ABSTRACT:Hematopoietic stem cell transplant-associated thrombotic microangiopathy (TA-TMA) is a potentially fatal multisystem complication of hematopoietic cell transplantation for which there is no approved treatment. In a single-arm study (NCT02222545), narsoplimab treatment for TA-TMA demonstrated a median overall survival (OS) of 274 days from date of diagnosis. Here, we compare OS observed in 2 cohorts treated with narsoplimab to OS in a well-matched external control to test survival benefit in patients with high-risk TA-TMA. OS in patients (aged ≥16 years) with high-risk TA-TMA treated with narsoplimab in a single-arm, open-label study (NCT02222545) or in the narsoplimab expanded access program (EAP; NCT04247906) was compared with OS in a control group with high-risk TA-TMA from the Kyoto Stem Cell Transplantation Group (KSCTG) registry. Narsoplimab-treated patients in the single-arm study (N = 28) had a fourfold reduction in risk of mortality compared with patients from the KSCTG registry (N = 111; hazard ratio [HR], 0.25; 95% confidence interval [CI], 0.19, 0.34; P < .0001). Similarly, in high-risk patients treated with narsoplimab in the EAP (N = 49), mortality risk was significantly lower than among high-risk patients from the KSCTG registry (N = 121; HR 0.38; 95% CI 0.28, 0.51; P < .0001). When narsoplimab-treated patients from the single-arm study and the EAP (N = 77) were compared with KSCTG patients, the HR for mortality was 0.28 (95% CI, 0.22, 0.37; P < .0001). In conclusion, in patients with high-risk TA-TMA, narsoplimab treatment significantly reduced mortality relative to a well-matched external control group who did not receive narsoplimab. These results support narsoplimab as a potential therapeutic option for TA-TMA.

Abstract Among NPM1‐mutated acute myeloid leukemia (AML) (NPM1mut), a distinct subtype has been described with an immunophenotypic profile resembling acute promyelocytic leukemia (APL‐like). In this retrospective multicenter study including 384 NPM1mut AML patients, we identified 95 (24.7%) cases exhibiting an APL‐like immunophenotype. This subset was characterized by significant abnormalities in coagulopathy markers (D‐dimer, D‐dimer/fibrinogen ratio, and disseminated intravascular coagulation [DIC] score). The cumulative incidence of vascular events at 30 days was significantly higher in the APL‐like group compared to the non‐APL‐like group (30.5% vs. 10.1%, P < 0.001). Notably, a higher cumulative incidence of early death due to vascular complications (within 30 days) was observed in the APL‐like group (6.3% vs. 0.35% in controls; P = 0.00015). In multivariate analysis, the APL‐like immunophenotype was the only significant factor associated with vascular‐related early death (hazard ratio [HR] = 19, P = 0.0063). There was a significantly higher rate of IDH1/2 mutations in APL‐like (68.3%) compared to non‐APL‐like (18.3%, P < 0.001) cases. We validated these clinical and molecular findings in an independent validation cohort of 302 NPM1mut patients enrolled in the acute myeloid leukemia study group (AMLSG) 09‐09 clinical trial, which included the administration of all‐trans retinoic acid (ATRA) to all patients and a randomization for gemtuzumab ozogamicin. In this cohort, the APL‐like immunophenotype was associated with events occurring within the first 15 days but did not influence mortality, likely due to protocol‐driven patient selection. Our findings have important clinical implications that warrant the development of studies exploring disease‐tailored clinical measures to mitigate the risk of early vascular events, as in current APL management.

Minimal residual disease (MRD) is the strongest prognostic factor in acute lymphoblastic leukemia (ALL). According to the European Guidelines, MRD monitoring is based mainly on real-time quantitative PCR (RQ-PCR) of IG/TCR rearrangements. However, RQ-PCR has some limitations, including the need for standard curves and the occurrence of positive non-quantifiable (PNQ) results, particularly at low disease levels. Digital droplet PCR (ddPCR) enables absolute quantification and may improve MRD resolution. We investigated whether MRD assessment by ddPCR could refine prognosis better than RQ-PCR in a cohort of adult Ph negative BCP and TALL enrolled into a clinical trial (NILG 10/07 NCT 00795756). Overall, 101 patients were analyzed. Concordance between RQ-PCR and ddPCR was found in 73 patients (71%), while ddPCR reclassified as positive 28/101 patients (29%) defined as negative or PNQ by RQ-PCR. This molecular reclassification identified a subgroup with a significantly higher cumulative risk of relapse at 5-year (CIR, 43% vs 18%, p=0.02). In BCP-ALL, RQ-PCRneg/ddPCRpos patients showed a relapse risk comparable to RQ-PCR-positive cases and had inferior RFS and OS compared with RQ-PCRneg/ddPCRneg patients. In TALL , ddPCR improved MRD resolution, although outcome differences were less pronounced. The findings suggest that ddPCR MRD can refine MRD risk stratification in adult ALL, particularly among patients with RQ-PCR-negative or PNQ results. Given the increasing adoption of NGS-based MRD assessmentour results also support a potential hybrid strategy in which NGS is used upfront for clonotype identification, and ddPCR is subsequently applied for sensitive, rapid, and cost-effective longitudinal MRD monitoring. Prospective validation is warranted.

Venetoclax (VEN) plus hypomethylating agents (HMAs) represents the standard of care for newly diagnosed acute myeloid leukaemia (AML) patients unfit for intensive chemotherapy, but prospective real-world observational data outside randomized clinical trials remain limited. The Gruppo Italiano Malattie Ematologiche dell'Adulto (GIMEMA) AML2320 is a prospective, multicentre, observational study (NCT04589728) including 193 newly diagnosed unfit AML patients receiving VEN plus azacitidine or decitabine between November 2020 and December 2021. Primary end-point was overall survival (OS); secondary end-points included composite complete remission (cCR), disease-free survival and safety. Median age was 74 years with 42% of patients being ≥75 years. After completing cycle 4, cCR was achieved in 73% of the patients, with 54% responding before cycle 2. After a median follow-up of 23 months, median OS was 13.0 months. cCR achievement within cycle 4 correlated with longer OS (19.1 vs. 9.1 months, p = 0.001). Patients receiving 400 mg VEN without azoles had improved OS compared with those on reduced doses with azoles (18.2 vs. 11.4 months, p = 0.015). An anchored matching-adjusted indirect comparison with the phase III VIALE-A trial (NCT02993523) showed comparable median OS (14.8 months vs. 14.9 months; p = 0.6). The GIMEMA AML2320 trial confirmed the efficacy of VEN/HMAs in a prospective, real-world unfit population. Early remission was associated with improved outcomes.

Ravulizumab is a second-generation C5i engineered from eculizumab to achieve immediate, complete, and sustained inhibition of terminal complement activity in PNH. The REACTION observational cohort study describes the effectiveness and tolerability of ravulizumab in Italian patients who were previously treated with eculizumab. Eighty-one PNH patients were enrolled in this study. The primary endpoint was the percentage change in lactate dehydrogenase (LDH) from baseline to the end of observation (52 weeks follow-up). Among secondary endpoints, transfusion avoidance, breakthrough hemolysis (BTH) and patients’ quality of life (QoL) were evaluated. The median (25–75 percentiles) percentage change in LDH at 52 weeks follow-up was -2.6 (-11.5–13.4) U/L, with 92.3

In Ph+ acute lymphoblastic leukemia, frontline dasatinib plus blinatumomab (dasa+blina) is associated with long-term survival rates of 75-80%. The phase III GIMEMA ALL2820 trial has explored ponatinib with blinatumomab (pona+blina). In the present study, the immune modulation induced by dasa+blina and pona+blina was investigated. Immune cells were analyzed at the end of induction (T0) and after 2, 4 and 5 blinatumomab cycles (T2, T4, T5). Among 153 patients (43 dasa+blina, 110 pona+blina), the dasa+blina combination induced a significantly greater lymphocyte increase at T4 and T5 compared to pona+blina. The Treg counts decreased only in the dasa+blina treated patients. NK and NK-T cells increased significantly in the dasa+blina group, at all timepoints. Complete molecular responders (CMR) after dasatinib induction had significantly higher lymphocytes, T and NK cells compared to non-CMR patients. Bone marrow analyses showed higher activation (CD25, CD69) and lower exhaustion (PD1, TIM3) markers on NK and NK-T cells in dasa+blina treated patients. Dasa+blina patients exhibited a significantly enhanced NK cell capacity compared to ponatinib treated patients. Patients remaining on dasatinib maintained elevated NK cells with a more mature phenotype, suggesting a durable effect. These results highlight the greater dasa+blina immune activation, supporting a potential synergistic effect of the drug combination.

Patients with blast-phase (BP) myeloproliferative neoplasms have dismal outcomes, but allogeneic hematopoietic stem cell transplantation (alloHSCT) may offer a potential cure. However, the optimal pre-transplant blast-reduction therapy remains to be determined. We retrospectively analyzed outcomes in a molecularly annotated cohort of 24 patients with BP myelofibrosis (MF) who underwent alloHSCT between 2008 and 2023. Before conditioning, 20 patients received intensive induction chemotherapy, 1 received decitabine plus venetoclax, and 3 proceeded directly to transplant. At transplantation, 13 patients (54

Radiation-free treatment for early-stage classic Hodgkin lymphoma (eHL) has been shown to be less effective than standard combined-modality treatment (CMT; chemotherapy plus involved-node radiotherapy (INRT)), which achieves long-term disease control of 94-95%. Approximately 70% of patients can be cured with chemotherapy alone, whereas about 5% fail CMT. Identifying patients who can safely receive chemotherapy alone and those requiring intensified CMT could enable a risk-adapted treatment strategy. The RAFTING trial (NCT04866654; EudraCT 2020-002382-33) is an international, prospective, phase 2, non-inferiority study enrolling patients 18-70 years, stage I-IIA eHL without bulky disease, B symptoms, or extranodal involvement. Low-risk (LR) patients are defined by total metabolic tumor volume (TMTV) <84 mL and negative PET-2. Those with at least one modified EORTC (mEORTC) risk factor, in which bulky disease is replaced by a large nodal mass (5-10 cm), receive four ABVD cycles, while those without risk factors receive two ABVD cycles alone. High-risk (HR) patients, defined by TMTV ≥84 mL and/or positive PET-2, receive "triple therapy": 4 ABVD cycles, INRT (20/30 Gy), and nivolumab (240 mg q2w, ≤doses). LR patients are monitored using cfDNA. Limited relapse is treated with INRT (36 Gy) and nivolumab. The RAFTING trial is the first prospective eHL study to personalize treatment using TMTV and PET-2. It aims to omit radiotherapy in LR patients, intensify treatment in HR patients, and spare relapsed LR patients high-dose chemotherapy and autologous transplantation. CfDNA is being evaluated as a relapse marker. Despite the protocol's complexity, this study exemplifies personalized medicine and could transform treatment practices.

Chronic graft-versus-host disease (cGvHD) remains a major late complication of allogeneic hemato-poietic stem cell transplantation, leading to impaired quality of life and late non-relapse mortality. Belumosudil, an oral ROCK2 inhibitor with immunomodulatory and antifibrotic properties, represents a novel treatment for steroid-refractory or steroid-dependent cGvHD. We conducted a retrospective, multicenter study of 80 patients treated with belumosudil across 29 Italian transplant centers through a compassionate use program. Patients were heavily pretreated (74% with ≥3 prior lines, 84% previously exposed to ruxolitinib), with severe disease in 86% and a median of three organs involved. The best overall response rate was 62.5%, while overall response rates were 52.6%, 57.6%, and 55.0% at three, six, and 12 months, respectively. Median time to response was three months, and the 12-month duration of response was 83.4%. Failure-free survival at 12 months was 67.5%. Responses were observed in all involved organs. Patient-reported outcomes assessed through the National Institutes of Health Severity Index Score (0-10 scale) showed meaningful improvements (≥-2 points) in 33%, 36%, and 29% of patients at three, six, and 12 months, respectively. Treatment was well tolerated. These real-world findings confirm the effectiveness of belumosudil in patients with cGvHD refractory to multiple lines of immunosuppressive therapy.

We reviewed the emerging clinical and biological evidence that supports the broader interpretation of arterial thrombosis as a biological turning point that identifies patients who are entering a more aggressive phase of classic myeloproliferative neoplasms. Findings from multistate analyses, international registry studies, nested case-control investigations, and recent translational research were integrated. We showed that arterial thrombosis is associated not only with recurrent vascular events but also with increased mortality, progression to myelofibrosis and blast phase, and, in selected patient populations, the subsequent development of solid cancers. We discuss the biological mechanisms that may underlie these associations, including persistent JAK2-driven inflammation, endothelial dysfunction, platelet-leukocyte interactions, neutrophil extracellular trap formation, immune remodelling, and clonal evolution. Particular attention is given to emerging biomarkers, such as JAK2V617F variant allele frequency and the neutrophil-to-lymphocyte ratio, which provide complementary information on clonal burden and inflammatory activity and may improve biological risk stratification. Finally, we discuss the clinical implications of this evolving paradigm, proposing that patients experiencing arterial thrombosis should undergo closer surveillance and be considered for biology-directed therapeutic strategies aimed at suppressing both clonal expansion and chronic thrombo-inflammation, rather than receiving secondary vascular prevention alone.

Relapse of acute myeloid leukemia with CBFB::MYH11 fusion and KIT D816V mutation after allogeneic hematopoietic stem cell transplantation is uncommon and often associated with aggressive extramedullary spread and poor outcomes, particularly when the central nervous system is involved. We report a case of a 54‑year‑old man who developed extensive paravertebral, central nervous system, and multiorgan extramedullary relapse despite donor lymphocyte infusions and high‑dose chemotherapy. Avapritinib, a selective inhibitor of mutated KIT, was initiated as single‑agent therapy and resulted in rapid neurological improvement, complete metabolic response on positron emission tomography–computed tomography, and full molecular remission in peripheral blood. Due to temporary loss of off‑label access, avapritinib was discontinued, leading to a new extramedullary and central nervous system relapse. Remarkably, rechallenge with single‑agent avapritinib again induced molecular remission in both peripheral blood and cerebrospinal fluid, along with near‑complete metabolic response across all previously involved sites. The reproducibility of the response strongly supports a direct, target‑driven antileukemic effect. This case highlights the potential of avapritinib as an effective salvage therapy for KIT‑mutated acute myeloid leukemia with extramedullary and central nervous system involvement, including relapse after transplantation. The robust and repeated responses observed in this patient underscore the rationale the potential role of avapritinib as salvage therapy and support its investigation as a component of measurable residual disease-guided or post-transplant maintenance strategies.

Background:In advanced-stage classic Hodgkin lymphoma (cHL), risk-adapted therapeutic strategies have proven to be safe and effective, although long term efficacy data are lacking. Furthermore, some concern persists about the risk of late occurrence of second primary malignancies (SPM) or cardiovascular events (CVE) in survivors. Methods:HD0607 is a phase-2 multicenter prospective clinical trial enrolling stage IIB-IV patients with untreated cHL. All subjects started treatment with 2 ABVD cycles and subsequently underwent an interim PET (PET-2). PET-2 positive patients [Deauville score (DS) 4-5] switched to BEACOPP escalated/baseline (4 + 4 cycles), while PET-2 negative patients (DS ≤ 3) were treated with 4 more ABVD cycles. Patients with a large nodal mass (LNM, defined as ≥5 cm in diameter) at baseline and both PET-2 and end-of-chemotherapy (EoT) PET negative scans were randomly allocated to receive consolidation radiotherapy (cRT) or no further therapy (NFT). This clinical trial has been registered in the European Union Drug Regulating Authorities Clinical Trials Database under the EudraCT number 2007-007168-94 and is publicly available on the EU Clinical Trials Register. Findings:Out of 782 enrolled subjects, 630 (81%) had a negative while 150 (19%) a positive PET-2. After a median follow-up of 11 years (IQR 7-13 years), 102/630 patients with a negative PET-2 (16.2%) and 57/150 (38.0%) with a positive PET-2 progressed or relapsed. The 10-years PFS and OS were 83% and 96% vs. 58% and 85% (p < 0.0001) for PET-2 negative and PET-2 positive patients, respectively. Patients randomized to NFT did not have an increased risk of relapse or death (PFS HR 0.67, 95%CI 0.31-1.43; OS HR 0.49, 95% CI 0.09-2.68). During the follow-up 28 (3.6%) and 16 (2.1%) patients developed a SPM and CVE, respectively. Interpretation:After more than a decade of follow-up the HD0607 trial confirmed: i) the long-term predictive value of PET-2; ii) the persistent and sustained remission rate of PET-2 negative patients; iii) no PFS benefit consolidation RT over a non-FDG avid LNM; iv) the cumulative low incidence of SPM and CVE in the enrolled patients. Funding:This work was supported by Associazione Italiana per la Ricerca sul Cancro (AIRC), IG n.2013 to AG, by Associazione Italiana Lotta alla Leucemia (AIL) sezione di Bergamo and by a Research Grant of Cassa di Risparmio di Cuneo. Progetti di Rilevanza Nazionale PRIN PNRR (P2022PSMX4), STARS UNIPD 2023 to AV.

The Hodgkin lymphoma treatment in the elderly (eHL) is a challenge due to a narrow therapeutic window between therapy effectiveness and toxicity. Both bendamustine (Be) and brentuximab vedotin (BV) are well-tolerated, effective drugs in relapsing HL, but no data exist on Be-BV frontline treatment in eHL. The prospective, open-label, phase I/II Hodgkin lymphoma combining Adcetris® and Levact® in Old patients (HALO) study was launched (Clinical Trial.Gov Id. 02467946) to test safety and efficacy of Be-BV in untreated eHL. The mean age was 70.75 (62-79), stage IIB in 12, III in 14 and IV in 31 patients. Most had B-symptoms and an International Prognostic Score (IPS) ≥3 (39). Despite a good performance status and both a high activity of daily living (ADL) (≥6 in 85%) and instrumental activities of daily living (IADL) scores (≥8 in 77%), 68% of patients had ≥5 comorbidities, with a Cumulative Illness Rating Scale-Geriatric (CIRS)-G score >3 in 75%. A complete metabolic response (CMR) was achieved in 44/57 of patients. The 6-year overall survival (OS) and progression-free survival (PFS) in per-protocol (PP) analysis were 67% (95% confidence intertvals [CI] 53-84) and 45% (95% CI 32-65) respectively. A PFS event was observed in 35: 13 progressions (10 deaths), 13 relapses (6 deaths) and 9 deaths. Be-BV, when given in a full dose schedule, is an effective regimen for unselected, poor-risk elderly Hodgkin lymphoma (HL) patients.

Allogeneic hematopoietic cell transplantation (allo-HCT) hinges on a delicate trade-off between graft-versus-tumor control and graft-versus-host disease (GvHD), mediated by donor T-cell recognition of antigens presented by recipient human leukocyte antigen (HLA) molecules. We hypothesized that, beyond allele-level matching, sequence divergence at peptide-binding grooves across donor and recipient HLA loci shapes these responses. To this end, we evaluated the effect of HLA evolutionary divergence (HED), a metric quantifying amino acid variability at HLA peptide-binding sites, on selected hematological malignancies in 4,695 patients undergoing allo-HCT from a 9/10 mismatched unrelated donor (MMUD), reported to the EBMT database. We examined (i) locus-specific recipient HED (HED-R) and (ii) "HED-mismatch" (HED-MM), capturing immunopeptidome divergence at the mismatched locus. While dichotomous mismatch status explained differences in survival and acute GvHD risk (with overall greater detriment for class I loci), HED metrics uncovered substantial within-mismatch heterogeneity. In DRB1 mismatched subgroup, HED-MM at this locus, independently predicted inferior relapse-free survival (RFS) with an attenuating time-dependent association, further modulated by cross-locus HED-R. In this subgroup, higher HED-R at HLA-A and HLA-C associated with increased risks of acute GvHD and non-relapse mortality, respectively. Among HLA-B-mismatched pairs, higher DRB1 HED-R associated with worse overall survival (OS) and RFS and higher relapse risk. In the HLA-A-mismatched subgroup, higher HED-R at HLA-A increased chronic GvHD risk. Collectively, HED-derived metrics complement conventional mismatch classification by capturing qualitative differences in donor-recipient immunopeptidome interactions and reveal a complex, non-linear interplay among alleles across mismatch subgroups that modulates the clinical impact of mismatching.

Introduction Although ∼70% of patients (pts) with large B-cell lymphoma (LBCL) respond to frontline (1L) chemoimmunotherapy, outcomes are poor for high-risk (HR) disease and pts not achieving complete response (CR). Rapcabtagene autoleucel is an investigational CD19-directed CAR-T cell therapy rapidly manufactured in <2 d using the T-Charge™ platform. We report a descriptive interim analysis of the ongoing phase 2 trial of rapcabtagene autoleucel in pts with 1L HR LBCL (NCT03960840). Methods Pts had histologically confirmed LBCL, IPI score of 3-5, and/or MYC and BCL2 and/or BCL6 rearrangement (DHL per WHO 2016). After 2 cycles of 1L therapy, eligible pts had stable disease (SD) or partial response (PR) by PET scan. Pts with progressive disease or CR were not eligible. Lymphodepletion was followed by a single rapcabtagene autoleucel infusion (12.5 × 106 cells). The primary endpoint was CR rate (CRR), defined as best overall response of CR post infusion. Secondary endpoints included overall response rate (ORR), duration of response (DOR), progression-free survival (PFS), event-free survival (EFS), overall survival (OS), adverse events (AEs), and cellular kinetics. Results As of January 22, 2025 (enrollment ongoing at data cutoff), 37 pts received rapcabtagene autoleucel (median follow-up: 4.2 mo). At diagnosis, 86% had an IPI score ≥3, 38% had DHL, 95% had stage III-IV disease, 51% had germinal center B-cell (GCB) LBCL, and 41% had non-GCB. In total, 57% had an IPI of 4-5 or DHL, and 43% had an IPI of 3 without DHL. After 2 cycles of 1L therapy, 86% had PR and 14% had SD. Among 31 infused pts with ≥1 mo post-infusion follow-up, CRR was 74% and ORR was 90%. AEs (any grade) occurred in 100% of infused pts. Cytokine release syndrome (CRS) occurred in 38% (all Gr 1), immune effector cell-associated neurotoxicity syndrome (ICANS) in 8% (all Gr ≤3), and infections in 49% (Gr ≥3, 8%). Median times to CRS onset and resolution were 9.5 d and 4 d, respectively. Among pts with CRS, 50% (7/14) received tocilizumab; none were admitted to the ICU. Median times to ICANS onset and resolution were 17 d and 19 d (1 case ongoing), respectively. One pt developed immune effector cell-associated hemophagocytic lymphohistiocytosis-like syndrome (Gr 2), which resolved after tocilizumab and anakinra treatment. Among pts with Gr 3 or 4 cytopenias at 1 mo post infusion, the probability of resolution by mo 3 was 100% for neutropenia, leukopenia, and anemia, and 87% for thrombocytopenia. No deaths or secondary malignancies were reported. Robust in vivo expansion (median Cmax: 31,000 copies/µg DNA) was similar to that reported for 3L r/r DLBCL (median Cmax: 41,800 copies/µg DNA). Conclusions Single-dose rapcabtagene autoleucel showed promising initial efficacy and a manageable safety profile in pts with 1L HR LBCL. Immunophenotyping and efficacy data for the final pt population with longer follow-up (≥6 mo for most pts) will be presented.

Essential thrombocythemia (ET) and polycythemia vera (PV) are traditionally viewed as distinct Philadelphia chromosome–negative myeloproliferative neoplasms, yet both frequently harbor the JAK2V617F mutation, suggesting a biological continuum. Occasional reports describe progression from JAK2-mutated ET to overt PV, but this evolution has never been systematically studied. We present the background and design of ET-2-PV, an international, multicenter, retrospective observational study conducted by the Mayo Clinic and European referral centers. Approved by the Lombardy Territorial Ethics Committee and registered at ClinicalTrials.gov (NCT07203768), it includes patients initially diagnosed with JAK2V617F-positive ET according to 2022 ICC criteria who, after at least one year, newly fulfill diagnostic criteria for PV—minimizing misclassification. The study employs two analytical frameworks: (1) a nested case–control analysis comparing ET-to-PV cases with matched JAK2-mutated ET controls without progression to identify clinical, proliferative, and molecular predictors of progression; and (2) a retrospective cohort comparison assessing outcomes of ET-to-PV patients versus matched individuals with de novo PV. The primary objective is to define the clinical and biological significance of phenotypic evolution from JAK2-mutated ET to PV and its prognostic impact. Secondary aims include identifying risk factors for progression, characterizing clonal dynamics, and determining whether PV arising after long-standing ET differs from de novo PV in vascular risk, disease evolution, and survival. By integrating molecular data with robust epidemiologic design, ET-2-PV aims to define phenotypic evolution from ET to PV as a distinct and clinically meaningful entity, informing risk-adapted monitoring and therapeutic strategies.