Molecular imaging phenotyping may go beyond patient selection and provide useful information during and post-treatment for monitoring of temporal heterogeneity of the disease and dynamically risk-stratify patients. In addition, advances in the understanding of genomic-phenotypic classifications of pheochromocytomas and paragangliomas led to an archetypical example in precision medicine by utilizing molecular imaging phenotyping to guide radioligand therapy. Novel non-SSTR based peptide receptors have also been explored diagnostically and therapeutically to overcome the tumour heterogeneity. In this paper, we review the current molecular imaging modalities that are being utilized for the characterization of the NENs with special emphasis on their role in patient selection for radioligand therapy.Neuroendocrine neoplasia (NEN) is an umbrella term that includes a widely heterogeneous disease group including well-differentiated neuroendocrine tumours (NETs), and aggressive neuroendocrine carcinomas (NECs). The site of origin of the NENs is linked to the intrinsic tumour biology and is predictive of the disease course. It is understood that NENs demonstrate significant biologic heterogeneity which ultimately translates to widely varying clinical presentations, disease course and prognosis. Thus, significant emphasis is laid on the pre-therapy evaluation of markers that can help predict tumour behavior and dynamically monitors the response during and after treatment. Most well-differentiated NENs express somatostatin receptors (SSTRs) which make them appropriate for peptide receptor radionuclide therapy (PRRT). However, the treatment outcomes of PRRT depend heavily on the adequacy of patient selection by molecular imaging phenotyping not only utilizing pre-treatment SSTR PET but  Neuroendocrine neoplasms (NENs) represent a group of rare malignancies that originate from the secretory cells of the neuroendocrine system. NEN is an umbrella term that includes the well-differentiated neuroendocrine tumours (NETs), and the aggressive neuroendocrine carcinomas (NECs). The site of origin of the NENs is linked to the intrinsic tumour biology and is predictive of the disease course . Based oIt is understood that NENs demonstrate significant biologic heterogeneity which ultimately translates to widely varying clinical presentations, disease course and prognosis. Thus, significant emphasis is laid on the pre-therapy evaluation of markers that can help predict tumour behavior and the appropriate selection of choice of therapy. These broadly include assessment of pathology (including Ki67 immunohistochemistry (IHC) or mitotic count as markers of proliferation, cellular differentiation, IHC for specific hormones or cell surface antigens), serum biomarkers, molecular genetics , clinical presentation and imaging .68Ga- or 64Cu- labeled somatostatin analogs  has superior diagnostic performance in comparison to SPECT with 111In-Pentetreotide (Octreoscan), with the former being the modality of choice for functional imaging of the NETs , 48111In131I-MIBG and 177Lu-DOTATATE. Molecular imaging with 123I/124I-MIBG and SSTR PET can serve as the primary gatekeeper for the assessment of the most suitable radiopharmaceutical therapy for the patients [18F-FDG PET to detect sites of dedifferentiated disease which may be non-targetable by one or either of these radionuclide therapy agents, however, this needs to be further verified in future trials [While surgical resection remains the backbone of the majority of cases, for non-surgical or metastatic disease, genetically driven cluster-specific therapy appears to be appealing but not widely established in routine clinical practice . A uniqupatients . Despitepatients , 52. Some trials .Fig. 8A 131I-sodium iodide forms the mainstay in the treatment of advanced differentiated thyroid carcinoma (DTC) after surgery and is the first-line therapy for metastatic DTC. However, approximately 20–30% of patients with DTC are refractory to radioiodine or lack sufficient uptake to warrant treatment and, therefore, require alternative therapies. Variable levels of SSTR expression have been reported in DTC. However, the relatively uncommon and aggressive Hürthle cell carcinoma has a relatively higher SSTR expression compared to the more common papillary and follicular carcinomas [177Lu-DOTATATE therapy performed in a small series of five patients with DTC showed slightly better outcomes in patients with Hürthle cell carcinoma  compared to papillary and follicular thyroid carcinoma [177Lu-DOTATATE therapy. Other radiotracers, including the neo-angiogenesis targeting 68Ga-RGD might be better suited for imaging and evolving theranostics [Radioiodine therapy with rcinomas . 177Lu-Darcinoma . The subanostics , 57.90Y-DOTATOC showed no correlation between the grade of radiotracer avidity on SSTR imaging (planar 111In-pentetreotide scintigraphy) and response to treatment [18F-FDG PET. It is quite plausible that the majority of these participants might have harbored aggressive disease at baseline, not amenable to PRRT. A retrospective review of 43 patients with metastatic MTC who underwent 177Lu-DOTATATE therapy showed lesion size (< 2 cm) and low avidity on 18F-FDG PET (SUVmax < 5) to be significant predictors for treatment response [18F-DOPA and 18F-FDG have been shown to provide complementary information in the re-staging of patients with MTC. Similar to GEP NENs, 18F-FDG positivity is associated with aggressive tumour biology, reflected by rapidly doubling times for serum calcitonin. On the other hand, 18F-DOPA PET detects the less-aggressive tumours, often with lower calcitonin levels and longer calcitonin doubling times [Medullary thyroid carcinoma (MTC) is a neuroendocrine malignancy originating from the parafollicular C-cells. It poses a challenge, both in terms of detection and treatment, as about 50% of patients experience disease recurrence/ relapse despite aggressive primary surgical treatment . SSTR tareatment . Howeverresponse . 18F-DOPng times . Molecul18F-FDG PET in a small study [177Lu-DOTATATE alone or in combination with immune checkpoint monoclonal antibodies. A phase Ib/II study (NCT04261855) is underway that will evaluate the efficacy of the combination of avelumab with 177Lu-DOTATATE  has undergone multiple refinements. These include a spectrum of presentations extending from neuroendocrine differentiation in prostate adenocarcinoma, mixed with acinar adenocarcinoma, carcinoid tumour to small cell carcinoma . In its ing NEPC . While ting NEPC . Studiesing NEPC . Howevering NEPC –75.111In, 64Cu and 68Ga and therapeutically to 177Lu [68Ga-NODAGA-JR11 compared to 68Ga-DOTA-JR11 [68Ga-DOTA-JR11 detected significantly more liver lesions, due to lower liver uptake, it showed fewer bone lesions compared to 68Ga-DOTATATE [68Ga-NODAGA-JR11 is the preferred diagnostic SSTR antagonist and can be used as theranostic pair of 177Lu-DOTA-JR11. A first-in-human study of the theranostic pair of 68Ga-NODAGA-LM3 and 177Lu-DOTA-LM3 has shown a favorable biodistribution, efficacy and toxicity profile with a longer effective half-life in tumours and normal organs leading to higher radiation doses than SSTR agonists [Radiolabeled SSTR antagonists are one of the different strategies aimed at improving the targeting of this peptide receptor. Despite a low internalization rate, SSTR antagonists have greater receptor binding sites due to the recruitment of inactive SSTRs on the cell surface of NENs. The three SSTR antagonists of clinical interest include LM3, JR10 and JR11 and have been conjugated to the chelators DOTA and NODAGA and complexed with various diagnostic radiometals such as to 177Lu . NODAGA OTA-JR11 . Interesagonists .In addition to SSTR-2 and SSTR subtypes (SSTR-3 and SSTR-5), other regulatory peptide receptors such as incretin receptor glucagon-like peptide 1 (GLP-1) and cholecystokinin receptor family (CCK-1 and CCK-2 subtypes), glucose-dependent insulinotropic polypeptide receptor (GIP) and gastrin-releasing peptide receptors are overexpressed in several human cancers . GLP-1, 111In and 99mTc, as well as PET radionuclides such as 68Ga, 64Cu, 18F and 89Zr. PET tracers have a higher special resolution compared to gamma-emitting tracers, which is a major advantage in the detection of small-sized insulinomas. The two most used tracers in clinical studies include 68Ga-DOTA-exendin-4 and 68Ga-NODAGA-exendin-4 [68Ga-NODAGA-Exendin-4 PET has shown a significantly higher sensitivity compared to SSTR PET  and appears to be superior to conventional imaging for the detection and localization of benign insulinoma [68Ga-NODAGA-exendin-4 PET in the detection of insulinoma compared to conventional imaging (NCT03189953). The proposed clinical utility of this agent includes localization of potentially resectable insulinoma for the work-up of endogenous hyperinsulinemic hypoglycemia following inconclusive conventional imaging [18F-DOPA has demonstrated high localization rates for insulin-producing tumours, especially in the pediatric population [68Ga-NODAGA-exendin-4 showed a higher target-to-background, interobserver agreement and higher sensitivity (100% versus 71%) in the detection of focal abnormality in congenital hyperinsulinemia compared to 18F-DOPA PET [111In and 177Lu, preclinical studies indicate a prohibitive absorbed dose to kidneys, limiting the therapeutic index of exendin-based PRRT [GLP-1 receptors are widespread within the gastrointestinal tract and pancreas, and overexpressed in various NETs Fig. , particuxendin-4 , 81. Insxendin-4 . In contsulinoma . This stsulinoma . A prosp imaging . However imaging . Althougsed PRRT . Furthersed PRRT . In contsed PRRT , 89.Fig.111In which is currently in a clinical trial [68Ga [177Lu has been successful in preclinical studies [The CCK-2/gastrin receptor is overexpressed in several tumour types, including NENs, such as MTC > 90%), GEP NETs , and approximately two-thirds of bronchial NET but also other tumours such as small cell lung cancer , 90. The%, GEP NEal trial  and alsoal [68Ga . Given tal [68Ga . Radiola studies . However studies .111In-DTPA -GIP or 68Ga–DOTA-GIP [The gastric inhibitory polypeptide (GIP) receptor is a promising target with high incidence and receptor density expression in a variety of GEP and bronchial NENs and low expression in normal tissues . GIP recDOTA-GIP , 98. TheIn-vitro studies have demonstrated NENs often coexpress more than one and often up to 3 peptide receptors . The abi177Lu allows for post-treatment whole body mapping of the radiopharmaceutical distribution and the relative intensity uptake ratio of tumour lesions to normal organs provides important information on the therapeutic index of 177Lu-DOTATATE. The quantitative analysis of post-treatment images in its most sophisticated method by SPECT at multiple time points from 1 h to 7 days yields a radiation dose map to the tumour and normal organs. However, the lack of consistent and uniform dosimetry methodology, limited accessibility due to its resource-intensive nature, patient burden requiring additional clinic visits and lack of reimbursement in some jurisdictions have posed significant challenges in its wide adoption by the institutions across the world. Meanwhile more simplified dosimetry methods are actively pursued. In addition to quantitative assessment, the relevant information obtained from a qualitative assessment of post-treatment SPECT/CT imaging may impact the patient management and dynamic risk stratification in a subset of patients.Monitoring of biological target expression during the targeted treatment is desirable. Gamma decay of 177Lu-DOTATATE. The semiquantitative parameters and heterogeneity of the SSTR expression at baseline SSTR PET appear to predict the response and the outcome of 177Lu-DOTATATE [177Lu-DOTATATE scintigraphy imaging, variation between the lesional correlation of the theranostic pair can be encountered. These could be due to lesion heterogeneity and differences in target densities, as well as disrupted or increased regional blood supply by pathologic tumour vessels that may affect the rate of uptake and retention of the radiotracer in the tumours. In addition, differing SSTR-2 affinity of 68Ga-DOTATATE (IC50 = 0.2 nM) compared to 177Lu-DOTATATE (IC50 = 2.0 nM) may need to be considered [177Lu-DOTATATE scintigraphy can guide the decision of either completing the standard course of treatment (4 cycles) for instance in the context of emerging toxicities, or early abortion due to futility  may provide an early risk stratification , bone disease can be more efficiently followed up by molecular imaging. Beyond response assessment, the unique advantages of molecular imaging may need to be leveraged by its incorporation into the clinical trials to guide the choice of treatment modality, to risk stratify patients following the treatment and for the intensity and duration of follow-up. Development of segmentation tools that allow assessment of the serial evolution of molecular imaging phenotypic subclones will improve global response assessment and help to establish patterns of response that warrant different management paradigms. For example, an increasing volume of FDG-avid, low SSTR-expressing disease may warrant a change to chemotherapy even in the context of a partial response on SSTR-expressing disease based on volumetric regression. Such tools will need to be cross-validated with other measures of response and with clinical outcomes. Artificial intelligence algorithms may help integrating an increasingly complex and deep combination of data relevant to patient outcomes in this diverse and heterogeneous malignancy.Molecular imaging has become the mainstay of the management of patients with NENs. While the patient selection based on molecular imaging phenotype remains integral to the success of the radioligand therapy, temporal variation in the expression of the biological target and the responsiveness of the different components of disease during and after treatment are among increasingly understood roles of various molecular imaging agents in the post-treatment setting. In certain diseases such as PPGLs, genotyping is now entered the clinical practice and may dictate the choice of the molecular imaging agent, however, whole-body molecular imaging phenotyping remains the key to the success of the targeted radioligand therapy. Promising advances have been made in leveraging the novel peptide receptors to overcome the heterogeneity of the established targets for diagnosis and targeted therapy of certain neuroendocrine tumours. Future advances may include novel approaches to enhance target engagement such as using SSTR antagonists or multitargeted radiopharmaceuticals.


COVID-19 is a contagious viral infection caused by severe acute respiratory syndrome coronavirus 2 (Sars-CoV-2). One of the key features of COVID-19 infection is inflammation. There is increasing evidence pointing to an association between cytokine storm and autoimmunity. One autoimmune disease of interest in connection to COVID-19 is hyperthyroidism. COVID-19 has been shown to decrease TSH levels and induce thyrotoxicosis, destructive thyroiditis, and de novo Graves’ disease. It has also been suggested that the immune response against SARS-CoV-2 antigens following vaccination can cross-react through a mechanism called molecular mimicry which can elicit autoimmune reactivity, potentially leading to potential thyroid disease post vaccine. However, if the COVID-19 vaccine is linked to reduced COVID-19 related serious disease, it could potentially play a protective role against post COVID-19 hyperthyroidism (de novo disease and exacerbations). Further studies investigating the complex interplay between COVID-19 or COVID-19 vaccine and thyroid dysfunction can help provide substantial evidence and potential therapeutic targets that can alter prognosis and improve COVID-19 related outcomes in individuals with or without preexisting thyroid disease. •A careful review of current literature suggests a possible correlation of COVID-19 induced inflammation and hyperthyroidism.•The association could be possibly explained by molecular mimicry between the proteins of SARS-CoV-2 with those in the thyroid.•Reports of de novo thyroiditis have emerged post COVID-19 vaccine, but the COVID-19 has not shown to cause exacerbations in preexisting thyroid disease.•There is a scarcity of literature on the complex interplay between COVID-19 or COVID-19 vaccine and thyroid dysfunction. COVID-19 is a contagious viral infection caused by severe acute respiratory syndrome coronavirus 2 (Sars-CoV-2). Since the first case in late December 2019, 510,270,667 confirmed cases of COVID-19, including 6,233,526 deaths have been reported to the WHO [COVID-19, like other coronaviruses, is a positive-stranded (+ssRNA) virus. SARS-CoV-2 enters the hosts' cells by binding the SARS-CoV-2 spike or S protein (S1) to the ACE2 receptors that are abundantly present on the respiratory epithelium such as type II alveolar epithelial cell .One of the key features of COVID-19 infection is inflammation. There is increasing evidence pointing to an association between one's immune response, inflammatory markers, and a potential cytokine storm with the progression, severity, and outcome of COVID-19. Studies have shown that a maladaptive immune response, with an increase in innate immune cell lineages and reduction in lymphocytes (lymphopenia), are associated with more severe disease and poorer outcomes . A delayMuch research has gone into understanding the pandemic and the effects that it has on both previously healthy patients and those with other comorbidities. This review discusses in detail the inflammatory response by COVID-19, on thyroid function  in indiv2Autoimmune disease could arise as a complication of COVID-19 infection. This is evidenced by numerous reports that have found a connection with the development of autoimmune diseases after SARS-CoV-2 infection such as cold agglutinin syndrome (CAS) and autoimmune hemolytic anemia . FurtherDe novo development of autoimmune disease induced by COVID-19 may complicate the prognostic course for patients with existing autoimmune conditions. During the pandemic, there was a sizable portion of patients with autoimmune diseases who had abandoned their medications, either from fearing the immunosuppressive influence of medications or due to lack of availability .One autoimmune disease of interest in connection to COVID-19 is hyperthyroidism. SARS-CoV-2 uses ACE2 combined with the transmembrane protease serine 2 (TMPRSS2) as the key molecular complex to infect the host cell which are expressed highly in both thyroid gland and lungs . Similar3Association between COVID-19 and thyrotoxicosis has been suggested by several studies. One such study is TGYRCOV study by Lania et al. (2020) that evaluated thyroid function by thyroid function test and serum interleukin-6 (IL-6) among 287 diagnosed COVID-19 patients .This finding was supported by another study where two groups were analyzed: 78 patients infected with COVID-19 and 85 in the control group, both of which did not have a history of thyroid disease . This stOn a similar note, Graves' disease, an autoimmune condition that can cause an overactive thyroid, has been found to be induced by COVID-19 infection ,19. A re3.1In addition to the risk of developing thyroid disorders following COVID-19 infection, concerns surrounding hyper/hypothyroidism post-SARS-CoV-2 vaccination have become a topic of interest . SeveralIn previous epidemics, thyroiditis development in previously healthy patients was implicated in vaccinations against influenza, HPV, and HBV . EmerginIn rare cases, Graves' Disease was implicated after SARS-CoV-2 vaccination but the pathophysiological mechanism underlying this remains unclear. To date, six reported cases of Graves' Diseases did not exhibit typical symptoms of exophthalmos or dermopathy, with five of these patients having received mRNA vaccines ,33. One Despite cases reporting new-onset autoimmune disorders after being vaccinated against COVID-19, future direction of research should consider the possibility of SARS-CoV-2 vaccination protecting patients from post-covid subacute thyroiditis or Graves’ Disease. The mechanism of the vaccine provides protection via SARS-CoV-2 antibodies, triggering adaptive immune responses and stimulating a hyperinflammatory reaction . SARS-Co3.2As implicated thus far, COVID-19 infection has been recently associated with thyroid dysfunction . This caHowever, the COVID19 vaccine is not contraindicated in patients with pre-existing thyroid diseases like Hashimoto's thyroiditis and Graves' disease. The American Thyroid Association and European Thyroid Association reported that if patients with thyroid disorders such as autoimmune thyroid disease and thyroid cancer are medically stable, they should still receive the COVID-19 vaccination . If the 4A careful review of current literature suggests a possible correlation of COVID-19 induced inflammation and hyperthyroidism. This association could be explained by the molecular mimicry between the proteins of SARS-CoV-2 with those in the thyroid. There is a scarcity of literature on a possible preventive role the SARS-CoV-2 vaccination against the development of autoimmune thyroid disorders. However, the COVID-19 vaccine has not been observed to cause exacerbations with preexisting thyroid disease and the benefits outweigh the risks. Even patients who developed hypo/hyperthyroidism post-COVID vaccine did not experience severe complications and received symptomatic relief with steroids and supportive care. Further studies investigating the complex interplay between COVID-19 and thyroid dysfunction can help provide substantial evidence and potential therapeutic targets that can alter prognosis and improve COVID-19 related outcomes in individuals with or without preexisting thyroid disease.N/A.N/A.Substantial contribution to the Conception and design of the work: All authors under the guidance of Aashna Mehta and Wireko Andrew Awuah. Drafting the work and critical revision: All authors under the guidance of Aashna Mehta, Wireko Andrew Awuah, and Rohan Yarlagadda, and Mohammad Mehedi Hasan. All the authors read and approved the final version of the manuscript.N/A.mehedi.bmb.mbstu@gmail.com (MMH).Mohammad Mehedi Hasan, Department of Biochemistry and Molecular Biology, Faculty of Life Science, Mawlana Bhashani Science and Technology University, Tangail, Bangladesh; Not commissioned, externally peer reviewed.No data available.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


Several viral and human mimic epitopes from these homologous proteins were predicted as strong binders of human HLA alleles, with IC50 < 50 nM. Downstream molecular docking analyses identified that lead virus-human homologous epitopes feasibly interact with HLA and TLR4 types of immune receptors. The vast majority of these top-hit homolog epitopic peptides belong to the herpes simplex and poxvirus families. These lead epitope biological sequences and 3D structural-based molecular mimicry may be promising for interpreting herpes simplex virus and poxvirus infection-mediated autoimmune disorders in humans.Clinical epidemiological studies have reported that viral infections cause autoimmune pathology in humans. Host-pathogen protein sequences and structure-based molecular mimicry cause autoreactive T cells to cross-activate. The aim of the current study was to implement immunoinformatics approaches to infer sequence- and structure-based molecular mimicry between viral and human proteomic datasets. The protein sequences of all the so far known human-infecting viruses were obtained from the VIPR database, and complete human proteome data were retrieved from the NCBI repository. Based on a predefined, stringent threshold of comparative sequence analyses, 24 viral proteins were identified with significant sequence similarity to human proteins. PathDIP identified the enrichment of these homologous proteins in nine metabolic pathways with a  The human immune system defends against various diseases by recognizing and eliminating pathogens and damaged cells. If this approach is unsuccessful, an elicited immune response is initiated against the body’s healthy cells and tissues, resulting in various autoimmune illnesses (AIDs) ,2. Over One of the key mechanisms that causes autoimmune disorders is molecular mimicry, in which the pathogenic antigens exhibit sequence and structural resemblance to host self-antigens. Viruses are hypothesized to contain antigens that are structurally similar to self-antigens and activate B and T cells, resulting in a cross-reactive response against both self-and non-self antigens, which leads to autoimmunity ,13,14. SIn addition to molecular mimicry, there is a mechanism of “bystander activation,” where a non-specific and highly reactive antiviral immune response in a localized pro-inflammatory milieu causes the release of self-antigens from injured tissue. These self-antigens activate autoreactive T lymphocytes, which induce inflammatory responses and contribute to autoimmunity ,20. A viBystander activation as well as molecular mimicry pathway involvement have been reported in autoimmune encephalomyelitis (EAE) models of MS, TMEV-IDD, and myasthenia gravis (MG) mediated by West Nile virus (WNV) ,25,26. FNumerous hypotheses have been proposed to better understand the underlying processes of virus-induced autoimmunity; however, in most cases, a well-defined specific mechanism remains unclear. Despite the absence of a clear molecular explanation, multiple epidemiological and animal model experiments have shown that a broad spectrum of viruses may cause an autoimmune response. The emergence of autoimmune diseases after viral infection is a complicated process that is affected by several variables, including immune response, infectious dosage, and infection duration .The viral and human proteins and their corresponding epitopes that share sequence and structural homology as well as exhibiting biochemical interactions with major histocompatibility complex (MHC) molecules may activate autoreactive T-cells, which eventually provoke autoimmune diseases. Currently, bioinformatics and immunoinformatics tools have gained considerable attention. These platforms facilitate the understanding of the complexity of peptide binding to different MHC molecules, forecasting cytokine release, and identifying the lead T- and B-cell epitopes ,45. We uParamyxoviridae, Caliciviridae, Phenuiviridae, Flaviviridae, Hantaviridae, Pogaviridae, Hepeviridae, Filovirdae, Herpesviridae, nairoviridae, Arenaviridae, Peribunyaviridae, Poxviridae, Rhabdoviridae, Reoviridae, Coronaviridae, Dengue viruses, Ebola viruses, Enteroviruses, Lassa viruses, and hepatitis C viruses. The compiled dataset is comprised of 129,191 protein sequences. In total, 74,468 non-redundant human proteins were retrieved from the NCBI database [The complete proteome sequences of the human pathogenic viruses available in the ViPR database were retrieved. These include viruses belonging to −6  allele has been shown to influence the susceptibility and severity of rheumatoid arthritis. Numerous autoimmune diseases have been linked to HLADRB1-DQA1-DQB1 haplotype components encoded by HLA class-II alleles, including type-1 diabetes, Graves’ disease, and RA [The immunogenic nature of proteins and peptides gives them the potential to bind to the MHC molecules with high binding affinities. MHC-I molecules are found in virtually all nucleated cells and precisely represent endogenous proteins or antigens processed by the cytosolic pathway, which represents cytotoxic T lymphocytes (CTLs). Exogenous antigens, usually the surface proteins of pathogens, are processed by endocytic processes and presented to T lymphocytes or CD4+ T cells . Several-binders . The epi ≤ 50 nM . The ana, and RA . Likewis, and RA . SLE and, and RA .The trRosetta server  was usedMolecular docking analysis was performed to evaluate the MHC-II binding promiscuity of human and virus-mimicking peptides. Protein-protein rigid body docking was performed using the ClusPro server based on sampling billions of confirmations, RMSD-based clustering, and energy minimization-based structural refinement . Human aAutoimmune disorders (AID) are caused by an abnormal immune response that fails to distinguish between self and non-self antigens ,2. MolecAmong the top viral-human mimic candidates, the human herpesvirus and poxvirus proteins exhibited significant 3D structural and sequence homology with human host proteins . SeveralHerpesvirus infections, particularly Epstein-Barr virus (EBV) infections, have been reported in many studies in association with several major autoimmune diseases ,59. We iSignificant sequence and structural homology was observed between cercopithecine betaherpesvirus 5 (CHV5) and human peptides in the current study. The prostaglandin G/H synthase 2 of CHV5 showed homology with the human prostaglandin G/H synthase 2 peptide. Human prostaglandin G/H synthase 2 (PTGS2) is involved in the biosynthesis of fibrous tissues, which eventually regulate immune responses during inflammation . LikewisThe current study inferred that various strains of the Poxviridae family share substantial sequence and structural similarities with immunogenic peptides of human proteins. Viruses secrete an array of virus-encoding soluble cytokine receptors or cytokine analogs that act as molecular decoys to inhibit the activity of host cytokines. The variety of poxvirus gene products systematically sabotage essential components of the inflammatory response and manipulate various intracellular signal transduction pathways that initiate proinflammatory responses. Numerous poxvirus genes that interfere with these pathways exhibit striking similarities with host immune system genes . In our Metabolic pathways control lineage determination and immune system function, thereby affecting the onset of autoimmune disorders . The majThe findings of the current study are based on immunoinformatic platforms and constrained prediction methods that may be uncertain due to conventional benchmarking, and a lack of precise datasets. The virus-human molecular mimic candidates prioritized in the current study, therefore, need additional validation via clinical and experimental approaches.Structural bioinformatics and comparative sequence analysis platforms were followed in this study. The methodological workflow is shown in Complete proteome sequences of all human pathogenic viruses were retrieved from the Virus Pathogen Database and Analysis Resource (ViPR) . Redunda−6 and a threshold of ≥100 bit score, ≥60% query coverage, and ≥50% sequence identity.A standalone version of the Basic Local Alignment Search Tool (BLAST) was used to compare the viral and human protein sequences . Comparap-value <0.0001 and other default parameters. The Path-DIP database is a curated reference of signaling cascades in human and non-human species that includes core pathways from major curated pathway databases as well as pathways predicted using orthology and physical protein interactions. The Path-DIP provides access to both computationally predicted and experimentally confirmed protein–protein interactions (PPIs) [The Path-DIP server was used for protein pathway enrichment analysis with a s (PPIs) .50) cutoff values of less than 50 nM. Peptides with IC50 values less than 50 nM were considered highly compatible binders. The enriched proteins in the metabolic pathways and their respective homologs were subjected to IEDB by selecting HLA class-II binding alleles  . The NN- alleles .The 3D structures of the top viral-human homolog peptide epitopes were docked against the human leukocyte antigen (HLA) and toll-like receptor 4 (TLR4) immune receptors. The protein 3D structure data for HLA and TLR4 were acquired from the Protein Data Bank (PDB) via the 5JLZ and 3FXI PDB IDs, respectively. The peptide epitope 3D structures were modeled using the UCSF Chimera programme . The CluThe trRosetta server was used to predict the 3D structures of the peptides. The trRosetta server (transform-restrained Rosetta) is a web-based tool that accurately predicts protein and peptide structures. trRosetta is one of the most accurate methods for estimating the 3D structure of molecules via ab initio-based simulations . The 3D Comparative sequence analyses and immunoinformatics approaches were employed in the current study to uncover sequence- and structure-based molecular mimics of viral-human proteins as possible autoimmune candidates. BLASTp analysis identified 24 viral proteins with significant sequence homology to human host proteins. Biological pathway enrichment analysis revealed the involvement of viral-human homolog proteins in a variety of human metabolic pathways. Immune epitope prediction analysis inferred that the viral-human homolog proteins shared 13 promising T-cell epitopes, suggesting promiscuous binding to human HLA class II alleles. The experimental validation of these proteins and their top-hit host-pathogen homolog epitopes may explain the virus-based autoimmune diseases in humans.


The heart is a highly metabolic organ with extensive energy demands and hence relies on numerous fuel substrates including fatty acids and glucose. However, oxidative stress is a natural by-product of metabolism that, in excess, can contribute towards DNA damage and poly-ADP-ribose polymerase activation. This activation inhibits key glycolytic enzymes, subsequently shunting glycolytic intermediates into non-oxidative glucose pathways such as the hexosamine biosynthetic pathway (HBP). In this review we provide evidence supporting the dual role of the HBP, i.e. playing a unique role in cardiac physiology and pathophysiology where acute upregulation confers cardioprotection while chronic activation contributes to the onset and progression of cardio-metabolic diseases such as diabetes, hypertrophy, ischemic heart disease, and heart failure. Thus although the HBP has emerged as a novel therapeutic target for such conditions, proposed interventions need to be applied in a context- and pathology-specific manner to avoid any potential drawbacks of relatively low cardiac HBP activity. Glutamine fructose-6-phosphate amidotransferase (GFAT) isoforms are location-specific with GFAT1 expressed in skeletal muscle and the heart, while GFAT2 is predominant in the heart, placenta, and spinal cord , 21. Nabrylation . Bindingrylation . O-GlcNAproteins . The dynO-GlcNAc moieties on proteins can be crudely divided into two categories: overall and site-specific. The use of antibodies (particularly CTD110.6) designed to detect O-GlcNAcylated serine and threonine residues are most commonly utilized in Western blotting to determine the overall change in specific (via immunoprecipitation) or total protein modifications  highlighted the time-dependent decrease in cardiac O-GlcNAc from birth , hypertrophy, hypertension, and heart failure. These data reveal that the HBP is intricately involved in cardiac function and pathology and that O-GlcNAcylation affects various pathways and proteins ) and enhances cardiac contractility  decrease αB-crystallin’s function as a molecular chaperone, O-GlcNAcylation on threonine170 attenuates cardiomyocyte apoptosis through increased αB-crystallin activity and translocation  serine642 elevates its activity and hinders gene transcription, ultimately lowering transforming growth factor-beta (TGF-β) myoblast differentiation and hypertrophy , stabilizing it and preventing its binding to glycogen synthase kinase 3β, and ultimately augmenting downstream TGF-β signaling   . Subsequg (mPTP) , 149. Acg (mPTP) .O-GlcNAcylation of mitochondrial proteins such as voltage-dependent anion channels (VDAC), carnitine-palmitate transferase 1B (CPT1B), and fatty acid oxidase (FAO) contributes to attenuated fatty acid β-oxidation, impaired calcium handling, increased mitochondrial fragmentation, and overall mitochondrial dysfunction  and nuclear factor of activated T cells (NFAT)), or promote apoptotic and inflammatory signaling depending on the duration of the ischemic event , 104. Cofunction , 56, 150rtension , 81, 82.Although downregulating HBP activity should abate the negative consequences of chronic HBP activation, this is not always the case. Repression of OGT or OGA upregulation are primary intervention targets that are influenced by E2F transcription factor 1 (E2f1). E2f1 promotes entry into the S-phase of the cell cycle and alters metabolism by increasing pyruvate dehydrogenase kinase 4 activity which delinks glycolysis from mitochondrial oxidative phosphorylation . IncreasO-GlcNAcylation through OGT/OGA dynamics (O-GlcNAcylation influences Bcl-2 translocation (an intrinsic part of cell-death machinery) and cytoplasmic calcium concentration which mitigate injury following reperfusion  and endothelial nitric oxide synthase activity (eNOS) , and creates a negative feedback loop in terms of HBP activity  . Here, Oactivity , 157. Thactivity , 73, 1121177,615,633 phosphorylation and inhibited by threonine495 phosphorylation (O-GlcNAc targets serine1177 and 615 without influencing other phosphorylation sites and lowering eNOS activity (O-GlcNAcylation through an activating transcription factor 4 (ATF4)-mediated increase in GFAT1 expression while shifting cardiac metabolism towards free fatty acid (FFA) β-oxidation versus glycolysis (O-GlcNAcylation (a major transporter of FFAs into the cytosol) which increases its activity and FFA influx into cardiomyocytes .ex vivo murine heart concluded that neither acute changes in glucose availability nor cardiac workload influenced its flux in a healthy heart  mediated cyclin D2 expression (cell cycle progression), as well as repressor element 1-silencing transcription factor (REST) and forkhead box proteins of class O subgroup (FOXO) O-GlcNAcylation, ultimately promoting hypertrophic gene expression (db/db) mice and those injected with streptozotocin display distinct pathophysiological alterations that result in diabetes but may slightly alter their susceptibility to hypertrophy (in vitro) or pressure overload intervention (in vivo/ex vivo) also contributes to the degree of dysfunction observed  is directly proportional to mammalian target of rapamycin (mTOR) activity . This rehy heart . In vivopression , 58, 101ertrophy . Moreoveobserved 4.O-GlcNAcylation is observed in the context of cardiac hypertrophy and hypertension. Increased substrate availability combined with reduced antioxidant defense systems promotes flux into the HBP and O-GlcNAcylation of proteins such as AMPK and CD36. However, the effects of the HBP are not entirely clear under conditions where hypertension and cardiac hypertrophy exist in combination with diabetes. The degree by which the HBP influences all three pathologies centers around the duration and intensity of the stimulus  as well as the experimental conditions.In summary, increased HBP activity and O-GlcNAc together with lowered miRNA-24 expression levels were found in patients with attenuated cardiac function ), increase apoptotic/autophagic stimuli, and promote mitochondrial stress. The combination of such PTMs contributes towards cardiac fibrosis, hypertrophy, and increased susceptibility to ischemic injury  and troponin (serine150) functionality  expression thus inhibiting apoptotic signaling and improving cardiac function  which provides a final clinical endpoint for enhanced HBP flux over an extended period  highlighted the role of excessive en death . Transgeen death . Of noteactivity . MitochoO-GlcNAcylation, apoptotic stimuli and ubiquitin proteosome activity are elevated, thus contributing to cardiomyocyte death independently of chronic O-GlcNAcylation. Another diagnostic marker for heart failure is the increased serine phosphorylation of insoluble desmin  and instead likely be due to the acute upregulation of other O-GlcNAcylation targets during heart perfusion.A recently emerging biomarker of heart failure is miRNA-423-5p as congestive heart failure patients displayed increased plasma levels , 140. OGe desmin . Desmin actility , 166. Alfunction . These dO-GlcNAcylation. Although pre-clinical work resulting in the downregulation of OGT expression indicates the role of O-GlcNAcylation in the initial phases of autophagy, chronic HBP upregulation hinders this process by modifying synaptosomal-associated protein 29 (SNAP29 – involved in the formation of the autophagolysosome)  . Misfoldysosome) . In suppO-GlcNAcylation in heart failure is somewhat controversial. Increased O-GlcNAcylation levels are observed in patients with heart failure and may contribute to autophagic dysregulation, impaired mitochondrial respiration, and altered ketone metabolism  is beneficial while higher BCAA levels (lowered catabolism) can be damaging . Pre-clioverload , 167. De pathway Figure 2 pathway , 167. Pr pathway . In cont pathway . Therefoin vitro cell differentiation is a lesser investigated area of research. The HBP is integral in mesenchymal stromal cell differentiation which extends to adult and embryonic cardiac stem cells  expression and activity, and decreased GATA binding protein 4 (GATA4), atrial natriuretic peptide (ANP), p-phospholamban, and p-cardiac troponin I levels   demonstrated an increase in O-GlcNAcylated phospholamban with a concurrent decrease in phosphorylated phospholamban and cardiac function  . Phospholaxation . Howeverfunction . Additiohandling . Furthers CaMKII , 58, 125function , 176.O-GlcNAcylation, the localization of OGA and OGT also impacts cardiac function. Under normal conditions, OGT is primarily localized to the Z-line of myofilaments with OGA to the A-band , substrate availability, or elevated intracellular oxidative status, contribute towards chronic protein O-GlcNAcylation and subsequent cardiac dysfunction , National Research Foundation (129325 to MFE) and National Research Foundation (MND210428597749 to MC).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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Endothelial dysfunction underlies many of the major complications following hematopoietic cell transplantation (HCT), including transplant-associated thrombotic microangiopathy (TA-TMA), veno-occlusive disease/sinusoidal obstruction syndrome (VOD/SOS), and engraftment syndrome (ES). Emerging evidence similarly implicates endothelitis and microangiopathy in severe COVID-19-related multi-system organ dysfunction. Given the overlap in these two illness states, we hypothesize that prior COVID-19 infection may increase risk for HCT-related endotheliopathies. This retrospective, multicenter study included patients aged 0-25 years who underwent autologous or allogeneic HCT for any indication between January 1, 2020 and September 21, 2021, with close attention to those infected with COVID-19 in either the six months prior to transplant or twelve months following transplant. Incidences of TA-TMA, VOD/SOS, and ES were compared among patients with COVID-19 infection pre-HCT and post-HCT, as well as with historical controls who were never infected with SARS-CoV-2. Those who underwent HCT following COVID-19 infection displayed significantly increased rates of TA-TMA compared to those who were never infected. Additionally, our data suggests a similar trend for increased VOD/SOS and ES rates, although this did not reach statistical significance. Therefore, a history of COVID-19 infection prior to undergoing HCT may be a nonmodifiable risk factor for endothelial-related complications following HCT. Further studies are warranted to better clarify this relationship among larger cohorts and in the era of the Omicron SARS-CoV-2 variants. While scientific knowledge regarding the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has expanded rapidly since the beginning of the coronavirus disease 2019 (COVID-19) pandemic, unanswered questions remain pertaining to the impact of this illness on medically unique populations. Pediatric patients undergoing hematopoietic cell transplantation (HCT) are a medically complex group in which the impact of SARS-CoV-2 infection is not well understood. While pediatric patients in general seem to be at lower risk for severe disease from COVID-19, adults undergoing HCT appear to be at increased risk for COVID-19-related severe disease and mortality .Data characterizing the experience of this unique pediatric population is limited and predominately describes patients infected following HCT. Lucchini et al. recount the UK experience, in which the majority of their post-HCT pediatric patients who became infected with SARS-CoV-2 had mild illness, although one of the nine patients did develop severe COVID-19 infection with cytokine-release syndrome . A serieMounting evidence suggests that severe disease from SARS-CoV-2 is largely mediated by systemic endothelial injury , 8. AnalThe effect of COVID-19 infection on endothelial function may persist long after the acute infection has resolved. A study by Chioh et al. demonstrated that there were persistent cellular and biochemical markers of endothelial injury and cytokine hyperactivation among convalescing patients . AdditioThe systemic endothelial dysfunction seen in severe SARS-CoV-2 infection shares a similar pathophysiology with the endotheliopathies seen following HCT , 20. ThiGiven these shared mechanisms, as well as the lingering nature of the endothelial dysfunction following COVID-19 infection, we hypothesize that patients with SARS-CoV-2 infection in the time period immediately pre- or post- HCT may be at increased risk of developing HCT-related complications mediated by endothelial dysfunction. Therefore, in this study we assessed the incidence of transplant-related endotheliopathies in patients with COVID-19 infection pre-HCT and post-HCT compared to historical controls without documented SARS-CoV-2.via retrospective review of the medical record and stored on a de-identified, secure database.This multicenter study evaluated patients across four geographically diverse academic pediatric centers. All patients aged 0-25 years who underwent autologous or allogeneic HCT for any indication from January 1, 2020 to September 21, 2021 were included. The study group was comprised of all patients with a laboratory confirmed case of COVID-19 in either the six months prior to or twelve months following HCT. Clinical variables of interest were collected Data was summarized using frequencies and percentages for categorical data and medians with either ranges or interquartile ranges for continuous data. Data was compared between groups (COVID-19 pre-HCT vs COVID-19 post-HCT) using a Fisher’s exact tests for categorical data, and a Wilcox rank sum test for continuous data. All tests were two-sided, and p-values ≤ 0.05 were considered statistically significant. All analyses were performed using R version 4.1.2 .This study was approved by the institutional review boards at each of the participating centers. Patient consent was not required given the de-identified and retrospective nature of the investigation.A total of 374 pediatric and young adult patients underwent HCT for any indication during the specified date range across the four sites. Ten patients contracted COVID-19 in the six months prior to HCT, and 13 contracted COVID-19 in the twelve months following HCT. Demographic characteristics of the infected patients are in Clinical data regarding HCT variables were compiled for patients who contracted COVID-19 Table 1BCOVID-19 infection characteristics were compiled Table 2.Incidence of TA-TMA, VOD/SOS, and ES were compared between patients infected with COVID-19 Pre- and Post-HCT, as well as to the larger group of historical controls who were never infected with COVID-19 Table 3.Individual case details for the 10 patients in the COVID-19 Pre-HCT group are outlined in In this study, we sought to understand the impact of COVID-19 infection on pediatric HCT outcomes, particularly transplant-associated endotheliopathies. Among this small group of pediatric and young adult patients, those who underwent HCT following COVID-19 infection displayed significantly increased rates of TA-TMA compared to those who were infected after transplant or historical controls who were never infected. Additionally, our data suggests a similar trend for increased VOD/SOS and ES rates, although this did not reach statistical significance. We do acknowledge that rates of VOD/SOS and ES were lowest in our cohort of patients who contracted COVID-19 following HCT, however we suspect this is due to small sample size and low statistical power rather than a true protective effect. Finally, for both patients from the COVID-19 Pre-HCT cohort who died, multiple identified endotheliopathies contributed to mortality.To our knowledge, no other studies have reported on HCT-associated outcomes in pediatric patients with a history of prior COVID-19 infection. However, there are a few cases in the literature that support the pathophysiologic link between transplant endothelitis and COVID-19 endothelial dysfunction. Among the patients described by Lucchini et al., one patient who had mild illness from COVID-19 infection on day +138 went on to develop TA-TMA, in the absence of other commonly accepted TA-TMA risk factors . The autEvidence to support the increased risk of TA-TMA among transplant recipients who experience COVID-19 infection reaches beyond the realm of HCT. Two cases of TMA concurrent with COVID-19 infection in renal transplant recipients have been reported. The first describes an adult patient who was nine years post-allograft receipt and developed TMA 11 days following COVID-19 diagnosis; other known causes of TMA were ruled out. His course was also characterized by multisystem organ dysfunction and myocardial infarction, suggestive of global endothelial dysfunction . The secvia the classical, lectin, and alternative complement pathways (The shared pathogenic mechanism between severe COVID-19 infection and post-HCT endotheliopathies may be rooted in excess complement activation. SARS-CoV-2 infections have been shown to cause aberrant complement activation pathways , 25. Genpathways . FurtherAdditionally, excess and prolonged cytokine release is likely a shared pathophysiologic mechanism that unifies severe COVID-19 illness and HCT-associated endotheliopathies. IL-6, IL-1β, and TNF-α have been named as key cytokines that become overexpressed in the setting of severe COVID-19 infection . ParticuTwo clinical applications of interest arise from these findings. First, our reported findings may suggest that prior COVID-19 infection could be a nonmodifiable risk factor for transplant-associated endotheliopathy. As such, institutions may consider implementing additional screening for affected patients throughout their transplant process. For example, we endorse the TA-TMA screening guidelines recommended by Dandoy et al., which includes twice weekly lactate dehydrogenase measurement and weekly urinalysis with urine protein creatinine ratio for the first 30 days post-HCT. For patients undergoing HCT for non-malignant and non-urgent indications who contract COVID-19 prior to HCT, consideration may be given to delaying HCT. The appropriate interval for delaying HCT is not yet defined, and further investigation is required prior to formalizing this recommendation , 32.Currently, the impact of SARS-CoV-2 infection on success of HCT engraftment and ultimate outcome is unknown. Key endothelial cell populations are thought to be involved in homing, engraftment, and restoration of bone marrow functioning following HCT , 34. DamThe following limitations must be considered while interpreting the results of this study. First, although this study was conducted across four pediatric HCT centers, the frequency of patients infected with COVID-19 in the peri-HCT period was low. The sample size of our population of interest is small, which limits study power and ability to perform complete statistical analyses, including multivariate analysis. We strongly encourage ongoing investigation regarding this topic, as more patients will be available for study as the COVID-19 pandemic progresses. Second, he patients included in this research contracted COVID-19 prior to the emergence of the Omicron variants. The Omicron variant infected significantly more pediatric patients nationwide, however severe clinical outcomes were fewer as compared to pediatric patients infected with the Delta variant . Follow 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 Mayo Clinic IRB, UCSF IRB, MD Anderson Cancer Center IRB, Dana Farber/Boston Children’s IRB. Written informed consent from the participants’ legal guardian/next of kin was not required to participate in this study in accordance with the national legislation and the institutional requirements.SA, MK, KMM, MZ, LL designed the research. SA, DR, SK, GC, RB, GM, AF, MK collected the data. SA, KM, MK analyzed the data. SA, MK wrote the paper. All authors provided edits for the paper. SA and MK directly accessed and verified the underlying data reported in the manuscript. All authors should confirm that they had full access to all the data in the study and accept responsibility to submit for publication. All authors contributed to the article and approved the submitted version.


Immunotherapy using immune checkpoint modulators has revolutionized the oncology field, emerging as a new standard of care for multiple indications, including non-small cell lung cancer (NSCLC). However, prognosis for patients with lung cancer is still poor. Although immunotherapy is highly effective in some cases, not all patients experience significant or durable responses, and further strategies are needed to improve outcomes. Therapeutic cancer vaccines are designed to exploit the body’s immune system to activate long-lasting memory against tumor cells that ensure tumor regression, with minimal toxicity. A unique feature of cancer vaccines lies in their complementary approach to boost antitumor immunity that could potentially act synergistically with immune checkpoint inhibitors (ICIs). However, single-line immunization against tumor epitopes with vaccine-based therapeutics has been disappointingly unsuccessful, to date, in lung cancer. The high level of success of several recent vaccines against SARS-CoV-2 has highlighted the evolving advances in science and technology in the vaccines field, raising hope that this strategy can be successfully applied to cancer treatments. In this review, we describe the biology behind the cancer vaccines, and discuss current evidence for the different types of therapeutic cancer vaccines in NSCLC, including their mechanisms of action, current clinical development, and future strategies. Lung cancer is currently the leading cause of cancer death worldwide . DespiteOver the last decade, major improvements have been achieved in treatments for NSCLC, thanks to the development of targeted therapies and immunotherapy . Immune high. T effector cells and CD4+CD25high T regulatory cells express master transcription factor FoxP3, with the latter having a detrimental effect on immune response in multiple solid cancers [The spectacular therapeutic impact of recent vaccine clinical development in the management of SARS-CoV-2 (COVID-19) has been seen globally. However, successful immunization in other fields, including against tumor epitopes via vaccine-based therapeutics—the subject of research for many years—is lagging behind, and has not resulted in the hoped-for outcome in lung cancer. The body’s natural specific T-cell response against tumor cells relies on several steps. The first step is the tumor antigen encountered by antigen-presenting cells (APCs) such as dendritic cells (DCs). The antigen-loaded APCs ultimately reach the draining lymph nodes, where T cell activation or priming occurs, giving rise to antigen-specific T-cells. DCs present the antigens on MHC class I and class II molecules to CD8+ and CD4+ T-cells, respectively. The generation of tumor-specific T cell responses occurs via costimulatory signals that allow for the generation and expansion of activated tumor-specific CD4+ and CD8+ T-cells. This step is crucial, as the nature of the immune response depends on the critical balance between activated conventional CD4+ effector cells and CD4+CD25 cancers ,15. Fina cancers .Cancer vaccines are designed to select suitable antigen targets to induce new antigen-specific T cell responses against tumor cells, to amplify pre-existing responses, and to increase the breadth and diversity of the tumor-specific T cell response . The maiAs a result, cancer vaccine research is evolving along new avenues to stimulate the immune system, such as with tumor-specific antigens (TSAs), not expressed by healthy tissue, as well as combination strategies to induce deeper immune responses .In addition to tumor antigens, the development of a successful cancer vaccine depends on another two key components: immune adjuvant platforms, and delivery vehicles. The identification of neoantigens and novel platforms are major advances in this field, and are reviewed in detail here.Cancer vaccines can be explored in the prophylactic or the therapeutic setting. Prophylactic vaccines are used to prevent infection by oncogenic viruses, while therapeutic vaccines aim to boost the immune system to eradicate neoplastic cells and revolve around tumor antigens.Viral antigen-based vaccines against hepatitis B virus (HBV) and human papillomavirus (HPV) represent the paradigm for prophylactic cancer vaccines, with both used to prevent infections caused by known oncogenic viruses . VaccinaA prophylactic vaccine is not yet considered to be a promising option for lung cancer since oncogenic viruses involved in NSCLC pathogenesis have not been identified. Choosing the right tumor antigen, expressed only by tumor tissue, to promote an immune response in the host remains challenging, as well-defined tumor antigens are usually expressed by normal tissues .Tumor antigens can be grouped in two main categories: tumor-associated antigens (TAAs), which are self-antigens abnormally expressed in cancer cells and, therefore, also expressed in normal cells; and TSAs or neoantigens, which are encoded by tumor-specific somatic mutations and, therefore, only expressed by neoplastic cells .The first and most crucial step in cancer vaccine development is the choice of an antigen, which should ideally satisfy several conditions: that it is expressed uniquely by cancer cells and not by normal cells, that it is homogenously expressed across all cancer cells to avoid cancer escape and metastasis development, that it is essential for cancer cell survival, and that it is highly immunogenic .In the past, TAAs have been widely investigated but have shown limited clinical benefit, likely due to preexisting central tolerance to self-antigens ,23. ImmuUnlike TAAs, neoantigens are tumor and often patient-specific; they arise from molecular alterations and are less likely to be subject to central tolerance . Solid tAdditionally, it is not feasible to determine neoantigen load in daily practice. Tumor mutation burden (TMB), defined as the total number of somatic/acquired mutations per coding area of a tumor genome (Mut/Mb), has failed to consistently predict response to ICIs thus far ,28.With the ongoing advances in next-generation sequencing technology and bioinformatics, neoantigen identification for cancer vaccines development is becoming increasingly feasible . KRAS-muThe four main types of vaccine platforms encoding TAAs that have been developed for cancer therapy are cell-based, protein/peptide-based vaccines, viral vectors, and gene-based vaccines (DNA or RNA). They are reviewed here, with a focus on NSCLC, and are summarized in Cell-based vaccines are designed using dead or living tumor cells that are able to induce an immune response in the host, with the aim of protecting the host from future disease or infection. Strategies employing this approach include the use of allogenic tumor cell lines, irradiated autologous tumor cells, or autologous tumor lysates . Early sThe first FDA approved cancer vaccine was Sipuleucel-T for metastatic castration resistant prostate cancer. Sipuleucel-T is an autologous dendritic cell-based vaccine loaded with a prostatic acid phosphatase (PAP) antigen fused to GM-CSF. Despite a small but statistically significant survival benefit demonstrated in a phase III trial , severalCell-based vaccines have been investigated in NSCLC, but with disappointing results. The GVAX vaccine is a whole tumor cell vaccine, genetically modified to secrete GM-CSF. A platform composed of autologous tumor cells mixed with an allogenic GM-CSF secreting cell line was developed. Safety and efficacy were explored in a phase I/II trial; however, objective tumor responses were not seen . EfficacBelagenpumatucel-L is an allogeneic whole tumor cell vaccine containing four NSCLC cell lines transfected with a human transforming growth factor (TGF)-β2-antisense vector designated pCHEK/HBA2. Phase II trials initially demonstrated the safety of this cell-based vaccine in patients with NSCLC, with encouraging efficacy ,48. A ph1650-G is an allogenic cellular vaccine comprising a lethally irradiated tumor cell allogenic line and GM-CSF. A pilot study conducted by Hirschowitz et al., in 11 patients with NSCLC confirmed safety and demonstrated an immunological response in 6 patients . ClinicaPeptide-based vaccines mimic the epitopes of the antigen that triggers an anticancer immune response. Early studies with single-antigen based short peptides have not shown robust immune responses. In the pre-ICI era, the gp100 peptide vaccine in addition to IL-2 was associated with a higher response rate and longer progression-free survival compared to IL-2 alone in patients with advanced melanoma . SeveralThe MAGE-A3 cancer vaccine has been explored in the adjuvant setting, in patients with resected NSCLC. This vaccine combines recombinant MAGE-A3 protein (a TAA expressed in 30–50% of NSCLC) which is given with AS15, an immunostimulant. A randomized phase III clinical trial  was conducted in patients with fully resected stage IB-IIIA MAGE-A3-positive NSCLC. Patients were randomized to receive MAGE-A3 vaccine versus placebo. The outcome of this trial was negative and there were no differences in disease-free survival between groups . MAGE-A3p = 0.1) [CIMAvax-EGF is an epidermal growth factor (EGF)-based vaccine, composed of human recombinant EGF coupled to a carrier protein, recombinant P64. A randomized phase II trial using CIMAvax-EGF in advanced NSCLC was developed in Cuba . CIMAvaxp = 0.1) . CIMA-vap = 0.004). Median progression-free survival in vaccinated patients was 5.3 months versus 3.9 months for placebo  [Racotumomab-alum is an anti-idiotype vaccine targeting the NeuGcGM3 tumor-associated ganglioside. Neu glycolyl (NeuGc)-containing gangliosides are glycolipids present on NSCLC cells, but not on the cytoplasmic membrane of normal cells ,53. Seve= 0.039) . RacotumTecemotide (L-BLP25) is a MUC1 antigen-specific vaccine. Preclinical and early-phase studies showed adequate safety and immunogenicity, as well as preliminary efficacy signals ,57. A phThe PReferentially expressed Antigen in Melanoma (PRAME) is a testis-selective cancer testis antigen (CTA) with restricted expression in somatic tissues and preferentially expressed in variety of cancers, including NSCLC, metastatic melanoma, breast cancer, and neuroblastoma . The safViral vector-based vaccines are used to administer antigens in the host and provoke an immune response. In 2015, the FDA approved the first oncolytic virus vaccine talimogene laheparepvec (T-VEC) for advanced melanoma . T-VEC iAnother viral-based vaccine, PROSTVAC, used recombinant poxviruses expressing prostate-specific antigen in castration-resistant prostate cancer. However PROSTVAC was discontinued due to lack of efficacy, and this technology has not been extended to other tumor types .In advanced NSCLC, viral-vector based vaccines targeting TAAs have been investigated with disappointing results. TG4010 is a recombinant viral-based vaccine targeting MUC, a TAA overexpressed in many solid tumors. Phase II clinical trials of TG4010 in combination with chemotherapy demonstrated encouraging efficacy results and no safety signals . TG4010 A phase I/II trial of the MG1-MAGEA3 vaccine constructed with an adenovirus expressing MAGE-A3 in combination with pembrolizumab is ongoing (NCT02879760). This exploration is based on preclinical models showing superior tumor clearance and survival, and induction of CD8+ T-cell infiltration turning ‘cold’ tumors into ‘hot’ tumors .LV305 is a lentivirus-based vaccine designed to selectively transduce DCs in vivo through the DC-SIGN receptor. LV305 induces expression of NY-ESO-1 cancer testis antigen in DCs, to promote immune responses against NY-ESO-1-expressing tumors. A phase I study including patients with advanced sarcoma, ovarian cancer, melanoma, and lung cancer showed a favorable safety profile, induction of antigen-specific responses, and potential clinical activity . OngoingDNA vaccines use plasmids to deliver genes encoding tumor antigens, stimulating the adaptative immune response towards cancer cells. The DNA vaccine pVAX1-MAGEA3-sPD1 is based on the MAGE-A3 antigen, enhanced with soluble PD-1 (sPD1). A series of DNA plasmids encoding MAGE-A3, and the extracellular domain of murine PD-1 (sPD1) was developed and showed immunogenicity and tumor growth inhibition in mice .RNA vaccines offer some advantages over DNA vaccines thanks to their mechanism of action. Unlike DNA, which has to be integrated into the DNA machinery in order to be expressed, RNA only needs to enter the cytoplasm for expression, limiting its oncogenic potential , and reiThe extremely rapid development and high level of efficacy of several vaccines against SARS-CoV-2 ,69 has hSeveral technology platforms have been explored for the development of SARS-CoV-2 vaccines, including whole virus vaccines , nucleicAs some of the mechanisms of acquired resistance to immunotherapies correlate with downregulation of MHC-I and defects in antigen-presenting machinery, the signal-sequence-derived peptides and their carrier proteins, such as ppCT  are attr®-derived CV9201 cancer vaccine in 46 patients with advanced NSCLC demonstrated an adequate safety profile. Immune responses against all five encoded antigens  were reported [mRNA vaccines are also under investigation in NSCLC. CV9201 and CV9202 are mRNA-based cancer vaccines containing sequence-optimized mRNAs encoding different cancer antigens to facilitate antigen expression and activation of the immune system, inducing an adaptive cellular and humoral immune response ,81,82. AA deeper understanding of the basic mechanisms of T cell recognition of neoantigens, and computational approaches to discover somatic mutations and neoantigen prediction, will likely enable greater clinical benefit with future neoantigen-based immunotherapies . AdvanceThe neoantigen peptide-based vaccine, NEO-PV-01, has recently been evaluated in a phase Ib trial in combination with nivolumab (an anti-PD-1 ICI) in patients with NSCLC, bladder cancer, or melanoma. It showed an acceptable safety profile and a response rate of 39% in the 18 patients treated in the NSCLC cohort .Vx-001 is a vaccine based on optimized cryptic peptides, a new family of tumor antigens which are derived from universal tumor antigens but are identified by the immune system as neoantigens or ‘non-self’, being strongly immunogenic. Vx-001 targets TERT (TElomerase Reverse Transcriptase) and has been tested in a phase I/II clinical study in patients with different solid tumors, mainly NSCLC. However, a phase II clinical trial found no differences in overall survival, disease control rate, or time to treatment failure . SeveralRO7198457 is an RNA-Lipoplex Individualized Neoantigen-Specific Immunotherapy (iNeST), with up to 20 patient-specific neoantigens. It is manufactured on a per-patient basis, and it aims to induce T cell responses against neoantigens. A first-in-human phase Ia study of RO7198457 was conducted in patients with locally advanced or metastatic solid tumors, and demonstrated a manageable safety profile and strong neoantigen-specific immune responses . A combiKRAS mutation is a genetic driver of multiple cancers, including NSCLC. Neoantigens encoded by KRAS mutations are tumor-specific and highly immunogenic . KRAS muALK rearrangement is found in approximately 5–6% of NSCLC. In preclinical studies by Voena et al., an ALK vaccine containing a DNA plasmid coding the intracytoplasmic domain of ALK was shown to be effective in a mouse model of ALK-rearranged NSCLC by inducing a tumor-specific cytotoxic response . A phaseTherapeutic cancer vaccines aim to establish the body’s long-lasting immunological memory against tumor cells, thereby leading to effective tumor regression while minimizing non-specific or adverse events . While aThe main reason for cancer vaccine failure is the complexity of identifying specific target tumor antigens shared by multiple tumor types, and that are also unique or overexpressed only by the tumor cells compared to normal tissue. Most tumor antigens incorporated in cancer vaccines have been TAAs or non-mutated overexpressed self-antigens; however, the high-affinity T cells recognizing self-antigens are eliminated during development by the immune system’s tolerance mechanisms, limiting the potential vaccine efficacy. Therefore, T cells activated by such vaccines would be those with low-affinity T cell receptors (TCR), which are unable to stimulate an effective antitumor response , and addMoreover, cancer cells can develop mechanisms for preventing immune cells from infiltrating the tumor microenvironment (TME) despite adequate immunogenicity , such asCancer cells can also downregulate the expression of target antigens, MHC or co-stimulatory molecules leading to failure of T-cell recognition . Lung caThe advent of cancer immunotherapy using ICIs has revolutionized clinical treatment of multiple solid cancers, including NSCLC. However, further strategies are needed as less than one third of patients with non-oncogene addicted advanced NSCLC benefit from ICIs long-term . Cancer


With the large global burden of latent tuberculosis infection (LTBI), screening for LTBI for various reasons has been widely used, including the low-prevalence settings in which targeted testing is the standard practice , 2. InteThe results showed acceptable intra- and inter-run precision as well as cutoff verification across the 2 analyzers at the aforementioned levels . OverallLastly, the method comparison showed excellent results comparing the 2 kits/platforms . In our Altogether, the 2 methods were highly comparable. LIAISON QFT-Plus, which is a fully automated, random-access platform is a suitable alternative to semi-automated batch testing  in high-volume laboratories.


Cell, Afkhami and colleagues systematically compared different routes of vaccine delivery, origin of the vaccine platform as well as valence of the vaccine and demonstrated that the respiratory mucosal delivery of a trivalent chimpanzee’s adenovirus (Ad)-vectored vaccine is superior to any other of the tested conditions in inducing broadly-acting immunity and protection against current severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and possibly future variants of concern (VOC).1In a recent study published in 3The ongoing global coronavirus disease 2019 (COVID-19) pandemic caused by SARS-CoV-2 has forced an uniquely fast development of novel mRNA- and vector-based vaccines. While these vaccines have proven effective for the control of COVID-19 caused by the ancestral SARS-CoV-2 strain, different VOC escape vaccine-induced immunity resulting in limited protection efficacy against mild to moderate COVID-19. Therefore, there is an urgent need for the development of improved next-generation vaccines.1 developed trivalent vaccine candidates expressing the SARS-CoV-2 antigens spike protein 1 (S1), nucleocapsid and the RNA-dependent RNA polymerase (RdRp) protein in adenoviral vectors of human (Tri:HuAd) or chimpanzee (Tri:ChAd) origin  in the airways. In contrast, mucosal vaccine delivery proved to be highly effective in inducing IFNγ-producing CD4+ and multifunctional CD8+ T cells, indicated by the high frequency of IFNγ, TNFα and/or IL-2 cytokine producers with cytotoxic potential in addition to the induction of durable multifunctional TRM in the airways  was clearly superior in inducing neutralizing antibodies, TRM and TII compared to the Ad-vector of human origin (Tri:HuAd). Thus, the authors unequivocally demonstrated the outperforming nature of the mucosal delivery route in combination with the chimpanzee-derived Ad-vector vaccine platform.While most studies addressing vaccine efficacy exclusively focus on antibody and T cell responses, Afkhami and coworkers also included the dependency of induced trained innate immunity (TII) on the route of vaccine delivery in their survey. More specifically, they characterized the trained MHC II1 Importantly, in contrast to first-generation COVID-19 vaccines which were less effective against immune-evasive VOC,3 mucosal vaccination with the Tri:ChAd vaccine conferred potent protection not only against lethal challenge with the wild-type ancestral SARS-CoV-2 strain, but as well against the VOC B1.1.7 and B.1.351.To ultimately prove that the multilayered immune response induced by mucosal delivery of Tri:ChAd would confer highest protection against fatal SARS-CoV-2 infection, Afkhami and colleagues vaccinated mice either intranasal or intramuscular with a single-dose Tri:HuAd or Tri:ChAd, respectively, followed by a lethal challenge with a mouse-adapted SARS-CoV-2 virus. Indeed, in line with the superior induction of humoral, cellular and trained innate immunity, the outstanding features of the mucosal, but not systemic, applied Tri:ChAd vaccine translated into full protection against an otherwise lethal infection.Next to the delivery route and the origin of the Ad-vector vaccine, the valence of the vaccine might be decisive for vaccine efficacy. To experimentally prove this, the authors constructed in addition to the trivalent vaccine the bivalent vaccine Bi:ChAd (nucleocapsid and RdRp) and the monovalent vaccine Mono:ChAd (S1) Fig. . Mucosal1 Without any doubt, the worldwide concerted effort that resulted in the incredibly fast development of first-generation SARS-CoV-2 vaccines was a great success in containing the global pandemics. However, since we are facing the problem that the virus is continuously evolving and thereby capable of escaping immunity induced by current vaccines, the development of improved next-generation vaccines taking into account recent research data is imperative.2 Notably, authorized first-generation SARS-CoV-2 vaccines (i.e. mRNA and vector vaccines) clearly differ from the ideal vaccine described by Afkhami et al. as they are generally applied intramuscular and are monovalent.4 While e.g. the ChAdOx1nCov-19 vaccine from AstraZeneca actually is based on a vector system of chimpanzee origin, it is still monovalent and delivered intramuscular, thus offering potential for further optimization.5 Indeed, there is growing effort in probing the applicability of first-generation COVID-19 vaccines for respiratory mucosal delivery. However, most of the studies published so far did not distinguish between mucosal and systemic delivery routes, nor did they include different VOC.5 Therefore, the study by Afkhami et al. highlighted here should be considered as a milestone for future vaccine development since it unequivocally demonstrates the superiority of mucosal delivery of a trivalent ChAd-vectored vaccine in protection against ancestral SARS-CoV-2 and VOC.In conclusion, considering many different facets of vaccine design, Afkhami and coworkers made several important key findings that should be considered as blueprint for the development of sophisticated next-generation vaccines. They identified mucosal delivery of a trivalent vaccine incorporated in a chimpanzee-derived Ad-vector as the ideal tool for the stimulation of systemic and, even more important, mucosal antibody and T cell responses together conferring protection against an otherwise devastating SARS-CoV-2 infection.


Total knee arthroplasty (TKA) is widely recognized as an effective treatment for end-stage knee osteoarthritis (OA). Compared with conventional TKA, robotic-arm assisted TKA may improve patients’ functionality and resulting quality of life by more accurate and precise component placement. Currently, the literature on cost-effectiveness of robotic-arm assisted TKA in the US is limited. The objective of this study was to assess the cost-effectiveness of robotic-arm assisted TKA relative to TKA in the Medicare-aged population including exploring the impact of hospital volume on cost-effectiveness outcomes.We developed a decision-analytic model to evaluate the costs, health outcomes, and incremental cost-effectiveness ratio (ICER) of robotic-arm assisted TKA vs TKA in Medicare population with OA. We evaluated cost-effectiveness at a willingness-to-pay (WTP) threshold of $50,000 per quality-adjusted life-year (QALY). We sourced costs from the literature including episode-of-care (EOC) costs from a Medicare study. We assessed cost-effectiveness of robotic-arm assisted TKA by hospital procedure volume and conducted deterministic (DSA) and probabilistic sensitivity analysis (PSA).For the average patient treated in a hospital with an annual volume of 50 procedures, robotic-arm assisted TKA resulted in a total QALY of 6.18 relative to 6.17 under conventional TKA. Total discounted costs per patient were $32,535 and $31,917 for robotic-arm assisted TKA and conventional TKA, respectively. Robotic-arm assisted TKA was cost-effective in the base case with an ICER of $41,331/QALY. In univariate DSA, cost-effectiveness outcomes were most sensitive to the annual hospital procedure volume. Robotic-arm assisted TKA was cost-effective at a WTP of $50,000/QALY only when hospital volume exceeded 49 procedures per year. In PSA, robotic-arm assisted TKA was cost-effective at a $50,000/QALY WTP threshold in 50.4% of 10,000 simulations.Despite high robotic purchase costs, robotic-arm assisted TKA is likely to be cost-effective relative to TKA in the Medicare population with knee OA in high-volume hospitals through lowering revision rates and decreasing post-acute care costs. Higher-volume hospitals may deliver higher value in performing in robotic-arm assisted TKA. Total knee arthroplasty (TKA) is widely recognized as an effective treatment for end-stage knee osteoarthritis (OA). In the United States (US), TKA is one of the most expensive surgical procedures among adult patients, with average total costs ranging from $31,558 to $37,370 . Demand Robotic-arm assisted TKA is an alternative to TKA which has the potential of reducing costly complications and readmissions with robot-assisted techniques. Before surgery, a CT scan is utilized to produce a 3D model of the patient’s knee, allowing doctors to place the implant more precisely , 11. DurThe literature on cost-effectiveness of robotic-arm assisted vs conventional TKA in the US is limited. Following a review of the literature, we identified two published studies comparing the cost-effectiveness of these two interventions . Using aGiven robotic-arm assisted TKA’s potential to improve patient outcomes and reduce costs, particularly in higher procedure volume hospitals, we used a decision-analytic model to assess the cost-effectiveness of robotic-arm assisted vs conventional TKA using Microsoft Excel. The model parameters were obtained from published studies on transitional probabilities, costs, and outcomes of both conventional and robotic-arm assisted TKA. Our study doesn’t involve human subjects or personal level data.We developed a decision-analytic model composed of decision node and a recurring Markov process to evaluate a cohort of Medicare beneficiaries aged 65 years undergoing treatment for end-stage knee OA. In our base case, we assumed patients received care from a hospital with an annual volume of 50 procedures. TKA is a safe and common inpatient procedure that relieves pain and improves the functional status of patients with advanced knee osteoarthritis, the most common type of arthritis among older people . TherefoWe made several assumptions in the decision-analytic model. First, robotic arm-assisted TKA was first introduced in 2006 thus long-term patient outcomes are not yet available in published studies . TherefoMortality rate. Based on a nationwide study on Medicare beneficiaries, we used 90-day perioperative mortality rates of 1.1% and 0.7% for primary TKA and revision TKA respectively [ectively . Becauseectively .Revision rate. Over time, failure of the initial TKA might occur and require revision surgery. Using estimates from a 10-year follow-up study on 71 robotic-arm assisted TKAs, we set the annual probability of revision at 0.28% for robotic-arm assisted TKA [sted TKA . Using tHealth utilities in the model were defined as quality-adjusted life-year (QALY) weights and were identified from a review of the literature. HRQoL after undergoing TKA with or without robotic assistance was set using a QALY weight of 0.835 . SimilarDisutilities. In the model, we assessed disutilities when a patient undergoes either primary or revision surgery. The disutilies represent the diminished HRQoL during the perioperative period. The disutility of the initial surgery was omitted in the analysis as both robotic-arm assisted TKA and conventional TKA groups would experience the same magnitude of disutility. Similar to Slover et al., the disutility of having revision surgery was set at 0.1 which is equivalent to losing one-tenth of a year of perfect health [t health .We considered 90-day episode-of-care (EOC) costs from a healthcare sector perspective, including intraoperative, inpatient, postoperative costs. For the robotic system and associated costs, we obtained them from Cotter et al.  who sourPrimary outcomes of our analysis were total QALYs, total costs, the incremental cost-effectiveness ratio (ICER), and incremental net monetary benefits (INMB) of robotic-arm assisted TKA relative to TKA. We considered 3 commonly used willingness-to-pay (WTP) thresholds: $50,000 per QALY, $100,000 per QALY, and $150,000 per QALY . RoboticWe used probabilistic sensitivity analysis (PSA) to test the robustness of the analysis by assuming a probability distribution for each parameter and changing all parameters in the model simultaneously. Then we carried out deterministic sensitivity analysis (DSA) where we changed each of the parameters used in the model while holding other parameters constant to identify factors with the greatest impact on cost-effectiveness. The parameters used in sensitivity analysis included perioperative mortality rates, revision rates, QALYs, and specific components of 90-day EOC costs.There was an inverse relationship between annual surgical volume and INMB for robotic-arm assisted TKA. Robotic-arm assisted TKA was cost-effective when case volume exceeded 49 cases per year . At a loThe results from probabilistic sensitivity analysis suggested that for a hospital with an annual surgical volume of 50, robotic-arm assisted TKA had a 50.04% chance of being the more cost-effective procedure compared to the conventional TKA at the WTP threshold of $50,000 per QALY gained. If the WTP threshold was set to $100,000 per QALY gained, robotic-arm assisted TKA had a 50.91% chance of being the preferred choice.Deterministic sensitivity analysis revealed variables that exerted a significant effect on INMB of robotic-arm assisted TKA . OverallThis study used a decision-analytic model to evaluate cost-effectiveness of robotic-arm assisted TKA. The results suggested that robotic-arm assisted TKA was likely to be cost-effective relative to TKA in the Medicare-aged population at a hospital that performed more than 49 procedures per year. Though robotic-arm assisted technology requires a significant amount in fixed-asset investment , high purchase costs can be offset by savings through reduced revision rates and fewer post-acute care costs.Our sensitivity analysis revealed that high-volume hospitals may deliver higher value in performing in robotic-arm assisted TKA. Robotic-arm assisted technology requires a high initial investment in the equipment, high-volume hospitals can achieve economies of scale by spreading the investment over more TKA cases. Notably, deterministic sensitivity analysis demonstrated that costs that occurred in preoperative, intraoperative, and postoperative stages affected the results in wide ranges. In our model, transitional probabilities and costs were not modeled as a function of hospital volume. High-volume hospitals and surgeons were associated with improved patient outcomes and lower Medicare inpatient payments –38. TherThough there is limited evidence on comparative effectiveness between robotic-arm assisted and conventional TKA, our study sheds light on key drivers of the incremental effectiveness of robotic technology. The one-way deterministic sensitivity analysis demonstrated that the robotic system needs to achieve lower than a 0.46% failure rate to be cost-effective. Early clinical evidence suggested that robotic technology has the potential benefits of delivering more accurate and precise bone cuts and implant positioning and offering soft tissue protection , 13, 16.The study has several limitations. First, there might be hidden costs that we didn’t incorporate in the model regarding robotic-arm assisted technology. The surgical team, including the surgeon and the technical engineer, needs additional training to operate on the robotic arm and install software applications. Also, the surgical team has a learning curve to efficiently perform robotic-arm assisted TKA. The initial phase of the learning process might increase in the time of operation , 40. AddOur model suggested that, under conservative assumptions on cost savings and QALY improvement, robotic-arm assisted TKA may be a cost-effective procedure in the Medicare aged population at high-volume hospitals with >49 procedures per year. The threshold identified may assist hospital administrators with deciding whether to adopt robotic technology in orthopedic surgery.S1 Data(XLSX)Click here for additional data file.


Nitrogen-vacancy (NV) magnetometry is a new techniquefor imagingspin waves in magnetic materials. It detects spin waves by their microwavemagnetic stray fields, which decay evanescently on the scale of thespin-wavelength. Here, we use nanoscale control of a single-NV sensoras a wavelength filter to characterize frequency-degenerate spin wavesexcited by a microstrip in a thin-film magnetic insulator. With theNV probe in contact with the magnet, we observe an incoherent mixtureof thermal and microwave-driven spin waves. By retracting the tip,we progressively suppress the small-wavelength modes until a singlecoherent mode emerges from the mixture. In-contact scans at low drivepower surprisingly show occupation of the entire isofrequency contourof the two-dimensional spin-wave dispersion despite our one-dimensionalmicrostrip geometry. Our distance-tunable filter sheds light on thespin-wave band occupation under microwave excitation and opens opportunitiesfor imaging magnon condensates and other coherent spin-wave modes. As such, several imagingtechniques have been developed, with most established techniques basedon the spin-dependent scattering of photons.8Spin waves are collective spinexcitations of magnetically ordered materials, with associated quasi-particlescalled magnons.10 This enablesmagnetic imaging with nanoscale spatial resolution and high sensitivity.The NV spin allows probing spin-wave spectra with a ∼1-MHzfrequency resolution through spin lifetime measurements and characterizingspin-wave amplitudes by measuring the NV spin rotation rate.11 Recently, NV magnetometry has been used to studydomain-wall-guided spin-wave modes,12 magnonscattering,15 spin chemical potentials,16 and frequency combs.17 To enable sensitivityto target spin-wavelengths, accurate control of the NV-sample distanceis crucial because the spin-wave stray fields depend exponentiallyon the distance to the sample at a length scale set by their wavelength.Nitrogen-vacancy(NV) magnetometry images spin waves by their microwavemagnetic stray fields. It uses the electronic spin of the NV latticedefect in diamond as a sensor, which can be read out through spin-dependentphotoluminescence (PL), is atomic-sized, and can stably exist withinnanometers from the diamond surface.Here, we demonstrate that controlling the NV-sample distance usinga diamond tip mounted on an atomic force microscope 1a create18 We excite spin waves by applying a microwave current toa stripline that is microfabricated onto the YIG surface . We apply a biasfield B0 along the NV axis to tune theNV electron spin resonance (ESR) frequencies (f±) relative to the spin-wave band. The orientation of B0 magnetizes the film in-plane and perpendicularlyto the stripline, enabling efficient excitation of “backward-volume”spin waves18 that travel parallel to themagnetization . The spin waves generate magnetic stray fields above the surfacethat drive our NV spin when resonant with an NV ESR frequency. Wedetect these NV-resonant spin waves via the NV center’s spin-dependentphotoluminescence19 (PL).Our system consists of a thin film of yttrium irongarnet (YIG),a magnetic insulator with ultralow spin-wave damping.B0 . Here, FMR-induced magnon–magnonscattering leads to spin-wave noise at the NV frequencies that causesNV spin relaxation and an associated PL reduction.16 Third, we observe a broad region of reduced PL when f– is in the vicinity of the FMR. In this region,the stripline efficiently excites spin waves because of their micron-scalewavelengths near the FMR . These spin waves in turn scatter efficiently to modesresonant with f– because they areclose in frequency and wavelength,20 causingNV spin relaxation. Correspondingly, the region of reduced PL endsabruptly when f– drops below thebottom of the spin-wave band , we observefast NV spin decoherence, indicating a strong presence of incoherentspin-wave noise. As further shown below, the noise is caused by acombination of thermal and microwave-excited spin wave modes. By liftingthe NV a few hundred nanometers, we suppress the noise sufficientlyand start observing NV Rabi oscillations, indicating a coherent microwavefield at the NV frequency. The nonexponential decrease of the Rabifrequency with a further increasing d (d.With the tip in contact with the YIG (k spinwave within an ensemble of frequency-degenerate spin-wave modes. Wedefine the contrast C by the ratio of the NV PL withand without microwave drive (C = 1 – PL/PL0). The spatial contrast arises due to the interference betweenthe field of the excited spin waves (which are propagating) and theuniform reference field that is supplied by our stripline.14 The in-contact scan  = 0.15, is reduced with respect to the maximum contrast atincreased distances Cmax(d > 200 nm) = 0.25. Second, the contrast equals its maximum valuethroughout the scan . The reduced ESR contrastof the in-contact scan is consistent with the strong increase of thestray field generated by thermally excited spin waves  and lead to PL reduction.27 The spatiallyhomogeneous saturation indicates a large amplitude of the microwave-drivenspin waves, as we will show in more detail below.Using spatial maps of the ESR contrast 2e, we dein waves 2b that ed = 0.2 μm, we findthat the contrast approximately doubles with respect to d = 0 μm. This is expected from the rapid suppression of thethermal spin-wave stray fields by our filter. However, we still findthat the contrast is saturated over the entire spatial map , both modes . The large ESR contrast enables a straightforward extractionof the wavelengths , which correspond well with the calculated spin-wave dispersion. Previous works34 demonstrated that such defects act as spin-wave scatterers and leadto the occupation of high-k modes.To interpret the wavenumber content of the spin-wavepatterns observedin spersion 4b. We obB0 >40 mT  shows that the amplitude of the direct stripline field is too smallto generate ESR contrast. We therefore conclude that the stray-fieldpatterns observed at B0 < 40 mT donot result from interference between the spin-wave and stripline fieldsbut are instead generated by standing spin waves that result fromscattering. These results highlight the coherent nature of the scatteringprocess and the efficiency by which it leads to the occupation ofhigh-momentum modes that are otherwise inaccessible to a one-dimensionalexcitation stripline.The absenceof ESR contrast for 35 or other coherent spin-wavemodes12 and could also be used to probemicrowave electric current distributions in devices.Nanoscale control of the NV-sample distanceserves as a tunablefilter that enables balancing the magnetic fields generated by anensemble of incoherent and coherently driven spin waves of differentwavelengths. This control enables selective imaging of a coherentspin-wave mode within a mixture of frequency-degenerate spin wavesand retaining a high-visibility response when imaging different wavelengths.In-contact scans at reduced drive power show a surprising patternof standing spin-wave modes. The Fourier transforms of these patternsreveal spin-wave occupation along the entire isofrequency contourof the two-dimensional spin-wave dispersion. We attribute the occupationof these high-momentum modes to defect-enhanced spin-wave scattering.The phase relation between the scattered modes is maintained, emphasizingthe coherent nature of the scattering process. Nanoscale control ofthe NV-sample distance and wavenumber-selective imaging of magneticoscillations at microwave frequencies paves the way for imaging magnoncondensates


The COVID-19 pandemic compromised psychological wellbeing, especially given public health guidance that restricted social contact. Engaging in daily social interactions is especially important for maintaining wellbeing, and virtual interactions may be a surrogate for face-to-face interactions when in-person contact is not possible. Embracing the idea that virtual communication may facilitate social connectedness, this project seeks to better understand the potential of virtual social interactions for supporting wellbeing. Using repeated-daily-life-assessments from an adult lifespan sample , we examined how number of virtual and face-to-face social interactions were associated with positive affect in individuals’ daily lives. We expected that face-to-face interactions would have a stronger relationship with positive affect than virtual social interactions, but that engaging in virtual interactions would be positively related to affect during these unprecedented times. In line with our hypotheses, number of daily in-person (r(812)=0.14, p<.001) and total number of social interactions (r(812)=0.14, p<.001) were associated with higher positive affect at the bivariate level; number of daily virtual social interactions showed a positive trend with affect (r(812)=0.06, p=.07). Multilevel models including quantity of face-to-face and virtual interactions indicate that only face-to-face interactions were associated with concurrent elevations in positive affect  and overall higher positive affect . Future analyses will examine whether social interactions involving close ties are more powerful drivers of positive affect than distal ties, whether everyday closeness to others mediates the relationship between social interaction modality and positive affect, and we will unpack age as a moderator in these relationships.