. The presented multi-modal imaging technique has the potential to study the progression of bone damage in relation to inflammation that otherwise would not be possible with either imaging technique alone. The multi-modal image registration technique will be helpful to understanding the development and pathogenesis of RA-associated bone erosions. Additionally, multi-modal imaging may provide a technique to probe the tissue-level changes that occur as a result of treatment regimes. Inflammatory arthritis conditions are complex in pathophysiology and affect many joint tissues. Imaging plays an important role in the diagnosis, treatment evaluation and understanding of pathophysiological processes. Every imaging modality has its own strengths and weaknesses for tissue and disease assessment, due to their differing abilities to provide tissue contrast, spatial resolution, and access to joints of interest. In the context of inflammatory arthritis, conventional radiography provides 2-dimensional (2D) planar, projection images of structural damage  of bony features. Computed tomography (CT) provides 3-dimensional (3D) views, resulting in greater contrast and spatial resolution to visualize the same bony features; however, this is at the expense of greater radiation exposure depending on the joints of interest and their proximity to radiation-sensitive tissues and organs. High-resolution peripheral quantitative computed tomography (HR-pQCT) is a CT modality adapted for imaging extremities and provides significantly enhanced contrast, superior spatial resolution of bony features, and reduced radiation dose when compared to conventional whole-body CT. While originally introduced to image the distal tibia and distal radius, applications of HR-pQCT have extended to include the hand, wrist and knee joints –3. HR-pQIn contrast to HR-pQCT's excellent spatial resolution of bone, ultrasound and magnetic resonance imaging (MRI) have superior contrast and resolution of soft tissue and can detect features of inflammation. While ultrasound can acquire multiplanar images and facilitate the identification and grading of superficial bony features , 11, thiTo date, most multi-modal imaging studies examine each imaging modality independently from one another. However, the 3D multiplanar image acquisition from CT and MRI can facilitate the superimposition of images after accurate image co-registration and transformation, providing complementary information  to better characterize the entire joint.A strategy to visualize and understand bone damage in inflammatory arthritis within a patient is to align and superimpose images acquired from longitudinal time points or multiple imaging modalities using a computational tool known as image registration. We present a brief overview of image registration as a technique that can be used for joint-based imaging on HR-pQCT and MRI datasets.rigid or non-rigid fashion. Rigid image registration aligns the anatomy within the images, without changing the shapes, by a series of rotations and translations. Rigid registration is particularly useful when aligning images from the same individual where differences in overall bone shape and size are not expected but the position may differ; acquired either at different times from the same modality, or from multiple modalities at the same time. In contrast, non-rigid or deformable image registration may allow for local image deformations to facilitate their registration. This technique is beneficial to align images from different individuals to either compare differences in shape or define a common region of interest across multiple individuals, or from the same individual when differences in anatomical shape or size exist between the images.Image registration is a computational process which iteratively searches for the best alignment based on common information within two or more images. The “best” alignment is defined by metrics such as mutual information or the cross-correlation coefficient , 17. TheAn initial guess of the translations and rotations is typically required to initialize the registration; this can be accomplished by identifying anatomical landmarks on each image, or by using physical properties of the image such as the center of mass. An optimization algorithm then iteratively searches for the most appropriate transformation  to reorient and optimally fit one image onto another image , until nrigid image registration is ideal to align baseline and follow-up images from the same participant on the same imaging modality—ensuring the same region-of-interest is evaluated at both timepoints and improve reproducibility , and new structural damage is small relative to the overall size and shape of the bone. However, the main barriers to accurate measures of bone remodeling using this technique are patient motion during the scan time and slow bone remodeling rates, as thickness changes must exceed the true spatial resolution of the scanner at ~100 μm . As intensity values between imaging modalities represent different tissues, we use mutual information to align images from multiple modalities , 25. ThiTimely, target-driven therapeutic intervention with disease modifying medications is currently an effective mechanism to achieve clinical remission in rheumatoid arthritis (RA). Clinical remission is typically defined by a combination of low tender and swollen joint count, patient reported outcomes, and inflammatory biomarkers in RA patients. However, many patients classified as in clinical remission, with an absence of painful, tender or swollen joints on clinical exam, have evidence of “sub-clinical inflammation” present on MRI or ultrasound . UnfortuIn a preliminary study of nine RA participants recruited based on physician-classified clinical remission, we acquired HR-pQCT  images of the 2nd and 3rd metacarpophalangeal (MCP) joints and MR images  of 2nd to 5th MCP joints of the same hand at baseline and 6-month follow-up. The combination of HR-pQCT and a 6-month follow-up was selected because previous research has demonstrated that bone changes may be detected with HR-pQCT as early as three- to 6-months ; thus, HThree-dimensional (3D) volumetric joint space width  was quantified on HR-pQCT images . Erosionp < 0.05. Changes in erosion volume and JSW at the individual joint level were evaluated against the least significant change (LSC)  in RStudio v1.1.423. To examine group-level time effects, the Wilcoxon rank sum test was used for clinical outcomes and RAMRIS scores, while a non-parametric marginal model for longitudinal designs [nparLD package in R ] was usege (LSC) , which wge (LSC) . Using tge (LSC) . ResultsThe nine participants  in clinical remission [DAS28CRP 1.75 (1.63–2.6)], ESR 7 (3–11), CRP 3.4 (1.1–4.2), were 62 (59–63) years old, and had been diagnosed with RA for 7.8 (5.1–8.0) years. All participants were being treated with conventional disease-modifying anti-rheumatic drugs , six with biologic DMARDs , 1 with denosumab (a biologic non-DMARD) and 1 with 2.5 mg bi-daily prednisone.p = 0.03). There were trends toward further improvements in DAS28 , Jebsen Taylor Hand Function test z-score , HAQ score , the self-reported Disabilities of the Arm, Shoulder, and Hand questionnaire  and pain .Group level results are presented for those in clinical remission only. Over the 6-month follow-up, there was a significant improvement in patient global assessment . When compared with the LSC, the joint space parameters remained stable except for one patient who showed a decrease in minimum joint space width (−0.42 mm) in one joint.The analysis for JSW and erosions was performed on the acquired HR-pQCT of the 2nd and 3rd MCP joints; however, for both analyses, the same two participants were excluded due to motion (4 joints) and 2 additional joints from two separate participants could not be segmented accurately. Therefore, a total of 12 joints were analyzed across 7 participants. At the group level, there were no significant changes over time in any of the joint space outcomes . When compared against the LSC, 5 patients had erosion volumes that stayed stable in 10 joints, one patient had a decrease in total erosion volume (−2.3 mm3) in one joint, and one participant had an increase in erosion volume (+2.1 mm3) in one joint. These changes can be visualized with longitudinal image registration .Across the 12 joints from 7 participants, 19 erosions were found to range in size from 0.19 mmp > 0.05) in RAMRIS scores between baseline and follow-up for synovitis, edema, or erosions.The RAMRIS total score across MCP joints 2–5 for all 9 patients in clinical remission was 3.0 (1–6) for synovitis, 2.0 (1–2) for bone marrow edema, and 2 (2–4) for erosions at baseline. At follow-up the mean total scores were 5 (3–6) for synovitis, 2 (1–5) for bone marrow edema, and 3 (2–6) for erosions. There were no significant differences , and 8 joints had a synovitis score of 2 (moderate). Over the 6-month period, 9 joints were scored as stable, 5 joints had an increase of 1, 1 joint had an increase of 2, and 3 joints had a decrease in synovitis.For bone edema at baseline in the 2nd and 3rd MCPs, 10 joints had no edema at either the proximal phalange or distal metacarpal, and 8 joints had an edema score of 1 (which represents a volume of bone infiltration between 1 and 33% by the edema). Over the 6-month period, 11 joints had stable bone edema status, while 5 joints showed an increase in edema, and 2 joints showed a decrease in edema.For the baseline erosions scored on MRI, 9 participants had evidence of erosions on the 2nd MCP. Eight of these had an erosion score of 1 (1–10% of bone covered by erosion) and one bone had an erosion score of 2 (11–20% bone covered by erosion). For the 3rd MCP, 4 participants had evidence of erosions with 3 having a score of 1, and 1 participant having a score of 2. Over the 6-month period, 12 joints had stable erosion scores on MRI while 2 joints showed decreases and 4 joints showed increases.One participant with no evidence of bone marrow edema or synovitis near the site of the erosion underwent a significant decrease in erosion volume, assessed by HR-pQCT, over the 6-month follow-up. This was also consistent with a decrease in MRI erosion score. In contrast, all participants who presented with MRI-evidence of inflammation within the joints maintained no change in erosion volume over the 6-month follow-up, similarly to those in clinical remission.At the group level, baseline bone marrow edema was not associated with increased erosion volume, however the participant with the largest increase in erosion volume also demonstrated progression in the bone marrow edema score. In addition, more participants had changes in erosion severity when evaluated by MRI than by HR-pQCT .One participant had a significant decrease in minimum JSW . This paWe have presented the benefits of a multi-modal imaging approach through our ability to now localize how synovitis and bone marrow edema affect bone damage in RA patients. This was achieved by using accurate image registration, to facilitate improved reproducibility by adjusting for differences in positioning between scans and accurately mapping soft tissues and inflammation onto bone. In addition, we observed discordances in erosion changes assessed by HR-pQCT and MRI. The higher spatial resolution of the HR-pQCT images, combined with longitudinal registration allowed us to detect bone changes with greater sensitivity and reproducibility , 37, 38—While we have shown the utility of HR-pQCT for research purposes, its applicability as routine imaging in clinical studies remains unknown. Motion artifact due to patient motion during acquisitions can result in missing data. While we implemented an overlapping stacking process, which significantly reduced the need to discard scans due to motion artifact, rather than eliminating the artifact, this process simply smoothed the data . CurrentDespite these limitations, the finding of more erosion changes in RAMRIS scores than HR-pQCT was surprising. Two of the joints with erosion progression on MRI had an erosion that was identified at follow-up but not baseline on MRI; the same erosions were identified but at both times on HR-pQCT. This discrepancy may be the result of differences in positioning on the MRI at baseline and follow-up resulting in the inability to see the small erosion at baseline or the improved sensitivity of HR-pQCT as a tool for erosion identification. Also, there were scans that met our motion scoring criteria, but within the volume of the erosion on HR-pQCT there was motion that appeared to hinder the erosion volume segmentation on HR-pQCT. Finally, an increase of 1 for the RAMRIS erosion equates to only a 10% increase in erosion volume. Despite the increased sensitivity of HR-pQCT, a change of only 10% in the erosion volume would generally not result in a change that exceeds the LSC.Despite the minimal bone changes observed across the participants over multiple time-points, likely explained by the patients' low disease activity, short follow-up period and sample size, we have presented the benefits of a multi-modal imaging approach that can be utilized to simultaneously visualize, localize, and characterize how synovitis and bone marrow edema may affect bone damage in RA patients. The combination of HR-pQCT and MRI to visualize bone damage and inflammation, respectively, provides the ability to probe mechanistic questions about whether bone loss occurs via an inside-out or outside-in approach , 42, 43,Overall, multi-modal imaging can be combined synergistically with functional and biochemical imaging. Examples of other applications include combining CT with positron emission tomography (PET). PET/CT using 2-deoxy-2[18F]fluoro-d-glucose (FDG) to visualize glucose metabolism has been has recently been used to investigate increased glycolysis due to inflammation in inflammatory arthritis, demonstrating correlations between metabolic markers identified with PET and clinical diseases activity in rheumatoid arthritis , and betMulti-modal imaging enables investigation of underlying tissue pathology using non-invasive techniques. Advances in hardware and software have enabled unprecedented spatial and contrast resolution. Combined with image registration and other image processing techniques, multi-modal imaging provides the great potential to study the mechanisms underlying tissue changes in inflammatory arthritis that otherwise would not be possible with any single imaging technique alone.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Conjoint Health Research Ethics Board at the University of Calgary. The patients/participants provided their written informed consent to participate in this study.PS, GH, CB, and SM contributed conception and design of the study. SB, CB, and SM acquired the data. SB and JT performed data analysis. JT and SM drafted the manuscript. All authors contributed to manuscript revision, read, and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Among the 33 patients with detrusor overactivity (DO), patients who received BoNT-A had a higher cure rate of incontinence  and less required antimuscarinic agent or beta-3 agonist  compared to patients who did not receive BoNT-A injection. There was no significant difference in the incidences of adverse events between two groups. BoNT-A injection with MUS demonstrated efficacy and safety in the treatment of mixed urinary incontinence, specifically for women with DO. This study aimed to evaluate and compare the efficacy and safety of mid-urethral sling (MUS) with botulinum toxin A (BoNT-A) versus MUS only in women with mixed urinary incontinence. This was a comparative observational study, and total of 73 patients were enrolled. A total of 38 and 35 patients received MUS only and MUS with BoNT-A injection, respectively. The efficacy outcome included change in Urinary Incontinence Outcome Scores (UIOS), change in Overactive Bladder Symptom Score (OABSS), and use of antimuscarinic agent or beta-3 agonist. Safety assessments included adverse events including urinary retention, increased postvoid residual volumes, and urinary tract infection. MUS with BoNT-A injection was insignificantly better than MUS only in urinary incontinence outcome (88% vs. 71%, respectively,  Urinary incontinence is a common disease observed in women, with an approximately 29–75% prevalence . The comA high incidence of mixed urinary incontinence (MUI) is observed, or SUI and UUI coexist . AccordiWe made a hypothesis that combining MUS and intravesical BoNT-A injection could have a therapeutic effect on MUI better than that of MUS alone. This study aimed to compare the efficacy and safety of MUS with or without intravesical BoNT-A injection in women who have MUI. The primary endpoints are changes in UUI episodes from baseline to week three. The secondary endpoints are add-ons in antimuscarinic agents or beta-3 agonists compared with baseline. Safety assessments included all common potential adverse events of MUS and BoNT-A intravesical injection, including urinary retention, increased postvoid residual volumes, and urinary tract infection (UTI).p = 0.085, From July 2017 to June 2019, a total of 73 women with moderate to severe MUI were included in this observational study. The median age was 54.78  years. Of these, 38 patients underwent MUS only (group 1). Thirty-five patients received simultaneous MUS and intravesical injection of 80 units of BoNT-A (group 2). Detailed patient characteristics were shown in Seventeen of the 38 patients in group 1 had detrusor overactivity (DO), and 16 (94%) of them indicated that they wanted to receive treatment for OAB 3 weeks after surgery. On the contrary, 10 (48%) of the 21 patients without DO wanted to receive treatment for OAB. In group 2, 16 women had DO, and five patients wanted to receive medication treatment for OAB. In 19 patients without DO, only four patients wanted to receive medication treatment .p = 0.084). The OABSS in the MUS with BoNT-A group were 9.3 before surgery and 3.5 after 3 weeks of surgery, which showed significant improvement  in the MUS only group before and after 3 weeks of management were 8.5 and 6.1, which were not statistically different  were predictors of successful treatment when MUS was combined with BoNT-A injection , but the difference was statistically insignificant. More importantly, not only the symptoms of urinary leakage but also the symptoms of OAB improved in patients receiving both MUS and BoNT-A intravesical injection.p = 0.029) was considered a predictor for the increasing incidence of adverse event such as straining to void [The possible complication of urinary retention is a great concern of patients with MUI receiving MUS and BoNT-A intravesical injection simultaneously. Sun et al. reported that the complication risks of 100 units of BoNT-A intravesical injection included UTI (35%) and urinary retention (8–10%) . In our  to void . Thus, wWe found that using a lower dose of 80 units of BoNT-A prevents urinary retention. Previous studies have pointed out that the lower BoNT-A dose has shorter efficacy . Hence, There are several ways to treat urgency symptoms in MUI such as behavioral therapy, pelvic floor muscle training, and administration of oral medication . Most MUIn our study, decreasing urination flow rate after surgery was associated with MUS or BoNT-A intravesical injection. However, none of the patients required urinary catheterization in our study. Moreover, adjusting the tension of the sling was not needed while we performed MUS surgery combined with BoNT-A intravesical injection, although BoNT-A may strongly reduce the contractility of the bladder. Previous studies pointed out that the mechanism of MUS was supported by a “tension-free” method instead of urethral obstruction .In our study, all of the patients experienced MUI, but the proportion of DO that was observed during the urodynamic examination before surgery was 45%. According to the definition of the ICS , the diaThere were some limitations to this study. First, this was an observation study instead of a randomized controlled trial. According to the guideline of European Association of Urology and American Urological Association, both MUS and BoNT-A intravesical injection are standard treatments for urinary incontinence. In preoperative counseling we explained to every patient that BoNT-A intravesical injection carried 5% incidence of urinary retention and clean intermittent catheterization might be necessary [An 80-unit BoNT-A injection combined with MUS is not only effective but also safe in the treatment of MUI patients. DO and high OABSS are predictive factors for a satisfactory treatment outcome in patients.This retrospective observational comparative study was done in a tertiary referral center. The inclusion criteria were women who had at least one episode of SUI and one episode of UUI in a 3-day voiding diary. Patients with urethral diverticulum, urinary fistula, previous urinary incontinence surgery, intravesical BoNT-A injection, or pelvic floor reconstruction, and history of neurogenic bladder were excluded. If they had previously taken medications for OAB, a 3-week washout period was required before surgery. This study was approved by the Ethic Committee of China Medical University Hospital, and the protocol number was DMR-94IRB-083(FR) .Preoperative evaluation including history assessment, physical examination, urinalysis, urodynamic study, and assessment of OABSS and UIOS were done at the outpatient clinic. The decision of MUS only or MUS with BoNT-A intravesical injection was made by the patient after a detailed explanation of the procedure and morbidities. All patients were reassessed at 1 week, 3 weeks, 3 months, and 6 months after surgery. According to the UIOS, cure, improvement, and failure scored 0, 1–4, and 5, respectively. In our study, a score ranging from 1–5 was defined as the absence of cure .®, Neomedic International, Leganés, Madrid, Spain). The patients in the MUS with BoNT-A group received transobturator MUS and 80-unit BoNT-A intravesical injection.The patients in the MUS only group underwent a surgical procedure performed by a single surgeon (ECL Chou) using a transobturator MUS  version 19.0 statistical software  was used in all statistical analyses.All comparisons of patients’ categorical characteristics and outcomes were assessed using the Fisher’s exact test. Mann-Whitney U test was used to compare the means of continuous variables such as OABSS in two groups. We compare continuous data before and after intervention by Wilcoxon signed rank test. The predictive factor of successful treatment was evaluated by mixed linear regression. All statistical assessments were performed by two-sided analysis, and significant differences were considered at a


To report the first case of belatacept-associated multidrug-resistant Cytomegalovirus retinitis in a kidney transplant recipient.A 76-year-old African male renal allograft recipient was admitted for acute visual loss of the right eye. Ophthalmological examination of the right eye showed anterior uveitis and vitritis associated with large paravascular haemorrhages and yellow necrotic borders, involving the posterior pole but not the fovea. Both Cytomegalovirus DNA in plasma and aqueous humor were positive. The patient had had several episodes of Cytomegalovirus reactivation subsequent to the introduction of belatacept. His cytomegalovirus was multi-drug resistant, and was treated with maribarir, intravitreal and systemic injections of foscarnet, and anti-Cytomegalovirus human immunoglobulin. In parallel, belatacept was stopped and switched to tacrolimus. Cytomegalovirus DNA became undetectable and there was partial improvement of visual acuity at the last ophthalmologic examination, 18 months after the initial diagnosis of Cytomegalovirus retinitis.Cytomegalovirus retinitis is an uncommon opportunistic infection in kidney transplant recipients. Cytomegalovirus retinitis is a serious infection because of the risk of blindness and the occurrence of associated life-threatening opportunistic infections. In view of the recent literature, kidney transplant recipients treated by belatacept immunosuppression may be at increased risk for Cytomegalovirus disease, notably Cytomegalovirus retinitis. The occurrence of Cytomegalovirus retinitis may help improve the selection of patients converted to belatacept. Cytomegalovirus (CMV) is the most frequent pathogen after kidney transplantation. It occurs mainly during the first 6 months after transplantation, secondary to primo-infection (transmission from the donor organ), reactivation of latent infection or reinfection with a different strain . CMV repCMV infection  can result in CMV disease with a range of clinical manifestations from mild viral syndrome to encephalitis, gastro-intestinal disease, hepatitis, myocarditis, pancreatitis, pneumonia, nephritis, retinitis .CMV retinitis is a rarely encountered complication in kidney transplant recipients, in contrast to its frequency in HIV-infected patients. Akova et al. described only one case of CMV retinitis in a monocentric retrospective study over a ten-year period, involving 1156 patients who underwent renal transplantation . Eid et Given the development of belatacept, an immunosuppressive therapy acting as a selective T-cell co-stimulation blocker, and the fact that the immune response against the virus is cellular mediated by CMV-specific T-lymphocytes, it is necessary to identify new potential side effects of belatacept.A 76-year-old African male renal allograft recipient with diabetes mellitus and hypertension, was presented to the hospital with a 14-day history of reduced vision in the right eye.He had received a first kidney transplant in 1995 for end-stage renal disease due to unknown nephropathy. He also had a history of malarial splenomegaly, with a splenectomy in 1992. During his first transplant, the patient developed CMV primo-infection.He then returned for hemodialysis on 12/2003 following the deterioration of renal function in connection with episodes of acute cellular rejection and an allograft glomerulopathy confirmed by histological analysis. Transplantectomy was performed in October 2004 because of abdominal pain and hematuria.In September 2009, he received a deceased donor renal transplant. The donor was a 64-year-old woman, with a history of auto-immune cirrhosis treated by tacrolimus. Induction therapy consisted of basiliximab and maintenance immunosuppression, associated with tacrolimus, mycophenolate mofetil, and methylprednisolone.The CMV and the EBV serostatus at the second transplant were respectively donor (+) /recipient (+) and donor (+)/recipient (+) and he received prophylactic low-dose valganciclovir for 4 months after transplantation. CMV DNA detection, assessed twice on 02/2010, was negative (< 1000 copies/ml).Three months after transplantation, the graft function was impaired (serum creatinine level 320 μmol/L), and graft biopsy revealed tacrolimus toxicity and nephroangiosclerosis, without rejection. Tacrolimus was switched to sirolimus on 02/2010.On 02/2012, sirolimus was switched to belatacept  because of the occurrence of sirolimus-induced bronchiolitis obliterans organizing pneumonia.After 2012, several CMV reactivations occurred, treated by sequential valganciclovir 450 mg/day corrected by GFR . Methylprednisolone and mycophenolate mofetil were respectively lowered to 5 mg and 600 mg × 2/day. CD4 T-lymphocyte count was below 500 cells/μL.On 11/2017, CMV reactivation occurred despite permanent prophylaxy  having been introduced in 2016.He was then admitted with the chief complaint of decreased visual acuity in the right eye. Best corrected visual acuity (VA) was 20/200 in the right eye and 20/20 in the left eye. Intraocular pressure was 10 mmHg in the right eye and 18 mmHg in the left eye. Slit-lamp and fundoscopic examination of the right eye showed respectively anterior uveitis rated to 2+ for both anterior chamber cells and flare, according to the Standardization of Uveitis Nomenclature (SUN) guidelines and vitritis associated with large paravascular haemorrhages and yellow necrotic borders. The retinal lesion was located on the temporal superior vascular arcade and involved the posterior pole but not the fovea, which was confirmed by angiography  was ineffective and CMV DNA increased to 550,000 copies/mL. Analysis confirmed the presence of ganciclovir and cidofovir-resistant CMV, due to UL97 mutation (His520Gln) and UL54 mutation (Pro522Ser). He received an intravitreal injection (IVT) of foscarnet , associated with systemic maribavir 500 mg twice daily and anti-CMV human immunoglobulin . Surgery was not retained. It was decided to stop belatacept and mycophenolate mofetil, and switch to tacrolimus, in association with methylprednisolone 15 mg/day.Slit-lamp examination showed the disappearance of the anterior uveitis within 1 week. Fundoscopic examination showed progressive resorption of the vitritis, and no change in the retinitis , type and dosage of immunosuppressive drugs , donor age (over 60 years old), simultaneous kidney-pancreas transplantation, presence of acute rejection episodes, and chronic graft malfunction , 14. RisThere is insufficient data on the safety of beletacept in relation to CMV infection. Bassil et al. did not find a difference in the rate of CMV viremia between belatacept- and CNI-based regimen in his monocentric 36-month study . The sevIn our case, after the introduction of belatacept, the patient presented several CMV reactivations, then developed a CMV multidrug-resistant infection with active retinitis. The occurrence of CMV retinitis may contribute to the better selection of patients converted to belatacept. Further studies are needed to better identify risk factors for CMV retinitis in kidney transplant recipients.


Mantle Cell Lymphoma (MCL) is a lymphoproliferative disorder which represents less than 10% of all non-Hodgkin Lymphomas. The typical course of MCL is characterized by several relapses (“remitting-relapsing” course), and since its identification it has been considered an incurable disease. Allogeneic stem cell transplantation  has represented in the past years the only treatment which could ensure prolonged remissions, at least in younger patients. In our paper, we critically revised the available data on the use of allo-SCT in MCL. The aim of our review is to identify the subgroups of patients who could best benefit from this therapeutic strategy, the optimal timing for transplantation and the best ways to bridge patients to allo-SCT, in an era in which many novel agents have been developed.MCL is an uncommon lymphoproliferative disorder that has been regarded as incurable since its identification as a distinct entity. Allogeneic transplantation for two decades has represented the only option capable of ensuring prolonged remissions and possibly cure. Despite its efficacy, its application has been limited by feasibility limitations and substantial toxicity, particularly in elderly patients. Nevertheless, the experience accumulated over time has been wide though often scattered among retrospective and small prospective studies. In this review, we aimed at critically revise and discuss available evidence on allogeneic transplantation in MCL, trying to put available evidence into the 2020 perspective, characterized by unprecedented development of novel promising therapeutic agents and regimens. Mantle cell lymphoma (MCL) is an uncommon lymphoproliferative disorder accounting for 6–7% of non-Hodgkin lymphomas and is characterized by the translocation of the Cyclin D1 gene ,3,4. SurFor young and fit patients, high dose cytarabine (Ara-C) containing programs followed by ASCT are recommended ,6. MaintThis review was conducted by a panel of senior authors with expertise in research and clinical practice in MCL. In an initial meeting, which was held in Milan on 17 February 2020, the panel identified the areas of major concern and unmet needs regarding the use of allo-SCT in MCL. The main themes that emerged were indications to allo–SCT, bridging therapy, conditioning regimens, maintenance and salvage treatments for relapses and a comparison between allo–SCT and CAR-T cell therapy. Then, a review of the current state of knowledge on allo-SCT in MCL was performed. Articles published since 2000 on international journals were included in this review. In a subsequent web meeting, which was held on 27 May 2020 all the main points were discussed, some contents were added, and others were reduced. A first revised draft was reviewed from all authors and re-discussed in a web meeting on 22 October 2020.Allo-SCT may represent a therapeutic option for about 20% of all diagnosed MCL cases . UnfortuThese data support the idea that allo-SCT should be considered a well-weighed choice in the clinical practice and each physician should consider several aspects before suggesting this strategy. In the following part of the manuscript, we will analyze the position of allo-SCT within the complex MCL therapeutic scenario, with special attention to the profile of the “very high-risk” younger patients, where allo-SCT appears particularly indicated.One of the most relevant objects of debate is if allo-SCT might be positioned as consolidation of second-line therapy or if it could be adopted upfront in very selected cases .In the ESMO  guidelines edited in 2017, the authors stated that there were no data enough to support the application of allo-SCT as part of front-line treatment . However, allo-SCT, appeared a potentially curative option in the subgroup of early relapsed/refractory younger patients  . The JapThe updated version of the European guidelines confirmed that allo-SCT may represent the best option for young and fit subjects who relapse within 24 months from the first line treatment, but it also suggests to consider allo-SCT for cases with later relapse .A threshold of 24 months has been described to dichotomize patients with meaningful better (progression of disease (POD) > 24 months) or worse outcome (early POD) . In a reThe international retrospective “Mantle First” study, including 258 MCL patients in first relapse, evaluated outcome after second line treatment comparing ibrutinib, R-BAC, R-bendamustine or other approaches. A poorer outcome was observed in patients with early POD independently of the second line regimen; again, in this subgroup, allo-SCT conferred an advantage in terms of survival . On the Several studies demonstrated a similar outcome when allo-SCT was performed in the relapse setting, as compared to its use as consolidation of first line high dose chemotherapy. For example, the German group, in a series of 39 MCL patients, reported a TRM of 24%, a 5-year PFS of 67%, and an OS of 73%, without substantial difference between patients receiving transplant as consolidation of ASCT or at relapse . The absOn the other hand, in an EBMT study no differences were reported for patients who received allo-SCT at first chemosensitive response or later in the course of disease, regardless of the number of regimens needed to achieve this status. Finally, a French study found no survival difference according to number of lines of treatment prior to allo-SCT ,34.Comparison of different studies with such a great heterogeneity in terms of patients clinical and biological features may be tricky and unjustified. Furthermore, biological characterization of patients that were sent to allo-SCT is lacking.Patients experiencing early relapse or chemorefractoriness, similarly to those with an unsatisfying response to the second-line regimens, should be considered candidates for allo-SCT. The majority of the studies demonstrated a comparable survival when allo-SCT was performed in first remission or within second relapse, suggesting that its optimal setting might be first or second relapse, as indicated by international guidelines.primarily chemorefractory subjects, after a reinduction therapy;“very high risk” cases .In two particular subsets of patients, allo-SCT could be positioned earlier in the course of the disease, without a previous treatment with ASCT:Primary chemoresistance is a rare event, occurring in about 10% of cases .Life expectancy of this selected population is very low.The definition of “very high risk” is still matter of debate, because different risk scores have been developed in the last years but only few of them are really used in the clinical practice. MIPI and MIPI-c are based on clinical and histological features. The addition of the Ki-67 assessment to the classical MIPI  allows to classify patients in four prognostic groups with different outcomes , with median OS of 9.4, 4.9, 3.2, and 1.8 years respectively [MIPI-c is commonly used in the real life because it includes easily available parameters; nevertheless, many researchers tried to increase its predictive power by exploring other biological items, such as microRNA (miRNA) expression  and geneThe Fondazione Italiana Linfomi (FIL) MCL0208 trial found that TP53 mutations (tested by NGS) were associated with a dismal outcome: indeed, TP53-mutated patients presented lower median PFS (17 months vs. not reached) and shorter OS (51 months vs. not reached) in respect of wild-type cases. Interestingly, in the TP53-mutated subgroup, neither MRD-negativity before or after ASCT nor the addition of maintenance with lenalidomide seemed able to overcome the negative prognostic impact of TP53 mutations . In addiAllo-SCT seemed to eliminate prognostic differences related to TP53 status: in a cohort of 42 patients who underwent allo-SCT, 2-year OS was 80% and 70%, respectively, for TP53 wild-type and TP53 mutated cases, without a statistically significant difference. This is mostly due to the TP53 independent death mechanisms associated to immunological killing. One alternative hypothesis suggested by the authors is that TP53 alteration would modify the host immunocompetence inducing an immune-suppressive tumor microenvironment and that allo-SCT might have the potential to replace the dysfunctional host immune system and to synergize with chemotherapy .Alternative ways to identify the “very high risk” patients to whom propose allo-SCT include MRD testing and FDG-PET. However, the presence of minimal active disease at the time of allo-SCT does not appear to preclude long-term remissions in advanced MCL patients, differently from what was observed for chemotherapy and ASCT . MoreoveAllo-SCT represents an option always to be considered in refractory cases; moreover, emerging data show its potential curative role in a “very high risk” population. Unfortunately, a unique definition of “very high risk” is still lacking, and many of the tests necessary for calculating the biological risk are not practicable in the routine practice. We suggest that “very high risk” patients are those with at least two of the following adverse features: high proliferative index, TP53 mutations, blastoid morphology.after intensive immuno-chemotherapy (orange box), young and fit patients who achieve complete response (CR) proceed with maintenance .In case of partial response (PR), no response (SD) or relapse/progression (PD), patients receive re-induction therapy  .All patients relapsed before 24 months from the end of the first-line therapy who achieve a CR proceed immediately to allo-SCT .Subjects who relapse later than 24 months proceed to allo-SCT at the first signs of failure of second-line therapy  if <60 years, with matched (related) donor.Patients who do not respond to second-line treatment, receive a third-line therapy  and proceed to allo-SCT at reaching of PR/CR .For cases at very high risk , allo-SCT could be considered as first-line consolidation in some selected patients and discussed with each patient.Even if chemosensitivity prior to allo-SCT is the stronger predictor of outcome, prolonged remissions seem to be possible even among patients with chemotherapy unresponsive MCL. Hamadani et al. identified 202 patients with chemorefractory MCL reported to CIBMTR; 128 received RIC-allo-SCT. 3-years NRM was similarly high regardless of conditioning intensity , suggesting that patients with active disease have significantly increased risk of transplant-related complications. However, the 3-year PFS and OS were 25% and 30%, respectively, with no difference after myeloablative or RIC conditioning .On the other hand, the previously cited registry study by EBMT on 324 MCL patients receiving RIC-allo-SCT reported that the obtainment of CR or PR to the last pre transplant treatment was the best predictor of outcome and chemosensitive patients had less aGVHD. In this series, the cumulative incidence of relapse was 25% and 40% at 1 and 5 years, respectively, and patients with chemorefractory disease had a substantially higher risk of relapse and worse PFS and OS . TessoulOf note, in the cited studies a proportion of patients (15–25%) were unresponsive to the last pre allo-SCT line of treatment; however, also non-responding patients underwent allo-SCT.Nowadays, FDG-PET is widely performed before allo-SCT in order to identify persistent disease. Bachanova et al. evaluated the role of PET response before allo-SCT in patients in radiologic complete or partial response (documented by CT scan) and demonstrated that, in MCL, a positive pretransplantation PET was associated with an increased risk of relapse/progression. However, pre allo-SCT PET status did not appear as a strong predictor of survival, at least in chemosensitive disease by conventional radiographic criteria, and residual PET positivity should not be interpreted as a barrier to a successful allograft .It is not easy to define which strategies might be the best way to bridge R/R MCL patients to allo-SCT. Evidences on the role of transplant in MCL patients are represented by registry studies and refer to patients treated with disparate chemotherapy approaches , Recent Ibrutinib is the most widely used single agent therapy for R/R MCL and it permits the achievement of an ORR of 77% (CR 23%) with a median PFS of 15.6 months. It is reported to be more efficacious as early salvage therapy with published data of 33% CR and median PFS 25.4 months when used as second-line treatment . The preData on acalabrutinib and zanubrutinib seem to go in the same direction as ibrutinib efficacy data, but a more extensive follow-up is needed to confirm such results ,51.Venetoclax seems to be a promising approach, as depicted in a recent UK retrospective study; however, data are still immature  and the study was conducted in heavily pre-treated patients, particularly iBTK-failure patients  .Encouraging results have also been observed in R/R MCL with the combination of venetoclax and ibrutinib ; therefore, these two drugs together could represent an effective bridge strategy; however, data are still immature as in the phase 2 study no patients underwent allo-SCT . FurtherIn R/R MCL, rituximab+bendamustine has an ORR of 75% (CR 50%) and a median PFS of 18 months . R-BAC hIn the era of new drugs allo-SCT still represents the only curative potential approach for patients with R/R MCL.No systematic data are available on bridge to allo-SCT strategy. Available data indicated that ibrutinib may be the preferable bridge-to-transplant choice, while results with second generation iBTK or with the combination of ibrutinib and venetoclax are awaited.R-BAC may represent a good option as bridge to allo-SCT in patients who have relapsed or are refractory to iBTK.The choice of conditioning regimen is common to other histotypes of lymphoma, and not focused on MCL. Myeloablative, non-myeloablative and RIC-allo-SCT may be considered, but there is no clear evidence of the superiority of one of these approaches upon the others . UnfortuThe most used conditioning regimens for allo-SCT in Lymphoma, not only in MCL, are myeloablative conditioning  and non-myeloablative/RIC conditioning .The use of allogeneic stem cell transplantation for the treatment of MCL has been reported since the late 1990s, but the conventional myeloablative conditioning was associated with a high risk of NRM up to 40%, especially in MCL patients who are aged and often with many comorbidities ,58, so tOver the past two decades, nonmyeloablative and RIC regimens have been adopted; these regimens rely primarily on graft vs. lymphoma (GVL) induction, ensuring at the same time a reduced toxicity. Some data regarding RIC-allo-SCT in MCL were collected in 2018 in the previously cited study by the EBMT Lymphoma working party: a large retrospective study that included 324 patients who received RIC-allo-SCT for R/R MCL between 2000 and 2008 after Bu or Cy+ TBI+ purine analog + ATG, or melphalan + purine analog + CAMPATH using a sibling or unrelated donor . Forty tAnother previously cited large retrospective study evaluated RIC-allo-SCT in 106 patients who had received a prior ASCT for MCL, 72% of whom in a first line setting. NRM was described 29% after 12 months and 32% after 3 years, with a median PFS and OS of 30.1 and 62 months, respectively .In conclusion, RIC allo-SCT has been shown to be the safest and most effective strategy; no prospective randomized trials are available to define an optimal RIC regimen among patients with NHL. Myeloablative conditioning should be reserved to selected, very “fit” younger patients.There is no specific recommendation for donor selection in MCL lymphoma: donor age, gender, CMV status, donor-recipient AB0 compatibility, donor-specific antibodies (DSA) in the patient, are the principal characteristics that should be evaluated. Approximately 30% of patients have an HLA matched sibling donor and this represents the established gold standard donor source. In the absence of an HLA-identical sibling, an unrelated donor (URD) who is HLA-matched to the transplant recipient at the allele level at HLA-A, -B, -C, and -DRB1 is currently considered the preferred alternative donor . The likRecently, several Asian centers have reported favorable outcomes of haploidentical transplantation (haplo-SCT), utilizing T-cell–replete grafts with intensive immunosuppression using antithymocyte globulin (ATG) ,64.A different strategy of T-cell–replete haploidentical transplantation being increasingly used involves administration of post transplantation cyclophosphamide, which mitigates the risk of GVHD by targeting alloreactive T cells rapidly proliferating early after an HLA-mismatched transplant, relatively sparing regulatory T cells and leaving unaffected the nondividing hematopoietic stem and progenitor cells .In 2016, the CIBMTR performed a registry analysis in order to evaluate outcomes of lymphoma patients undergoing haplo-SCT and post transplantation cyclophosphamide in comparison with HLA matched sibling donors allo-SCT. Multivariate analysis showed no significant difference between haplo-SCT and HLA matched sibling donors allo-SCT in terms of NRM, Progression/relapse, PFS and OS. Three-year rates of NRM were 15 vs. 13%, relapse/progression 37 vs. 40%, PFS 48 vs. 48% and OS 61 vs. 62%. A lower risk of c GVHD was associated with RIC haplo-SCT with post transplantation cyclophosphamide at 1 year  .Between 2008 and 2013, the center for International Blood and Marrow Transplant Research (CIBMTR) collected data from more than 500 transplant centers worldwide, regarding 199 Hodgkin and 710 non-Hodgkin lymphoma patients (140 were affected by mantle cell lymphoma) undergoing their first RIC or NMA conditioning haploidentical or matched unrelated donor allo-SCT, these latter with ATG or without. Authors suggested that RIC haplo-SCT with post transplantation cyclophosphamide shows a similar, non-statistically different OS at 3 years (between 50–60%) when compared to matched unrelated donor allo-SCT, and that in multivariate analysis no differences were found in terms of NRM, relapse/progression and PFS in the groups. As in the previous registry analysis, a lower risk of c GVHD was associated with RIC haplo-SCT with post transplantation cyclophosphamide .In 2019 Bazarbachi on behalf of LWP-EBMT tried to study if donor characteristics, stem cell source and conditioning could be associated to a different outcome in the setting of haplo-SCT with post transplantation cyclophosphamide in lymphoma. Study population were 474 adults with Hodgkin (240), peripheral T (88), DLBCL (77), mantle cell (40) and follicular lymphoma (29). No advantage of donor age on transplant outcome was found; on multivariate analysis, a decreased risk of aGVHD grade II-IV was observed when offspring donors or bone marrow cells were used. On the contrary, extensive cGVHD was higher in patients in PR at haplo-SCT or when using sisters, haploidentical donors beyond first degree, or female donor in male patients. CR at haplo-SCT improved PFS and OS, whereas these were negatively affected by CMV donor/recipient status. PFS and OS were also different in different lymphoma histotypes: in MCL patients, 2-year PFS and OS of 56% and 61% were observed, respectively .A recent European retrospective study demonstrated superior outcomes in patients affected by Hodgkin and non-Hodgkin lymphomas treated with haplo-SCT in comparison with unrelated cord blood allo-SCT, in terms of OS and PFS .Even if data were extrapolated from studies regarding all lymphoma subtypes and not only MCL, haplo-SCT seems to be non-inferior to HLA-matched URD allo-SCT and superior to unrelated cord blood allo-SCT.Retrospective studies consistently demonstrate significant lower relapse rate for lymphoma patients receiving allogeneic rather than autologous transplantation, even if the high TRM of allogeneic procedure tempers this advantage. The first evidence of Graft Versus lymphoma (GVL) effect was described by Jones and colleagues in 1991, and confirmed by subsequent studies ,69,70. RA GVL effect is mostly demonstrated by the durable resolution of residual or progressive disease after allo-SCT with the withdrawal of immunosuppression and the administration of donor lymphocytes infusions and by the observation that T cell depletion is associated with an increased risk of relapse, even if this is particularly true in the setting of indolent lymphoma ,74,75,76Studies conducted in different lymphoma histotypes concluded that the superiority of allo-SCT on ASCT in terms of lower relapse rates is due to GVL effect and in part due to the reinfusion of purged stem cells. No data are available regarding the evidence of a clear GVL effect in MCL; however, evidences which were demonstrated in other lymphoma subtypes could also be extended to MCL.There are no systematic available data on post allo-SCT maintenance in MCL and no indications in international guidelines.In a pilot study, rituximab has been used in combination with donor-lymphocyte infusion (DLI) as prophylaxis of relapse after allo-SCT  . CurrentThe role of rituximab in pre-emptive treatment of MCL patients with molecular relapse/persistence  after autologous stem cell transplantation (ASCT) is well known ,79. TherESMO Clinical Practice Guidelines for MCL suggest the use of DLI in MRD+ patients post allo-SCT .Most of the studies regarding salvage treatments are retrospective and conducted on few patients. Therapeutic strategies which were adopted in these series include DLI, second allo-SCT, rituximab  ,80,81.The role of ibrutinib as post allo-SCT salvage treatment has been investigated in some studies. The previously cited EBMT study examined the outcome of allo-SCT in chronic lymphocytic leukemia (CLL) or MCL after prior exposure to ibrutinib. Interestingly, in 3 patients with MCL who had post-transplant disease recurrence, one patient was not retreated and rapidly died, another one was re-exposed to ibrutinib with transient response but died of progressive disease 8 months after relapse, and the third patient experienced MCL clearance after DLI .A Case report described complete remission in a MCL patient with a CNS relapse 5 months after allo-SCT, who received ibrutinib as salvage post-transplantation monotherapy .Moreover, two retrospective studies were conducted in MCL and CLL patients on the use of ibrutinib to treat post allo-SCT relapse: in the American study, eighteen-month OS and PFS rates for MCL patients (n = 6) were both 33% ; in the Another EBMT study including 56 patients, confirmed that ibrutinib is an effective and safe salvage therapy after allo-SCT in CLL: this safety message might be applicable to MCL patients, too .An ongoing prospective phase II clinical trial (NCT02869633) is evaluating the role of ibrutinib in patients with relapsed/refractory lymphoma (including MCL) post allo-SCT, and Other recruiting trials include the combination of selinexor and ibrutinib for the treatment of patients with relapsed/refractory CLL or Aggressive NHL, including patients who have undergone allo-SCT (NCT02303392).A recruiting prospective clinical trial (NCT01087294) investigates the use of anti-CD19-CAR-transduced T cells infusion in patients with persisting B-cell malignancies despite allo-SCT and at least 1 standard DLI. At the moment, results on 4 patients with MCL show that three patients maintained a stable disease and one patient achieved a partial response persisting at 3 months from CAR-T cell infusion . FurtherNo systematic available data on post allo-SCT maintenance in MCL;ESMO Clinical Practice Guidelines for MCL do not recommend MRD guided treatment in MCL, with the exception of the setting of DLI treatment post allo-SCT;salvage treatment: better considering DLI than 2 allo-SCT;salvage treatment: case reports of activity and safety of ibrutinib;a few prospective ongoing clinical trials .MCL relapsed/refractory patients after salvage treatment with iBTK have a dismal prognosis. In this setting of patients, allo-SCT represents an option only in patients achieving a second response with salvage regimens, and the NRM, even with reduced intensity therapy, is roughly 10–24%.The anti-CD19 CAR-T therapies are active in relapsed/refractory diffuse large B cell and aggressive lymphomas, where they represent the best third line treatment in young patients not eligible to transplant due to active disease.Preliminary results of CAR-T in MCL showed a promising activity and prompted the conduction of a phase II study.Wang et al.  recentlyThe objective response in all patients was 85%, with 59% complete remission rate; estimated PFS and OS at 1 year were 61% and 83%. In a subgroup analysis, the efficacy of KTE-X19 was independent by high risk features. 24% of patients died: 21% due to progressive disease, while 3% died for infective complications during lymphodepleting chemotherapy before CAR-T infusion.All patients experienced at least one adverse event, and the most frequent were hematological toxicities. Cytokine release syndrome (CRS) occurred in 91% of patients and neurological toxicities in 63% of patients; of note, no deaths related to CRS or neurologic events were observed.The results of ZUMA-2 were impressive and may change the clinical practice in the next future.CAR-T KTE-X19 treatment is feasible and effective also in patients with active disease; allo-SCT is a curative option only in patients achieving a second response with salvage regimens.The follow-up for CAR-T KTE-X19 is short compared to allo-SCT; moreover, even if the experience of aggressive B-cell lymphomas showed that the PFS and OS rates were maintained at longer follow-up periods in patients treated with CAR-T cells, this has to be proven in MCL, a disease characterized by a continuous pattern of relapse even after many years of ongoing complete remission.The results obtained with CAR-T KTE-X19 were observed in a population with a poor prognosis, and all of the patients were pre-treated with iBTK.At the time of relapse after CAR-T KTE-X19, patients could perform a salvage treatment and could receive an allo-SCT as consolidation. On the other hand, previous allo-SCT might impact on the feasibility of a subsequent treatment with CAR-T KTE-X19. The use of allo-SCT as consolidation after the obtainment of a CR with CAR-T KTE-X19 is purely investigational.The NRM ranged between 10 to 24% with transplant strategies; NRM related to CAR-T KTE-X19 is 3%.Regarding feasibility, transplant is based on the availability of a donor . The rate of failure in the manufacture of CAR-T KTE-X19 cells was 4%. However, the relevant economic impact of CAR-T KTE-X19 cells should be considered, as well as its accessibility, which is still limited.However, there are some issues to be considered see :CAR-T KThe integration of CAR-T into the MCL algorithm is still far from being fully established and a number of issues still need to be addressed. One of the most critical is the potential combination of CAR-T and allo-SCT as already performed in other neoplasms ,89,90. TCAR-T KTE-X19 therapy represents an effective and promising salvage treatment strategy in MCL with a high rate of complete responses and a low incidence of relevant toxicities; however, at the moment, follow up is too short to compare its long-term efficacy with that of allo-SCT and its feasibility is still limited.For many years, allo-SCT has represented the only potentially curative option in MCL. Despite this clear clinical effect, its broad usage has always been limited by toxicity and age-related limitations. Consequently, allo-SCT has remained a “niche” treatment reserved to small highly selected patient populations. In future years, the use of allo-SCT will possibly further reduce its therapeutic window due to the advent of several new immunotherapeutic approaches. This is to the case of the major success of current treatment strategies which is not limited to the exciting achievements of cellular therapy, but encompasses better induction treatments based on biological agents and effective maintenance strategies. Nevertheless, the potential benefit of combining allo-SCT and novel immunotherapeutic approaches is also a potential field of interest particularly for high-risk patients. From a historical perspective, it should be noted that many of the treatments currently under study (cellular therapies and T-cell engaging bispecific antibodies) have been conceived based on the bulk of knowledge accumulated in the context of allo-SCT strategies. In such a perspective, novel immunotherapeutic regimens may not be considered as an alternative to allo-SCT, but rather as the ultimate and sophisticated refinement of the old concept of “immunotherapeutic effect” of allogeneic transplantation, an idea that was originally postulated more than sixty years ago .


COVID-19 studies are primarily from the inpatient setting, skewing towards severe disease. Race and comorbidities predict hospitalization, however, ambulatory presentation of milder COVID-19 disease and characteristics associated with progression to severe disease is not well-understood.We conducted a retrospective chart review including all COVID-19 positive cases from Stanford Health Care (SHC) in March 2020 to assess demographics, comorbidities and symptoms in relationship to: 1) their access point of testing ) and 2) development of severe disease.Two hundred fifty-seven patients tested positive: 127 (49%), 96 (37%), and 34 (13%) at outpatient, ER and inpatient, respectively. Overall, 61% were age < 55; age > 75 was rarer in outpatient setting (11%) than ER (14%) or inpatient (24%). Most patients presented with cough (86%), fever/chills (76%), or fatigue (63%). 65% of inpatients reported shortness of breath compared to 30–32% of outpatients and ER patients. Ethnic/minority patients had a significantly higher risk of developing severe disease . Medicare-insured patients were marginally more likely (OR = 4.0 [0.9–17.8]). Other factors associated with developing severe disease included kidney disease (OR = 6.1 [1.0–38.1]), cardiovascular disease  and GI symptoms .Early widespread symptomatic testing for COVID-19 in Silicon Valley included many less severely ill patients. Thorough manual review of symptomatology reconfirms the heterogeneity of COVID-19 symptoms, and challenges in using clinical characteristics to predict decline. We re-demonstrate that socio-demographics are consistently associated with severity. During the week of February 23, 2020, community spread of the virus that causes COVID-19 was reported in California. On March 7 the Centers for Disease Control (CDC) reported 213 confirmed cases in the US [Health professionals have struggled to identify who is most at risk of severe disease, as COVID-19’s variable and wide-ranging symptoms make symptom-based diagnosis and prediction of progression to severe disease a challenge . InsteadAmidst this complex interplay of factors, the ambulatory presentation of milder COVID-19 disease, and which characteristics might predict progression to severe disease, remains poorly understood. Widespread testing and clinical documentation of ambulatory cases is necessary to fill in our understanding of the spectrum of COVID-19 disease. In March 2020, Stanford University in Santa Clara County was the first California healthcare system to institute drive-through testing available to anyone in the outpatient setting with COVID-19 symptoms, regardless of their insurance status .Stanford testing guidelines in March 2020 were relatively broad and symptom based, allowing testing of anyone with new-onset fever, cough, sore throat, or shortness of breath or flu-like symptoms in the preceding 14 days. By comparison, the CDC guidelines at the time limited testing to those with lower respiratory infection, travel to known high risk regions, and known or suspected close contact with COVID-19+ individuals. As a result of its criteria, in its first month of testing, Stanford included a broad population of less severely ill patients than most prior reported cohorts. Moreover, the tested cohort presents unique socio-demographic diversity, as Silicon Valley has both wide disparities in income and unique racial/ethnic diversity—Santa Clara and San Mateo counties’ have high population representation of Asian (39 and 30% respectively) and Hispanic/Latinx (36 and 24%), but relative under-representation of African American/Black (< 3%) , 8.We conducted a detailed chart review of COVID-19 positive patients presenting in the first month of wide-scale symptomatic testing to explore the patterns of sociodemographic, co-morbid conditions, and symptomatology to further our understanding of the disease.Stanford Health Care (SHC) is an academic health system in Silicon Valley. It began testing for COVID-19 on March 4, 2020 using a reverse-transcriptase polymerase chain reaction (RT-PCR) diagnostic test developed by Stanford’s clinical virology laboratory. The diagnostic test identifies the presence of viral RNA from nasopharyngeal swabs of potentially infected people, with an analytic sensitivity of 1 × 10–2 TCID50/mL and an analytic specificity of 100% [We first identified all positive COVID-19 RT-PCR’s performed by Stanford laboratory, from March 4 to March 31, 2020. These represented a mix of patients seen at an SHC clinic/facility and those seen at external hospital systems that were using Stanford as reference laboratory. Date and location of testing, age at specimen collection, gender, race/ethnicity, insurance plan, and county of residence were electronically extracted from Stanford’s electronic medical record system. Only age and gender were available for patients tested at an external hospital; these patients were only included to assess how this broader group of patients compared to the more well-defined Covid patient population who sought testing at Stanford with respect to age and gender as a way to inform regional generalizability of the patients for whom we have more in-depth data.We conducted a chart review on the subset whose tests were collected at SHC facilities, specifically, Stanford Hospital, Stanford ER, or one of ten Stanford primary care outpatient clinics including Stanford Express Clinic; patients whose test specimens were sent from a non-Stanford facility were excluded from the chart review Fig. . Abstrac2 test, Fisher’s exact test, or Monte Carlo estimate for the Fisher’s exact test were used to compare differences between patients that presented at outpatient, ER, and inpatient.We calculated descriptive statistics overall and by location of presentation for all COVID-19 positive patients, including both those captured in external specimens sent from non-Stanford facilities as well as for the subset included in chart review, i.e. patients seen at a SHC clinic/facility. χWe conducted logistic regression analyses on the chart review subset to assess factors associated with the odds of developing severe disease, defined as being hospitalized and/or death. Patients with insufficient data available to determine if they were hospitalized or died , were excluded from these analyses. In descriptive statistics and logistic regression models, we defined hypertension (HTN) to be in the absence of other cardiovascular disease (CVD) or stage 3+ chronic kidney disease (CKD), defined as pre-existing documentation of GFR < 60, in order to assess whether common HTN in the absence of more severe and often related complications/comorbidities, was associated with developing severe COVID-19.Two regression models were fit separately examining associations with: 1) patient socio-demographics and disease severity; and 2) comorbidities and symptoms with disease severity. We combined statistically significant variables from (1) and (2) to form a semi-final model. Because there was strong clinical interest regarding the estimates for the remaining comorbidities and symptoms, we added each into the semi-final model individually to evaluate their associations; our goal with these analyses was to build upon the growing early literature to better describe patients most likely to develop severe disease. The final mode included all variables in the semi-final model plus any additional variables that were significant when added individually to it. Variables were not included in any of the models if > 10% of the data were missing  or they prevented model convergence . Confidence intervals excluding 1.0 are considered statistically significant in logistic regression models. Analyses were performed using SAS .Eight hundred forty-two local patients tested positive for COVID-19 in March 2020 through Stanford Health Care’s laboratory; over half of which (54%) were specimens sent from non-Stanford facilities ). The ER testing setting had the highest proportion of patients with known contacts (46%) and the outpatient testing setting had the highest proportion of recent travelers (31%), however, neither of these differed significantly by testing access point.There were 257 patients in the chart review analysis: 127 (49%) outpatient; 34 (13%) inpatient; and 96 (37%) ER  except lung conditions, immunosuppressive conditions, neurologic conditions, and GI conditions . In contrast, inpatients had the highest proportion of every comorbidity examined, except for gastrointestinal (GI) conditions (Table p < 0.001) or GI symptoms . Loss of taste and back pain/ache were the least common presenting symptoms investigated, 9 and 3%, respectively.Table A total of 41 patients experienced severe disease, defined as hospitalization or death. One outpatient died at home and four others were later hospitalized. Eight ER patients were later hospitalized, one of whom died. Two of the patients initially tested as inpatients died for a total of four deaths in the cohort. Table CVD , HTN , and stage 3+ kidney disease , were all marginally statistically significantly related to development of severe disease in the final model  for outpatient COVID-19 testing.There were notably fewer differences amongst location of presentation in terms of presenting symptom and co-morbidities; our study provides important descriptions of both, but also reiterates the diversity of symptoms that make clinical prediction a challenge for this disease. The two symptoms identified were shortness of breath/dyspnea and GI symptoms, which unsurprisingly  was more common in hospitalized patients  than outpatient  or emergency room  presentations.In our cohort, the comorbidities we observed to predict severe outcomes were consistent with the CDC’s recent update from July 13, 2020, and we re-confirm a strong association with underlying CVD (OR 4.7) and chronic renal disease (OR 6.1) . In the Despite broad testing criteria and early ramp-up of testing in our local system, the cohort included in our one-month chart-review was of relatively small sample size, which was particularly limiting in our ability to examine comorbidities with somewhat lower prevalence  and data with high missingness (e.g. BMI and tobacco use). Further, the limitations on testing availability in March led to a selection bias. In our clinical experience, when testing was limited, many younger and healthier patients were assumed positive and not tested. Outpatient testing was prioritized for older persons, which may bias some of our estimates.Strengths of our study include our methodology of rigorous manual chart review, which allowed for comprehensive identification of both comorbidities and symptoms. The accuracy and completeness of these factors is beyond prior COVID-19 studies which has relied on diagnostic codes or used natural language processing to estimate COVID-19 symptomatology , 4. Our When and how care is accessed and the outcomes for COVID-19 severe disease is affected by ethnicity and insurance type. We reiterate the disproportionate impact of COVID-19 on minority populations and specifically find that in a largely ambulatory population, in a region with large Asian and Latinx representation, that both of these race/ethnicity groups were associated with more severe cases of COVID-19. We also find further marginal evidence to support the to-date uncertain association of hypertension  with more severe COVID-19 disease .