Over the last decades, T-cell immunotherapy has revealed itself as a powerful, and often curative, strategy to treat blood cancers. In hematopoietic cell transplantation, most of the so-called graft-vs.-leukemia (GVL) effect hinges on the recognition of histocompatibility antigens that reflect immunologically relevant genetic variants between donors and recipients. Whether other variants acquired during the neoplastic transformation, or the aberrant expression of gene products can yield antigenic targets of similar relevance as the minor histocompatibility antigens is actively being pursued. Modern genomics and proteomics have enabled the high throughput identification of candidate antigens for immunotherapy in both autologous and allogeneic settings. As such, these major histocompatibility complex-associated tumor-specific (TSA) and tumor-associated antigens (TAA) can allow for the targeting of multiple blood neoplasms, which is a limitation for other immunotherapeutic approaches, such as chimeric antigen receptor (CAR)-modified T cells. We review the current strategies taken to translate these discoveries into T-cell therapies and propose how these could be introduced in clinical practice. Specifically, we discuss the criteria that are used to select the antigens with the greatest therapeutic value and we review the various T-cell manufacturing approaches in place to either expand antigen-specific T cells from the native repertoire or genetically engineer T cells with minor histocompatibility antigen or TSA/TAA-specific recombinant T-cell receptors. Finally, we elaborate on the current and future incorporation of these therapeutic T-cell products into the treatment of hematological malignancies. Several studies in both humans and animals have conclusively shown that the recognition of alloantigens by T cells is central to the so-called “graft-vs.-tumor” (GVT) that occurs following AHCT –3. Howevta chain . T-cell AHCT's curative potential relies substantially on the GVT effect, which is largely based on the recognition of histocompatibility antigens by allogeneic T cells. These antigens result from the translation of germline-encoded genetic variants –10. Howe+ and CD8+ HLA-specific T cells and other cell types, such as natural killer (NK) cells in the recognition of HLA-mismatched cellular targets [reviewed in Paul and Lal  may be considered (The frequency of T cells capable to target mismatched HLA molecules is very high (1–10%) –24. Give and Lal ]. The in and Lal , 39. Hennsidered , 41.+ and CD8+) recognize MHC-bound polymorphic peptides derived from the host proteome and known as the MiHA. Both MHC class I and class II molecules have been shown to present MiHA . Therefore, a subclassification for TSA has recently been proposed; mutated TSA (mTSA) and aberrantly expressed TSA (aeTSA) . The mTSNeoplastic cells can overexpress, or aberrantly express, unmutated proteins that are recognized by the immune system , 81–83. The ideal antigenic targets should be highly cancer-specific, be universally applicable to all patients and cancer types and enable treatment without the requirement for AHCT. This last decade has seen the rise of anti-CD19 chimeric antigen receptor (CAR)-modified T cells which fulfill some of these characteristics . DespiteBecause they are encoded by germline polymorphisms instead of somatic mutations, MiHA possess features that make them attractive for immunotherapy . In contThe development of methods to identify and characterize MHC-associated antigens resulting from genetic variants is motivated by a strong impetus to design T-cell therapies to treat neoplastic diseases. These T-cell therapies may be used alone or in combination with other approaches, such as vaccination and immune checkpoint blockade but this review focuses on the current status of T-cell therapies aimed at MHC-associated peptides to treat hematological cancers.ex vivo manipulations for enrichment and/or expansion of T cells bearing native TCR specific to the targeted antigens. Alternatively, genetic engineering can enable the production of large numbers of TCR transgenic T cells directed against a given antigen.T-cell therapies can be antigen agnostic (administered without precise knowledge of the antigens targeted), such as in unmanipulated donor lymphocyte infusions (DLI) and TIL infusion, or targeted to known antigens. The administration of antigen-specific T cells requires prior ex vivo expansion. TIL therapy was pioneered in solid tumors, in melanoma particularly, where it has yielded high response rates and durable complete remissions (ex vivo. Expanded autologous “MIL” (marrow infiltrating lymphocytes) from multiple myeloma patients using anti-CD3/CD28 stimulation and IL-2 revealed that the bone marrow contained a high number of myeloma reactive T cells (relative to blood derived T cells from the same patients) capable of targeting both mature and precursor myeloma cells in vitro . However, the efficacy of donor T cells, collected after AHCT and infused in graded doses, has yielded variable results and has a risk of triggering GVHD in 60–70% of patients . There imissions . This apmissions . This prmissions . As suchin vitro . A cliniin vitro .The transfer of a large T-cell repertoire has advantages, such as broad applicability as well as the likelihood of targeting several antigens at the same time. However, antigen agnostic methods can miss the relevant targets by expanding/transferring T cells that are not specific for cancer associated/specific antigens . In the The current experience using T-cell therapies against MiHA, viral antigens, TSA and TAA demonstrates the possibility to expand antigen-reactive T cells in high numbers to treat patients. However, T-cell manufacturing continues to be challenging and the optimal approach to integrate these therapies in the patients' treatment trajectory remains to be determined. This section reviews the current approaches aiming to treat hematological malignancies through the specific targeting of MHC-associated antigens. A summary of the molecularly defined HLA-associated antigens that have been targeted in adoptive T-cell immunotherapy clinical studies is included in As described above, the MiHA have several conceptual advantages for immunotherapy. Vaccination against MiHA in the context of post-AHCT DLI has been reported to induce detectable MiHA-specific responses in myeloma patients. Although clinical responses were modest (transient regression or stable disease), the vaccination protocol was well-tolerated , 109. An+ clones obtained by co-culturing donor T cells with host-derived lymphoblastoid cells (EBV-transformed B-cells) , the procedure was not associated with clinical responses.Cell therapy is the other approach to selectively or preferentially target MiHA. The first trial reporting on a MiHA-specific T-cell therapy strategy used MiHA-specific CD8B-cells) . After rications . NonetheiHA HA-1 . Followiex vivo, compromises the further expansion and persistence of the T cells after adoptive transfer. Less-differentiated T cells bearing early memory T-cell features  have been shown to be superior compared to more differentiated T cells in several animal and human pre-clinical models . Although the TCR transgenic approach can solve the conundrum of late T-cell differentiation arising in the context of antigen-driven T-cell expansion, it has its own limitations. The production of clinical grade gene therapy vectors is costly and current reports investigating transgenic TCR therapy target only one antigen at a time. TCR transgenic therapies are also limited by the possible mispairing of alpha and beta chain with the endogenous TCR potentially giving rise to unwanted reactivity and toxic allo- or autoimmunity . This emphasizes the importance of discovering and characterizing a large number of MiHA derived from proteins expressed in the hematopoietic system, as well as MiHA presented by enough HLA alleles to treat most, if not all, AHCT patients.in vitro antigen expression system and co-culture with responder autologous TIL  allow the generation of multivalent T-cell products (ex vivo culture protocols, but is nonetheless feasible and well-tolerated (Adoptive T-cell immunotherapy against viral reactivations occurring after AHCT is highly effective, with response rates globally above 70% in otherwise refractory patients , 134. Inproducts . Virus-sproducts –139. Theolerated . BollardExpanding on the success of anti-viral therapy, it was shown that T-cell lines can be generated by stimulating with overlapping peptide libraries of multiple TAA . These TThe opportunities for antigen-specific T-cell immunotherapies are rapidly expanding. The MHC-associated antigens arising from genetic variants, both germline and acquired through the neoplastic process, are prime targets for the treatment of hematological cancers. The genuinely personalized approaches required to translate the complexity and multiplicity of MiHA, TSA, and TAA into therapy is certainly a challenge, but also a great promise. The discovery and characterization of an increasing number of antigens will enable the design of multivalent therapies capable to target all blood cancers and limit the emergence of immune escape variants associated with single antigen targeting. However, for such promise to materialize, manufacturing processes for these highly personalized therapies will have to be refined and made cost-effective. Nonetheless, T-cell therapies aimed at MHC-associated peptides have the potential to significantly expand existing paradigms in AHCT, autologous cell transfer and other T-cell therapies, such as CAR T cells. Indeed, the development of peptide-MHC specific antibodies may further increase the relevance of characterizing immunogenic MiHA, TAA or shared TSA for CAR-based immunotherapy , 143. AlThe timing of administration of T-cell therapies will need to be better studied . Cell th+ T-cell mediated, but most identified MiHA, TAA and TSA are MHC class I associated peptides (Several scientific and methodological issues remain to be addressed to improve T-cell therapies directed against MHC-associated peptides or the MHC molecule itself. A significant contributor to the response against genetic variants is CD4peptides . AlthougThe downregulation or loss of MHC expression, the genetic loss or silencing of antigen source protein are well-known immune escape mechanisms in cancer. This can be fairly extensive as described in haplo-identical transplants, where the loss of the entire mismatched haplotype can be observed . ElaboraTo conclude, the field is increasingly confronted with multiple antigens and approaches to target them. Careful selection of the best targets will need more research and rational combinations therapies are likely to be required for these antigens to reveal their full potential.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication. Specifically, VJ, CR, and J-SD contributed to the manuscript design. VJ, CR, SD, CC, and J-SD performed the literature search and contributed to the writing of the manuscript.J-SD and CC are authors on patents pertaining to the therapeutic use of minor histocompatibility antigens. The remaining 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.


Osteosarcoma is a very aggressive primary bone tumour, affecting mainly young populations. Most cases diagnosed have distant macro- and micro-metastases at the time of diagnosis. Surgical resection with neoadjuvant and adjuvant therapies improves the overall and disease-free survival of patients. Doxycycline, a synthetic tetracycline, has been found to act either as an antibiotic drug or as a chemotherapeutic agent. Its anti-neoplastic role has been found to be significant, in vitro and in vivo laboratory trials, in various types of cancer, such as prostate, intestinal, central neural system cancers and osteosarcoma. Inhibition of metalloproteinases (MMPs) in different stages of tumour expansion is the most well-understood mechanism. MMPs are secreted molecules from various normal cells, such as fibroblasts, leucocytes and vascular smooth muscles, as well as from cells with high proliferative potential, such as tumour cells. In osteosarcoma, MMPs have been found to be overexpressed. MMPs help osteosarcoma cells survive, grow and produce metastases in distant sites, mainly in the lungs. Doxycycline blocks extracellular matrix and basic membrane degradation by suppressing MMP function. As a consequence, osteosarcoma cells lose their ability to invade and metastasize. Additionally, doxycycline eliminates the secretion of vascular endothelial growth factor (VEGF) and deprives the supply of circulating nutrients by its anti-angiogenesis action. The aim of this review is to evaluate doxycycline’s action against osteosarcoma cells as an MMP-inhibitor and interpret its usage as a chemotherapeutic agent.We checked PubMed and Google Scholar for recently published data, on the tumour-supportive role of MMPs and VEGF in osteosarcoma cells. We further studied published experimental trials on the role of doxycycline as a tumour-suppressive agent via MMPs and VEGF inhibition.MMPs and VEGF have been found to play a fundamental role in osteosarcoma cells survival and high aggressiveness by in vitro, in vivo and clinical trials. Nevertheless, doxycycline has proved its tumour-suppressive effect by in vivo experimental trials in various cancers but not yet in osteosarcoma.Doxycycline remains a promising chemotherapeutic agent against osteosarcoma via MMP inhibition, showing the need for further in vivo and clinical trials to be carried out in the future. Osteosarcoma, also known as osteogenic sarcoma, is the most common primary bone tumour with highly metastatic and lethal behaviour . In the Proliferation of tumour cells, increasing tumour size and local invasion combined with new vessels formation for necessary nutrients and oxygen intake are basic steps for osteosarcoma cells to expand and produce distant metastases . Osteosa2+ and Ca2+ ions within MMPs can occur [Doxycycline, a chemically modified tetracycline, is an inexpensive drug with a safe profile. It is the only MMP inhibitor that acts in a concentration-dependent manner, approved by the US Food and Drug Administration for the treatment of periodontal disease . It is can occur . DespiteWe searched for published articles from PubMed and Google Scholar. Our first aim was to mention pre-clinical osteosarcoma trials to link the important role of several subtypes of MMPs with the level of invasiveness and metastatic attitude of osteosarcoma cells. Second, we checked bibliographies for the effect of MMPs and VEGF in clinical trials of osteosarcoma to guarantee that their neoplastic behaviour has been proven not only in experimental models but also in real osteosarcoma human specimens. After we recognized the tumourigenic action of MMPs, we focused our search on the anti-neoplastic effect of doxycycline in various types of cancer to ensure that it acts not only as an antibiotic drug but also as a tumor-suppressive agent via MMP inhibition. Additionally, we searched for the indirect anti-neoplastic effect of doxycycline by its VEGF-suppressing action that has been observed in malignant cells. Finally, we studied all published pre-clinical trials interpreting the anti-neoplastic effect of doxycycline in osteosarcoma experimental models to identify its action on osteosarcoma cells.Recent published articles. We mainly focused on literature from 2013 to 2019.Published articles evaluating the metastatic effect of MMPs in osteosarcoma pre-clinical trials.Data from in vivo experimental trials, investigating the anti-tumour effect of doxycycline as an MMP inhibitor in various types of human cancer.Three inclusion criteria were applied:Published in vitro and in vivo research on the anti-MMP effect of other tetracyclines on osteosarcoma cells.Research on MMP’s activity in preclinical trials of other types of human cancer.Experimental trials evaluating the usage of doxycycline in non-human cancer cells or syngeneic animal models.Exclusion criteria:Thirty-seven out of 49 (75.5%) cited articles were first published between 2013 and 2019. From the 1999 to 2013 interval, we observed a lack of experimental trials and published data referring to the antineoplastic effect of doxycycline in osteosarcoma.We found only three in vitro pre-clinical trials, interpreting the anti-metastatic behaviour of doxycycline and no in vivo experimental trials on osteosarcoma animal models that examined the blockage of metastases in distant organ from 1997 to 2020.MMP-1  has been found to be markedly upregulated after intra-tibial injection of 143B highly metastatic human osteosarcoma cells into SCID mice compared with injection of a non-metastatic HOS cell line . MMP-1 pThe detection of osteosarcoma using MMP-9 as a biomarker has been found to be extremely accurate in a metanalysis of Wang et al. in which a total of 892 patients in different clinical stages were included . Foukas Elevated levels of various MMPs can increase the expression of vascular endothelial growth factor (VEGF) and vice versa . VEGF isThe strict correlation between osteosarcoma lung metastases and poor survival, along with MMPs and VEGF overexpression, motivated research on inhibiting agents. One of them is probably doxycycline Fig. .Fig. 2Th2+ chelates, (iii) elimination of reactive oxygen species secreted by ECM cells that activate pro-MMPs, (iv) blockage of MMP activation via the MT1-MMP pathway [Doxycycline, as an MMP inhibitor, mediates extracellular matrix degradation and acts as an anti-proliferative, anti-invasive and anti-angiogenic agent, deteriorating the expanding and invasive potential of tumour cells. The molecular mechanism that supports MMP inhibition by doxycycline involves the following different assumptions: (i) MMP-mRNA becomes unstable, (ii) inactivation of MMPs via Zn pathway . Inactiv pathway . As a coA doxycycline-treated group and a control group of engrafted human MHCC97H cells of hepatocellular carcinoma into BALB/c mice showed that doxycycline acted as an MMP-2 and MMP-9 inhibitor . Doxycyc2+ chelation with doxycycline. It is obvious, to our knowledge, that doxycycline can eliminate MMPs either at the pre- transcriptional or post-transcriptional level acting as an adjuvant anti-invasive chemotherapeutic drug [The suppressive effect of doxycycline against oral squamous cell carcinoma has been associated with MMP inhibition . The ovetic drug . Shen ettic drug . DoxycycThe inhibitory effects of doxycycline on the expression of MMPs in prostate cancer are another example of its anti-metastatic usage. NF-kB signalling has been found to regulate the expression of MMPs in the nuclei of lipopolysaccharide (LPS)-induced PC3 human prostate cancer cells , 33. DoxThe cytotoxic effect of doxycycline via MMP inhibition was also demonstrated with in vitro and in vivo pre-clinical trials of xenografted HuTu-80 human duodenal adenocarcinoma cells in mice . A dailyThe anti-neoplastic effect of doxycycline on intestinal neoplasias has already been confirmed previously by Sagar et al. in human colorectal cancer cells (HT29 cell line) . DoxycycA study by Onoda et al. revealed that doxycycline causes dose-dependent inhibition of cell-growth on human colorectal cancer cell lines, LS174T and HT29 . MMP-2 aGlioblastoma multiforme is the most common brain cancer found to be susceptible to doxycycline, after in vitro treatment of highly aggressive U251HF human cells . DoxycycMMPs provoke angiogenesis, which is crucial for tumour viability, cells proliferation and metastasis in distant organs. MMPs contribute to angiogenesis in two distinct ways. First, MMPs degrade the basement membrane and extracellular matrix and provide the opportunity for endothelial cells of existing vessels to migrate and settle in new positions, creating a new supporting capillary network for tumour cells . Second,According to Merentie et al. doxycycline reduced the expression of VEGF in endothelial cells in vitro in a dose-dependent manner, but failed to downregulate its expression in transgenic mice in vivo . In contFife et al. were the first in 1997 to study the anti-proliferative and apoptotic effects of doxycycline in cultured human osteosarcoma cells in vitro . Their hCakir and Hahn, in 1999 described the suppressive effect of Doxycycline on MMP-1, beyond its antimicrobial usage. Their in vitro study on canine osteosarcoma cells, showed that 5 mg/ml and 10 mg/ml of Doxycycline, could minimize tumor volume 50% and 75%, respectively . MMP-1 sThe most recent study on the inhibitory effect of doxycycline in the pediatric human osteosarcoma cell line U2OS was conducted by Roomi et al. in 2013 . OsteosaDoxycycline has been tested in different doses to evaluate its anti-proliferative and tumor-suppressive action. We found a wide range of administered doses between several studies. For example, Shen et al. used a doxycycline dose of 3 mg/mice/day for SCC-15 xenografted nude mice , while GThe toxicity of doxycycline hyclate has been found to be dose-dependent in 3 groups of 38-week-old male Wistar rats. The first group received no drug, the second 25 mg/kg twice per day, and the third group 50 mg/kg twice per day intragastrically . The secOsteosarcoma aggression and metastases are strictly associated with the ability of tumour cells to secrete MMPs . MMPs arTo our knowledge, doxycycline has anti-MMP behaviour. Due to this function, it could be used not only as an antibiotic drug, but also as an adjuvant and neo-adjuvant chemotherapeutic agent. Doxycycline, as an MMP-inhibitor, blocks the potential growth and invasiveness of malignant cells as well as the formation of neoplastic new blood vessels and promises improvement in total survival rates in patients suffering from osteosarcoma , 21. DoxSearching for published articles on pre-clinical experimental trials for the anti-metastatic effect of doxycycline as an MMP-inhibitor, we concluded that literature is lacking. We found only three pre-clinical in vitro trials, interpreting the tumour-suppressing effect of doxycycline via MMP-inhibition. Surprisingly, we found no available publications on this topic during the period from 1999 to 2013. MMPs play a key role in tumor metastasis, and doxycycline found to act as a significant anti-MMP factor. In our opinion, further osteosarcoma preclinical trials must be designed, especially high quality in vivo experimental studies to evaluate the usage and safety of doxycycline as an anti-neoplastic agent.


CABG (n = 2250), with a minimum clinical follow-up of five years. Random effect risk ratios were used for efficacy and safety outcomes. The study was registered in PROSPERO. The primary outcome was major adverse cardiac events (MACE), defined as a composite of death from any cause, myocardial infarction or stroke. Results: Compared to CABG, patients assigned to PCI had a similar rate of MACE (risk ratio (RR): 1.13; 95% CI: 0.94 to 1.36; p = 0.19), myocardial infarction  and stroke . Additionally, all-cause mortality  and cardiovascular (CV) mortality  were not different. However, the risk of any repeat revascularization  was higher in patients assigned to PCI. Conclusions: The findings of this meta-analysis suggest that the long-term survival and MACE of patients who underwent PCI for unprotected LMCA stenosis were comparable to those receiving CABG, despite a higher rate of repeat revascularization.Background and Aim: Treatment of patients with left main coronary artery disease (LMCA) with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) remains controversial. The aim of this meta-analysis was to compare the long-term clinical outcomes of patients with unprotected LMCA treated randomly by PCI or CABG. Methods: PubMed, MEDLINE, Embase, Scopus, Google Scholar, CENTRAL and ClinicalTrials.gov database searches identified five randomized trials (RCTs) including 4499 patients with unprotected LMCA comparing PCI ( The available evidence supporting the treatment of patients with left main coronary artery disease (LMCA) in support of percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) remains unascertained. Current clinical guidelines recommend PCI as an appropriate alternative to the standard treatment with CABG in patients with LMCA and low-to-intermediate anatomical complexity ,2. RandoWe followed the guidelines of the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement . Due to We systematically searched PubMed-Medline, EMBASE, Scopus, Google Scholar, the Cochrane Central Registry of Controlled Trials and ClinicalTrial.gov up to May 2020 using the following key words: (“left main stem” OR “left main coronary artery disease”) AND (“percutaneous coronary intervention” OR “PCI”) AND (“coronary artery bypass grafting” OR “CABG”). Other potentially suitable trials for inclusion in the analysis included abstracts from selected congresses: Scientific Sessions of the American Heart Association (AHA), European Society of Cardiology (ESC), American College of Cardiology (ACC) and European Society of Atherosclerosis (EAS). Only articles published in English were included. No filters were applied. G.B. and F.Z.B. independently evaluated all articles separately. The finally selected articles were obtained in full text and searched carefully by the same two researchers independently. They extracted the necessary data and evaluated the articles’ quality. Disagreements were resolved by discussion with a third party (M.Y.H.).Studies eligible for inclusion were those fulfilling the following criteria: (1) randomized design comparing the efficacy and safety of PCI with that of CABG in patients with unprotected LMCA disease, (2) minimum follow-up of 5 years and (3) full-text studies published in peer-reviewed journals. Exclusion criteria were: (1) nonrandomized studies, (2) follow-up less than 5 years, (3) unpublished papers and (4) ongoing trials. Observational and unpublished studies were not included in the meta-analysis.Qualified studies were searched, and the following data were collected, including: (a) first author’s name, (b) date of publication, (c) clinical trial name, (d) place where the study was conducted, (e) number of centers involved, (f) study design, (g) number of patients in each of the two study arms who received LMCA treatment, (h) follow-up period and (i) detailed clinical outcome and nature of events in the two groups.The primary outcome of the analysis was the major adverse cardiac events (MACE), defined as the composite of death from any cause, stroke or myocardial infarction. The secondary outcomes tested in this meta-analysis were all-cause mortality, cardiovascular (CV) mortality, nonfatal myocardial infarction and any revascularization or stroke.Risk of bias assessment in the included studies was evaluated by the same investigators for each study and was performed systematically using the Cochrane quality assessment tool for RCTs . Tests fp-value < 0.05 was considered significant. Meta-analyses were performed using the fixed-effects model, and the random effect model was used if heterogeneity was encountered. Heterogeneity between studies was assessed using the Cochrane Q test and I2 index, with I2 < 25% indicating low, 25–50% moderate and >50% high heterogeneity . All. All7]. This meta-analysis of RCTs compared the long-term efficacy of a PCI strategy compared with a CABG strategy in treating symptomatic patients with unprotected LMCA. The main findings at a median follow-up of eight years can be summarized as follows: (1) There was no significant difference in the occurrence of MACE, all-cause mortality, cardiac death, myocardial infarction and stroke between patients assigned to PCI compared with those assigned to a CABG treatment strategy. (2) PCI was associated with higher rates for a need for unplanned revascularization during follow-up compared with CABG.This is the first meta-analysis that included only RCTs with a long-term follow-up with a minimum of five years of patients receiving revascularization for unprotected LMCA disease. The traditional well-established treatment of LMCA has been CABG with left internal mammary artery grafted to the left anterior descending coronary artery. This approach, over the years, has proved to provide excellent clinical outcomes to these challenging patients . With thThe results of this study have significant importance when compared to other recently published studies. Distinct from previous meta-analyses, we included only RCTs with minimum follow-up periods of five years, and consequently, the outcomes for both strategies were assessed over a median of eight-year follow-ups. This expanded the follow-up period compared with the recently published meta-analyses of RCTs that reported the outcomes in patients treated with PCI or CABG over five to six years of clinical follow-up ,19. The This meta-analysis clearly demonstrated comparable long-term clinical outcomes for PCI compared with CABG treatments of patients with unprotected LMCA disease. Hard clinical outcomes, including mortality, were not different between the two treatment strategies, but the higher need for repeat revascularizations with the nonsurgical procedure should be considered in the decision-making process. It is expected that, with the continuous development of better-quality stents, resulting in better arterial stability and tissue compatibility and a lower need for repeat revascularizations, PCI might become the established treatment for select patients with LMCA disease.The available number of RCT eligible for inclusion in this meta-analysis was small, particularly because of the required minimum five-year follow-up. However, despite the extended follow-up period, the main results are comparable to previously published meta-analyses ,19. As iThe findings of this meta-analysis, with the longest clinical follow-up currently available, suggest that the MACE rate and long-term survival of patients were comparable in patients receiving PCI or CABG for unprotected left main stem disease. However, the rate of repeat revascularizations was higher in patients treated with PCI.


This Special Issue highlights the recent developments and future directions of virus-based nanomaterials and nanostructures in energy and biomedical applications. The virus-based biomimetic materials formulated using innovative ideas presented herein are characterized for the applications of biosensors and nanocarriers. The research contributions and trends based on virus-based materials, covering energy-harvesting devices to tissue regeneration over the last two decades, are described and discussed. Virus-based biomimetic materials derived from plant viruses and bacteriophages rarely generate harmful side effects in human beings since phages do not consist of mammalian promoter sequences in their genomes . The strThe current Special Issue, including 11 original research works, focuses on highlighting the progress, challenges, and future directions in the area of virus-based nanomaterials and nanostructures with multiple applications in biomedicine and energy. Researchers have studied mineralization, magnetization, bioconjugation, and drug delivery for the development of biosensors and vaccines ,10,11,122 wide, a chamber of about 30 cc capacity, and a small webcam. This biosensor system is inexpensive and easy to apply in monitoring the environment and health care. The color change in the biosensor is caused by a reaction between the sensor array and external substances, detected by a complementary metal–oxide–semiconductor detector, and followed by employing hierarchical cluster analysis.Kim et al. propose an M13-bacteriophage-based colorimetric multi-array biosensor that can classify four different antibiotics  and hormone (estrogen) drugs including mercilon, gestodene, estrone, and estradiol by analyzing the color change . The senYuste-Calvo et al. developed turnip mosaic virus (TuMV)-based nanoparticles to detect antibodies with high sensitivity . TuMV isDamm et al. functionalized the surface of calcium phosphate (CaP) nanoparticles with stabilized trimers of the HIV-1 envelope (Env), resulting in Env-CaP-p30 nanoparticles, to demonstrate improvement of Env antibody responses by intrastructural help (ISH) . The EnvAtanasova et al. determined whether the surface hydrophilicity of tobacco mosaic virus (TMV) particles can be manipulated through covalent attachment of polymer molecules . Three dNeospora caninum profilin (NcPROF) in silkworm larvae by recombinant Bombyx mori nucleopolyhedrovirus (BmNPV) bacmid [B. mori (bx-PA-NcPROF), and bx-PA-NcPROF with additional C-terminal transmembrane and cytoplasmic domains of GP64 from BmNPV (bx-PA-NcPROF-GP64TM). Only bx-PA-NcPROF-GP64TM was found to be secreted as nanoparticles with binding affinity to its receptors and pelleted, whereas the remaining two were not.Suhaimi et al. developed a vaccine by expressing ) bacmid . They inRybka et al. characterized the assembly of hepatitis B virus capsid protein into virus-like particles (HBc VLPs) with the magnetic core of superparamagnetic iron oxide nanoparticles (SPIONs) . The synFinbloom et al. investigated three morphologically distinct VLPs, namely a 27 nm MS2 sphere, an 18 nm tobacco mosaic virus (TMV) disk, and a 50 nm nanophage filamentous rod conjugated to doxorubicin (DOX), for their drug delivery potential to glioblastoma . AlthougShin et al. provide a comprehensive review of the principles, properties, and role of organic piezoelectric biomaterials in energy and biomedical applications . The bioPark et al. describe methods to fabricate M13-bacteriophage-based piezoelectric energy-harvesting devices to develop high-performance and biocompatible energy devices for a wide range of practical applications . Due to In another review, Moon et al. highlight the recent progress made in the application of M13-bacteriophage-based sensor systems and discuss future M13 bacteriophage technology . GeneticRaja et al. describe the emerging trend of virus-based biomimetic materials in tissue regeneration . The revIn conclusion, as the Editors of this Special Issue, we would like to thank all the authors and reviewers, who contributed to this Special Issue with innovative ideas and constructive reviewers’ comments. We would like to express appreciation for the consistent support from the Editorial Office. We are sure that this Special Issue will provide our readers with a platform to understand the advantageous properties of benevolent virus-based nanomaterials and nanostructures with their pivotal roles in energy and biomedical applications.


The English-oriented, math-avoidant students showed the most distinct domain-specificity in their profile but, in general, profiles indicated more cross-domain generality than specificity. Overall, mastery-oriented students showed the most adaptive academic well-being, while avoidance-oriented students were the least engaged. Success-oriented students were characterized by high multiple goals in both subjects, elevated costs, and high scores on both positive (engagement) and negative (burnout) well-being indicators. The English-oriented, math-avoidant students perceived studying math as costly. The findings suggest that addressing students’ achievement motivation in different subjects may be useful for recognizing factors endangering or fostering student learning and well-being.Most studies utilizing a person-oriented approach to investigating students’ achievement goal orientation profiles have been domain-general or focused on a single domain , thus excluding the possibility of identifying distinct subject-specific motivational profiles. In this study, we looked into this by examining upper secondary school students’ subject-specific achievement goal orientation profiles simultaneously in mathematics and English. As distinct profiles might contribute to how students invest time and effort in studying, we also examined differences in perceived subject-specific cost  among students with different profiles and how this was linked with students’ more general academic well-being . The 434 Finnish general upper secondary school students participating in the study were classified based on their achievement goal orientations in the two subjects using latent profile analysis, and the predictions of the latent profile on distal outcomes  were examined within the mixture model. Five divergent achievement goal orientation profiles were identified:  Students’ achievement motivation plays an essential role in everyday school life. The school environment often places emphasis on performance as students are confronted with different types of tasks and communicated expectations, by some of which they are also graded. As children and adolescents move through the educational system, emphasis on performance seems to increase  and, forThe goals students hold and adopt in achievement contexts is one likely factor contributing to this. Although the widely studied achievement goals have often been researched generally in relation to learning and studying see , it is rAchievement motivation is a product of the interaction of the person and the context—including social environment and personal goals, beliefs, and emotions—and is, thus, also inseparably linked with an individual’s well-being. Achievement goals have indeed been found to have implications for different aspects of well-being, for example, the quality of engagement in schoolwork and emotional experiences in school . BuildinAccording to the achievement goal theorists, the goals individuals are pursuing create a kind of framework within which the individuals interpret situations and which further produce patterns of cognition, emotion, and behavior . BasicalStudies on achievement goals differ also in which goals they take into account. Early research focused on two contrasting goals: mastery and performance , that isvs. normative) with valence (approach vs. avoidance) took a different view on avoidance and suggested that both mastery and performance goals consist of two interdependent approach–avoidance components  or regarding specific school subjects or domains . What seems to be still lacking is an examination of the relative emphasis of students’ achievement goal orientations simultaneously in several subjects.versus specificity. For example, the theories of intelligence have been proposed to be domain-general rather than domain-specific  to high (performance- and avoidance-related orientations) among students of different ages . This, tAchievement goals or goal orientations are not mutually exclusive despite being independent dimensions. Research has widely supported the notion that students can hold multiple goals simultaneously e.g., . Until nWithin the numerous studies on achievement goal orientation profiles, there are variations in the achievement goal variables chosen for classification, sample characteristics, and analytical methods see . StudiesWith respect to subject-specific profiles, the mathematics-related achievement goal profiles have usually included a predominantly mastery-oriented profile , emotional cost , and opportunity cost  . These subfacets of cost are separate in meaning but often strongly associated  and negative  indicators. School engagement is defined as a positive, fulfilling study-related state of mind characterized by energy, positive cognitive attitude toward studying, and being absorbed in studying . School Research employing a person-oriented approach has consistently demonstrated the adaptability of mainly mastery and combined mastery and performance-approach goal profiles. For instance, mastery-oriented students have displayed a positive pattern of academic and emotional functioning, including high enjoyment, engagement, and academic achievement and, at the same time, low anxiety, negative affect, and perceived costs . StudentPerformance-approach goals, if coupled with high mastery goals, thus entail some favorable outcomes, but it seems clear that endorsing mainly performance goals and especially performance-avoidance goals leads to unfavorable concomitants. For example, the combination of high performance-avoidance goals and relatively low mastery goals has been linked with low effort and achievement, high anxiety and negative affect, and low self-esteem . StudentTo summarize, students with high mastery or high approach goal  profiles consistently show more adaptive patterns of academic and emotional functioning than students with predominantly performance-oriented, moderate goal, low goal, or work-avoidant profiles .Previous research informs us about the cross-domain generality and specificity of achievement goal orientations , but lesFor this, we followed an operationalization of achievement goal orientations that represents a wide array of goals relevant in the classroom , we expected some profiles to demonstrate domain-specificity  participated in the study by filling in online questionnaires. The participants were from all grades  of one general upper secondary school in Southern Finland. In Finland, after the compulsory 9-year comprehensive school (children aged 7–16), students can opt either for general (academic track) or vocational  upper secondary education. The general upper secondary school is based on courses with no specified year classes; in practice, students choose courses according to their individual study programs. The completion of general upper secondary school usually takes 3 years, but due to the course-based syllabus, it may also take less time or longer. Data collection took place mainly during regular classes, that is, only students who were absent during those classes filled in the questionnaires on their free time. Participation was voluntary, and the participants were assured of the confidentiality of their responses. The ethical review board in humanities and social and behavioral sciences (University of Helsinki) has reviewed the study and stated that it is ethically acceptable.Altogether 434 general upper secondary school students , mastery-extrinsic , performance-approach , performance-avoidance , and avoidance  orientations. In the questionnaire, the item stems were presented on the left and the subjects (mathematics and English) on the right in separate columns, with Likert-type scales ranging from 1  to 7 (completely true).Students’ achievement goal orientations were assessed by using an instrument originally developed by plus 8 (2(80) = 312.44/280.96, p < 0.001, CFI = 0.94/0.93, RMSEA = 0.082/0.076, SRMR = 0.064/0.060 . However, according to the modification indices, error covariances between one pair of similarly worded items were freed for both models  = 261.94/261.23, p < 0.001, CFI = 0.95/0.94, RMSEA = 0.073/0.073, SRMR = 0.060/0.060, thus verifying the hypothesized structures.Analyses concerning the structural validity of all scales were first conducted using confirmatory factor analysis (CFA) in Mplus 8 . Models plus 8 , root meplus 8 , and staplus 8 . Accordieffort required , emotional cost , and opportunity cost . The cost item stems were presented on the left and the subjects (mathematics and English) on the right in separate columns, with seven-point Likert-type scales ranging from 1  to 7 (completely true).Students’ perceived cost was assessed by utilizing a subscale of an instrument  develope2(24) = 181.07/102.98, p < 0.001, CFI = 0.93/0.97, RMSEA = 0.123/0.087, SRMR = 0.056/0.032 , although the RMSEA values were elevated. Based on the modification indices, for mathematics, one item (“Learning mathematics exhausts me”) was excluded from further analysis and, for both mathematics and English, error covariances between one pair of similarly worded items were freed (see 2(16/23) = 56.00/64.48, p < 0.001, CFI = 0.98/0.98, RMSEA = 0.076/0.065, SRMR = 0.030/0.026.The initial CFAs on subject-specific cost  described the data rather well, χreed see . These mexhaustion , cynicism , and inadequacy . Students answered on a Likert-type scale from 1 (completely disagree) to 6 (completely agree).Students’ engagement was measured by utilizing the schoolwork engagement inventory (EDA) by 2(146) = 442.50, p < 0.001, CFI = 0.93, RMSEA = 0.069, SRMR = 0.054, and the fit was further improved through correlating measurement errors between one pair of items measuring engagement, χ2(145) = 415.32, p < 0.001, CFI = 0.94, RMSEA = 0.066, SRMR = 0.053.Finally, a CFA for academic well-being measures , and bivariate Pearson correlations for all variables are presented in r = 0.63), performance-avoidance (r = 0.79), and avoidance (r = 0.73) orientations than for mastery-intrinsic (r = 0.51) and mastery-extrinsic (r = 0.44) orientations, which is in line with prior research  that adequately describes the associations among observed continuous variables of five achievement goal orientations in two different subjects . Classes are added stepwise until the model optimally fits the data. Akaike Information Criterion (AIC), Bayesian Information Criterion (BIC), sample-size adjusted BIC (SABIC), and Vuong–Lo–Mendell–Rubin (VLMR), and adjusted Lo–Mendell–Rubin (LMR) likelihood ratio tests were used as statistical criteria for determining the optimal number of profiles. The model with lower AIC, BIC, and SABIC values is considered to provide a better fit to the data, and p-values smaller than 0.05 for VLMR and LMR suggest that the model with one less class should be rejected in favor of the estimated model  success-oriented, (3) mastery-oriented, (4) English-oriented, math-avoidant, and (5) avoidance-oriented  had average scores on all orientations, that is, they displayed a moderate goal profile with no peak on any orientation. Success-oriented students (26%) demonstrated high multiple goals in mathematics and English, as they expressed a strive for both absolute and relative success as well as for learning and gaining competence in both domains. Interestingly, they scored rather high also on avoidance orientation in both subjects. Mastery-oriented students (25%) emphasized mastery-intrinsic and mastery-extrinsic orientations in both mathematics and English and, in turn, scored relatively low on performance-related orientations and the lowest on avoidance. English-oriented, math-avoidant students (14%) showed the most distinct domain-specificity in the achievement goal orientations out of all the groups. They aimed for learning, getting good grades, and outperforming others in English but had very low aspirations toward learning and succeeding in mathematics. They were also characterized by high avoidance orientation in mathematics. In turn, the small group of avoidance-oriented students (6%) scored high on avoidance in both domains and, at the same time, low on all mastery- and performance-related orientations.p < 0.05) and also to be members of the English-oriented, math-avoidant profile compared to the success-oriented  and indifferent  profiles.Tests of multinominal logistic regressions indicated that girls were significantly more likely than boys to be members of the mastery-oriented profile compared to the success-oriented profile  and academic well-being  by employing the BCH method.The results of the equality tests of means across profiles using the BCH procedure showed that the groups differ significantly in effort required, emotional cost, and opportunity cost in mathematics and English . For exaNext, we proceeded to examine whether students with different subject-specific goal orientation profiles differ also with respect to well-being related to studying in general. The results demonstrated that the goal orientation groups differed significantly in school engagement and all dimensions of school burnout . The masversus specificity of profiles is needed. As striving for achievement-related goals involve investment in time and effort and since the implications of this might vary depending on the types of goals pursued, it is also of importance to examine how the different goal profiles contribute to students’ well-being. Accordingly, the present study aimed at investigating (1) what kinds of achievement goal orientation profiles in two key subjects, mathematics and English, can be identified among general upper secondary school students and (2) how students with different goal orientation profiles differ with regard to subject-specific cost and academic well-being.Despite the abundance of studies on goal profiles, studies examining students’ achievement goal orientation profiles in multiple subjects are lacking, and therefore more information on the cross-domain generality indifferent), (2) high multiple goals profile (success-oriented), (3) predominantly mastery goal profile (mastery-oriented), (4) a profile reflecting positive motivation in English but high avoidance goals in mathematics , and (5) predominantly avoidance goal profile (avoidance-oriented).In identifying students’ subject-specific achievement goal orientation profiles, our analyses revealed, mainly in line with prior studies examining goal orientation profiles in relation to studying in general e.g.,  or in maindifferent students (29%) display a rather balanced and average endorsement of all goals in both subjects, that is, they do not demonstrate a tendency to favor any specific orientation. This finding concurs with previous person-oriented studies extracting a group of students displaying a moderate goal profile  clearly value learning and developing competence but are also likely to place value on relative ability and avoiding demonstrating incompetence. This kind of group of students seemingly striving for multiple goals is often found  emphasize learning and developing competence  as well as succeeding on extrinsic criteria  in both mathematics and English. In turn, they do not exhibit performance- or avoidance-focused tendencies. A group of students holding a dominant tendency toward learning is identified in the vast majority of goal profile studies, both in relation to mathematics  was identified. These students show the strongest domain-specificity in the achievement goal orientations, that is, they demonstrate distinct subject-specific preferences for goals related to learning and succeeding in mathematics and English. These students aim for learning, getting good grades, and outperforming others in English but have very low aspirations toward learning and succeeding in mathematics and also express elevated avoidance orientation in mathematics. Thus, they seem to have an approach goal profile in English , yet in mathematics, they have a nearly equivalent profile to those of avoidance-oriented students  are characterized by a lack of thrive to learn, succeed, or outperform others but rather a strong focus on avoiding schoolwork and minimizing effort in both mathematics and English. In this study, avoidance goals seemed rather domain-general as four groups out of five showed very similar levels in avoidance tendencies in both subjects, and only the English-oriented, math-avoidant students exhibited clearly different levels of avoidance in the two subjects. Thus, the students’ tendency to invest as little effort as possible in studies might be rather context-independent  in studying mathematics seem particularly high among the English-oriented, math-avoidant students. With respect to studying English, however, these students display an adaptive motivational pattern with relatively high mastery and performance-approach goals and low costs. The results resemble those of versus specificity. Furthermore, it would be interesting to complement the design with situation-specific goals, values, and costs as well as with repeated in situ measurements of students’ well-being  and possible sources of cross-domain generality eing see .The present study was conducted in the context of Finnish general upper secondary school , and thus the generalizability of our findings to students in other less selective educational contexts and in other countries requires further investigation. Our study focused on two key academic domains, mathematics and English, but future research could examine students’ motivational profiles across even a wider array of domains.One possible weakness of the person-oriented method relates to the decision-making concerning the optimal number of profiles, which always involves researcher discretion. In this study, however, model-based techniques were used, and the fit indices provided by the LPA for facilitating decision-making were rather consistent and pointed quite clearly at the five-class solution, which was also supported by substantive interpretability. Another potential methodological bias related to an approach commonly used in person-oriented studies is that even though LPA permits a person membership in each cluster to a certain degree , still the modal assignment leads to a person being classified in just one cluster, that is, the one with the largest of the posterior probabilities . Here, hFinally, it should be noted that although the instrument measuring cost seemed to work well in terms of factor structure and validity, the subfacets of cost were rather highly correlated . Gaspard and her colleagues also detected high correlations . Mostly, these results echo previous findings, yet these also add to what we know about the cross-domain generality see also ; on the Second, our findings showed that the subject-specific achievement goal orientation profiles were associated with both subject-specific perceived cost and more general school engagement and burnout, which might have important practical implications. Conflating negative cost values alongside achievement goal orientations enabled the identification of students experiencing specific combinations of subject-specific motivations and pressures. Overall, mastery-oriented students perceived low costs and showed the most adaptive academic well-being. Based on our findings, we can encourage educational practitioners to create educational environments that foster mastery goals. In turn, avoidance-oriented students were the least engaged, although they did not perceive studying as particularly costly. The extraction of the small group of avoidance-oriented students aiming mainly at effort reduction in all schoolwork stresses the need for teachers to identify such students and attempt to support their engagement and valuing of school. In addition to the rather coherently adaptive (mastery-oriented) and maladaptive (avoidance-oriented) profiles, interesting asynchronous profiles were also found, for example, the profile of success-oriented students, in which not only all achievement goals but also costs were high, which was linked to both positive (engagement) and negative (exhaustion) indices of academic well-being. Regarding practical implications, it is thus important to note that there are many students who seemingly thrive in school but whose success coincides with strain and high cost. Teachers and parents should be aware that when a student aims to excel and demonstrate superiority over others, this sort of performance mode might result in not only academic success but also vulnerability for experiencing pressure, psychological cost, emotional exhaustion, anxiety, and fear of failure see also . FurtherIn addition to the success-oriented, the English-oriented, math-avoidant students also displayed mixed configurations of costs and well-being indicators as they perceived only studying math as costly, and in terms of academic well-being, they exhibited rather average engagement but slightly elevated burnout. By simultaneously considering several different motivational indicators  in key academic domains, a person-oriented approach allowed us to capture students’ multifaceted motivation and to better understand the multiple ways that students utilize motivational resources to support learning, engagement, and well-being see also .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 the ethical review board in humanities and social and behavioral sciences of the University of Helsinki, Finland. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.HT collected and analyzed the data, and wrote the first draft of the manuscript. HJ conducted preliminary analyses and contributed to the writing of the manuscript. MN provided support for the data analysis and contributed to the writing of the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


COVID-19 Pandemic has the potential to overwhelm the underserved health care systems of African countries characterized by inadequate infrastructure and too few medical personnel. In responding to the COVID-19 Pandemic, many African countries are using a combination of containment and mitigation activities but in this commentary, we focus on what we term the Non-SHEF2  model related control and containment measures which include seven key measures against COVID-19 doped ‘TITHQC2’ namely, T: Travel-related measures, I: Information and guidance, T: Treatment; H: Hospital containment measures; Q: Quarantine, C: Community containment measures, C: Case detection and contact tracing. COVID-19 is a reality and demands rapid and decisive action to be taken. Reducing the incidence, prevalence, morbidity or mortality of Coronavirus disease COVID-19) to a locally acceptable level in Africa will require a holistic approach and as such warrants additional measures such as the Non-SHEF2  model related control and containment measures which include seven unique measures against COVID-19 doped ‘TITHQC2’ namely, T: Travel-related measures, I: Information and guidance, T: Treatment; H: Hospital containment measures; Q: Quarantine, C: Community containment measures, C: Case detection and contact tracing. COVID-19 has the potential to overwhelm the underserved health care systems of African countries characterized by inadequate infrastructure and too few medical personnel. COVID-19 caused by a novel virus called Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) [9 to a loIn responding to the COVID-19 Pandemic, many African countries are using a combination of containment and mitigation activities with the intention of delaying major surges of patients and levelling the demand for hospital beds, while protecting the most vulnerable from infection, including elderly people and those with comorbidities [Non-SHEF2 model; the case of (“TITHQC2” containment and control measures against COVID-19 in Africa: a summary of the key features of the Non-SHEF2 model ((“TITHQC2”) to contain and control COVID-19 in Africa is shown in T: Travel-related measures: it is worthy to note that, if a large variety of travel-related restrictive measures were introduced earlier on in Africa, the COVID-19 Pandemic would not have been at its worst. Travel related measures by the affected countries themselves and also in response to WHO recommendations to detect COVID-19 cases among domestic and international travelers is an important measure to prevent them from travelling within or leaving the country as well as isolate them immediately on entry [on entry . Fear ofon entry . Millionon entry . EarlierI: Information and guidance on COVID-19: Africans are more liable to misinformation via social media. This notwithstanding, there is need to communicate the epidemiology and risks of COVID-19 clearly, both to health-care workers and to the general population among African member states, and to implement infection prevention and control measures that are based on sound scientific principles [inciples . AffecteWith the rise of COVD-19 pandemic in Africa, a huge propaganda machinery is essential to be activated to inform the public. Ways used to motivate and inform the community in Africa to protect themselves and fight against COVID-19 includes but not limited to health educational programmes, songs, banners, COVID-19 advertisements on buses and daily press conferences by the governments . “Today,T: Treatment of COVID-19: there is no specific antiviral treatment recommended for COVID-19, and no vaccine is currently available [vailable . The issvailable . Cameroovailable . This asvailable . The higvailable . The remvailable . Archbisvailable .H: Hospital containment measures: African countries isolate probable and suspect COVID-19 cases, either in a designated health facilities, as is the case in Cameroon or in separate triage facilities, for example, at hospitals specific wards to screen and separate symptomatic patients at the first point of presentation [entation . AdditioQ: Quarantine: a study by Cascella et al. [a et al. , suggesta et al. . In addia et al. . In AfriC: Community containment measures against COVID-19: community containment measures aimed at limiting social interaction and movement of people have been implemented in most African countries. Most African countries closed schools and students placed under home quarantine. While “lockdown” isn’t a technical term used by public-health officials, it could refer to anything from mandatory geographic quarantines to non-mandatory recommendations to stay at home, closures of certain types of businesses, or bans on events and gatherings. In Africa, it is difficult as earlier mentioned due to poverty as many people have to sustain their daily livelihood by going out. Public places such as bars, public libraries, film cinemas, indoor sports complexes, etc. By early April 2020, African countries made a strong move, to mobilise its population in a fight against COVID-19 and developed a people’s surveillance system where family members, neighbours, etc., monitored each other to ensure that COVID-19 cases were identified quickly [ quickly . AdditioC: Case detection and contact tracing of COVID-19: a big setback in Sub-Saharan African countries preparing for a COVID-19 outbreak is the cost required to prepare health systems to detect and respond to the disease [ disease . All Afr disease . It is l disease . As suchThe control measures implemented by countries worldwide closely resemble each other and are generally in line with the WHO recommendations. However, differences among the countries can be seen in the timeliness of implementation and in the mode and extent to which individual countries apply or enforce control measures. This is seen in African countries generally with weak health systems. Despite all these concerns, Africa ought to have some advantages over the COVID-19 Pandemic that has scorched countries in Asia, Europe, and the Americas. On the other hand, the fact that COVID-19 spread to African countries later than other regions around the world had to be considered an advantage in combating the COVID-19 pandemic. The rate of spread, and level of impact of the COVID-19 Pandemic had to be recognized early, and measures such as suspension of international flights, limited curfew practices, suspension of schools, , and quarantine implemented relatively at an early stage. In line with Africa CDC, we reiterate that the most successful response to COVID-19 in Africa must consider context and adaptability, and must be data-driven. We recommend the strengthening public health systems for immediate response and for a lasting recovery; Monitor data on how public health and social measures meet local COVID-19 conditions and needs. Non-SHEF2 model related control and containment measures which include seven key measures against COVID-19 in Africa doped ‘TITHQC2’ namely, T: Travel-related measures, I: Information and guidance, T: Treatment; H: Hospital containment measures; Q: Quarantine, C: Community containment measures, C: Case detection and contact tracing has global health impact. A dilemma of trying to maintain socio-economic stability while at the same time protecting public health would challenge any African nation. The COVID-19 Pandemic has enhanced indications of how dire the consequences of a highly infectious disease Pandemic could be. The significance of timely preparedness and establishing sensitive active and passive surveillance systems information is perhaps the main lesson that the COVID-19 is teaching us. In line with the steps being taken across the globe to control and contain COVID-19 Pandemic, African countries should strictly adhere to the Non-SHEF2 model.The authors declare no competing interests.


T cells have been recognized as core effectors for cancer immunotherapy. How to restore the anti-tumor ability of suppressed T cells or improve the lethality of cytotoxic T cells has become the main focus in immunotherapy. Bispecific antibodies, especially bispecific T cell engagers (TCEs), have shown their unique ability to enhance the patient’s immune response to tumors by stimulating T cell activation and cytokine production in an MHC-independent manner. Antibodies targeting the checkpoint inhibitory molecules such as programmed cell death protein 1 (PD-1), PD-ligand 1 (PD-L1) and cytotoxic lymphocyte activated antigen 4 are able to restore the cytotoxic effect of immune suppressed T cells and have also shown durable responses in patients with malignancies. However, both types have their own limitations in treating certain cancers. Preclinical and clinical results have emphasized the potential of combining these two antibodies to improve tumor response and patients’ survival. However, the selection and evaluation of combination partners clinically is a costly endeavor. In addition, despite advances made in immunotherapy, there are subsets of patients who are non-responders, and reliable biomarkers for different immunotherapies are urgently needed to improve the ability to prospectively predict patients’ response and improve clinical study design. Therefore, mathematical and computational models are essential to optimize patient benefit, and guide combination approaches with lower cost and in a faster manner.In this study, we continued to extend the quantitative systems pharmacology (QSP) model we developed for a bispecific TCE to explore efficacy of combination therapy with an anti-PD-L1 monoclonal antibody in patients with colorectal cancer.Patient-specific response to TCE monotherapy, anti-PD-L1 monotherapy and the combination therapy were predicted using this model according to each patient’s individual characteristics.Individual biomarkers for TCE monotherapy, anti-PD-L1 monotherapy and their combination have been determined based on the QSP model. Best treatment options for specific patients could be suggested based on their own characteristics to improve clinical trial efficiency. The model can be further used to assess plausible combination strategies for different TCEs and immune checkpoint inhibitors in different types of cancer. Colorectal cancer (CRC), especially metastatic CRC (mCRC) with proficient mismatch repair (pMMR) or microsatellite stable (MSS) tumors, is one of the leading causes of cancer-associated deaths in USA.10.1136/jitc-2020-001141.supp1Supplementary dataet al that the expression of PD-L1 in MSS CRC is mainly restricted to tumor-infiltrating immune cells.During the past few years, the US Food and Drug Administration has approved the application of anti-programmed cell death protein (PD-1) inhibitors, including nivolumab  and pembrolizumab  and the anti-PD-ligand 1 (L1) inhibitor atezolizumab . They have shown great potential for targeting PD-1/PD-L1 interaction in the treatment of patients with different types of cancer including melanoma, advanced NSCLC, renal cell carcinoma (RCC), head and neck squamous cell cancer, triple-negative breast cancer and microsatellite instability-high mCRC (MSI-H mCRC).et al developed patient derived CRC organoids to explore the mechanism of T cell bispecific antibody cibisatamab (CEA-TCB) sensitivity.et al reported the antitumor activity of CEA-TCB in 110 cell lines and the mode of CEA-TCB mediated CRC cell lysis in a mouse tumor model.et al developed a T cell-engaging bispecific antibody (BsAb) to target cell surface A33 antigen (huA33-BsAb), which is expressed in more than 95% of human colon cancers.13Despite the recent failure of anti-PD-1/PD-L1 therapy in MSS CRC patients, novel bispecific T cell engagers (TCEs) have been developed and tested in treating CRC both in vitro and in vivo. Gonzalez-Exposito Even though there are over 500 publications listed in PubMed reporting the preclinical and clinical investigations of BsAb,17Although great achievements have been made by the combination therapy of BsAb with anti-PD-L1 inhibitors in solid tumors, possible disadvantages may arise such as difficulties of determining the source of side effects, drug–drug interactions, cumulative side effects and higher cost.8 22et al developed a multiscale agent-based model of the tumor immune microenvironment, providing information for personalized treatment for individual patients.et al built a QSP model to represent the antitumor immune response in human NSCLC and identified biomarkers for checkpoint inhibitor-based immunotherapy.et al proposed a QSP model to determined potential predictive biomarkers to improve the antitumor response in HER2-negative breast cancer.31Previous studies have demonstrated the performance and ability of quantitative systems pharmacology (QSP) modeling in determining predictive biomarkers.In this work, we have extended our QSP model to include our previously developed TCE module and newly updated anti-PD-L1 module to study the efficacy of anti-PD-L1 monotherapy and the combination with TCE therapy for MSS CRC patients. We studied individual biomarkers for the three therapeutic approaches—TCE monotherapy, anti-PD-L1 monotherapy and their combination. In silico virtual clinical trials (VCTs) have been conducted to compare the response to different treatments for the same cohort of virtual patients (VPs), and to discover predictive biomarkers. Our novel QSP model enables development of biomarker-guided patient selection to improve clinical trial efficiency by providing the distributions of different biomarkers, recommend rational therapeutic regimen and alleviate the rising demand for personalized treatment.et alet al,The QSP model used in this study was based on our previous models developed for NSCLC and TCE.et al incorporated the dynamics of immune checkpoint blockade and demonstrated the general applicability of that module to any anti-PD-1/PD-L1 inhibitor. The model was then used to study anti-PD-1 therapy in NSCLC using nivolumab.et al and thus can be applied for atezolizumab. However, our previous model only considered the expression of PD-L1 on cancer cells. The expression of PD-L1 on antigen-presenting cells (APCs) is also an important factor leading to tumor immune evasion and has been reported to have a significant effect on the outcome of immunotherapy.34 35In a previous model, Jafarnejad Upregulation of PD-L1 on cancer cells is believed to be the major mechanism for tumor immune evasion.Parameter sensitivity analysis (PSA) was performed to assess the sensitivity of the QSP model to a set of parameters. Latin hypercube sampling (LHS) was used to assign the values for this set of parameters with uniform transformation such as tumor volume, density of Teff and Treg, Teff/Treg cell ratio in tumor compartment, and CD8 +T cell clonality in blood. Partial rank correlation coefficient (PRCC) analysis was performed to identify the most influential factors from the simulation results and was implemented by using the MATLAB Global Optimization Toolbox.Statistical analysis was performed for VPs’ subcohorts. Wilcoxon test was used to analyze the differences between responders and non-responders (NRs) under the atezolizumab/cibisatamab monotherapy and combination therapy using the ggpubr package embedded in RStudio V.1.2. The impact of sensitive parameters on the overall response rate (ORR) was also studied with 95% Agresti-Coull CI.A virtual cohort of 2000 patients was created by LHS method. Each VP was generated with a random sample of parameter values based on the list of parameters in the PSA. The baseline number and ranges of all parameters listed in the PSA were based on clinical and experimental evidence , the basThe ORR of atezolizumab monotherapy, cibisatamab monotherapy and combination therapy were investigated by simulating plausible VPs in each trial. In accordance with NCT02324257 and NCT02650713 trials, MSS CRC VPs in atezolizumab monotherapy were treated with atezolizumab 1200 mg Q3W. The same VPs were used in cibisatamab monotherapy and combination therapy in order to compare their responses to different therapies. They were treated with cibisatamab 60 mg QW for cibisatamab monotherapy and cibisatamab 60 mg QW with atezolizumab 1200 mg Q3W for combination therapy. Based on the screening rules, there were 1312, 1325 and 1299 VPs left in atezolizumab monotherapy, cibisatamab monotherapy and combination therapy, respectively. The simulated time-dependent percent tumor size changes are shown in PRCC was used for performing global uncertainty and sensitivity analysis to measure the degree of association between parameters and the tumor volume. In atezolizumab monotherapy and combination therapy, tumor growth rate and initial tumor diameter were significantly positively correlated to the tumor volume. Tumor mutational burden (TMB) defined as the number of clones of T cells that are activatedDistribution of parameters of interest between R and NR are shown in In clinical trials, it is difficult to know in advance which patients may benefit from combination therapy, particularly when only a small portion of patients are likely to derive benefits from such treatment. Prospectively being able predict patient response to combination therapies, especially for those patients who fail to respond or respond poorly to monotherapy, can lead to enhanced clinical trial design. VCTs make it easier to determine different responses to different therapies using the exact same cohort of VPs.Here, we focused on those VPs who had PD in atezolizumab or cibisatamab monotherapy but had SD (PD-SD) or PR/CR (PD-PR/CR) in combination therapy or had SD in atezolizumab or cibisatamab monotherapy but PR/CR (SD-PR/CR) in combination therapy. Other patients who had PD or SD in both monotherapy and combination therapy without any improvement  were grouped as reference. Then, we compared the differences between patients in these groups .When comparing atezolizumab monotherapy and combination therapy, patients who benefited from combination therapy including PD-PR/CR, PD-SD and SD-PR/CR had significantly higher TMB, Teff density in tumor and CEA expression in cancer cells, which demonstrated their important role in predicting treatment outcomes for combination therapy. Moreover, patients in PD-PR/CR and PD-SD groups also had higher Teff/Treg ratio and cibisatamab cross-arm binding efficiency (λ) than the PD-PD group. Parameters such as TMB, Teff density and Teff/Treg ratio in tumor and CEA expression in cancer cells of patients in the PD-PR/CR group were also significantly higher than those in the PD-SD group. The distribution of these parameters can not only estimate whether patients would benefit from receiving combination therapy, but also to determine how much benefit they might receive. In addition, patients in SD-PR/CR group had higher PD-L1 expression in cancer cells than the other four groups, and these patients had stable disease after receiving atezolizumab monotherapy. With the treatment of combination therapy, they were more likely to benefit and showed better treatment outcome (PR/CR) .For cibisatamab monotherapy and combination therapy, TMB and Teff density in tumor once again proved their ability to predict therapeutic effect and potential as predictive biomarkers. PD-L1 expression in cancer cells was higher in those three groups of patients with improved therapeutic effects. CEA expression was also higher in patients in group SD-PR/CR than SD-SD and their condition was improved after receiving combination therapy .In another perspective, if we can prospectively predict which treatment is most likely to be effective for patients prior to the start of clinical trials, we would be able to select subjects for inclusion in randomized clinical trials and potentially reduce the number of subjects to recruit to improve clinical trial efficiency. Based on our virtual trials’ results, we divided all patients into five groups based on their responses to three treatments: responder to atezolizumab monotherapy only (ROA), responder to cibisatamab monotherapy only (ROC), responder to both monotherapies (ROB), responder to combination therapy only (ROCMB) and NR to any therapies.We computed the distribution of several potential biomarkers in these five groups, respectively . In termIt is unlikely that a single biomarker will be sufficient to predict clinical outcomes in response to immune-targeted therapy. The effects of multiple factors need to be comprehensively considered to accurately predict outcomes. Nevertheless, a single biomarker can be used to predict the ORR, but the predictive performance of biomarkers is different. To determine the most predictive biomarkers, we computed and compared the predictive ability of each parameter and how its value affected the ORR of subcohorts of all VPs.We investigated the performance of preidentified biomarkers. The results were plotted as a receiver operating characteristic (ROC) curve. TMB, Teff density and Teff/Treg ratio in tumor had high area under the curve (AUC) in all treatments, which indicated their great potential as good predictive biomarkers . PD-L1 aThen we examined the relationship between the ORR and each parameter by calculating the ORR of patient subcohorts. First, we sorted all patients in ascending order according to a certain parameter, then every 20 patients were assigned into a group from the first patient, and the ORR of each group was calculated separately . All paret al have reported that tumor and APCs can both express PD-L2 in patients with advanced, treatment-refractory solid tumors including NSCLC, melanoma, kidney, castration-resistant prostate cancer) and CRC.et al.et al.PD-L2 has been widely reported as a second ligand for PD-1 and inhibitor of T cell activation. Effects of PD-L2 were also included in the current QSP model. The dynamics of PD-L2 has been reported and described in the However, this setting caused an issue when calculating the distribution of PD-L2 in responders and non-responders, responders showed significantly higher PD-L2 both in cancer and APCs , which wAccording to recent reports, the majority of CRC patients have MSS tumors, which accounts for 80%–85% of all CRC patients.Our model has successfully conducted in silico VCTs for atezolizumab monotherapy and combination therapy. The predicted ORR showed consistency with clinical trial results. Patients receiving monotherapy with PD-1 or PD-L1 agents typically well tolerate them based on previous studies, but combination therapies are always associated with elevated risk of immune-related adverse events. The identification of predictive biomarkers is critical to optimize patient benefit and reduce risk of toxicities. Important parameters such as TMB, amount of Teff in tumor microenvironment, and PD-L1/CEA expression in cancer cells have shown potential to be predictive biomarkers. PD-L1 expression in APCs could potentially be a biomarker for atezolizumab monotherapy, but it showed no correlation with patients’ response in combination therapy. Other parameters such as cross-arm binding efficiency λ and CD3-cibisatamab binding affinity could affect the efficacy of cibisatamab monotherapy, which should be noted and carefully selected in the design of TCE.We then explored if patients who failed to respond to monotherapies can benefit from combination therapy by studying patients in PD-PD, PD-SD, PD-PR/CR, SD-SD and SD-PR/CR groups. This analysis would help guide treatment recommendations by assessing if combination therapy may work for specific patients. We have shown how patients with different parameters responded differently. Although patients in PD-PR/CR and PD-SD groups can both benefit from combination therapy, patients in PD-PR/CR group had higher TMB, Teff density and Teff/Treg ratio in tumor, and PD-L1 or CEA expression in cancer cells than patients in PD-SD groups. However, if we only compare one parameter, the distribution of this parameter in patients of PD-PR/CR, PD-SD and PD-PD groups may overlap with other groups, resulting in false positive results, that is, high TMB patients in PD-PD group were predicted in PD-PR/CR or PD-SD groups. However, this can be avoided by comparing more parameters.Moreover, we computed the distribution of potential biomarkers in our VPs and studied how their distribution affected patients’ response, by grouping all patients into ROA, ROC, ROB, ROCMB and NR groups. This might solve the problem of unnecessary trials and help determine the best treatment option for patients and prospectively assign them to the right group. As we mentioned before, a small subset of MSS CRC patients can still respond to anti-PD-1/PD-L1 antibodies or TCE monotherapy. These patients need to be identified instead of being potentially excluded from a therapy that could be suitable for them. In addition, some patients are unlikely to respond to monotherapies, and should receive combination therapy. There is also a subset of patients who may respond to any treatment, for them the best treatment can be chosen based on the clinicians’ experience and other factors such as potential toxicity and patients’ preferred dosing regimen. Finally, patients who may not respond to any treatment can be identified and considered for other treatment options in a timely manner. Therefore, it is essential to implement novel biomarker-guided patient selection to improve the overall efficiency of clinical trials design. Ideally, if all these potential biomarkers can be measured, the best treatment can be identified for a specific patient based on the reference ranges obtained from a virtual population. However, realistically, in the most cases, not all parameters can be measured, therefore, the performance of these biomarkers can be compared with predict efficacy and a rough prediction of ORR can be made even when there are only a few biomarkers available.PD-L2 is commonly considered as an inhibitor of T cell activation, but its actual role in the tumor microenvironment are still being elucidated. An in vivo study of PD-L2 KO mice has shown a potential function of PD-L2 for augmenting T helper 1 and CTL responses.We have extended the ICIs module with PD-L1 expression in APCs. However, a higher level of PD-L1 expression in tumor-infiltrating immune cells especially tumor-associated macrophages (TAMs) and myeloid-derived suppressor cells (MDSCs) has been detected and proved to be associated with patients’ survival.In summary, we performed three in silico VCTs using our QSP model with an expanded ICIs module. The model reproduced clinical trial outcomes and showed good consistency with previous publications. For each therapy, we were able to identify potential patient selection biomarkers. By comparing the predicted outcomes of monotherapy and combination therapy in the same set of VPs, the model was able to identify the best treatment options for patients based on their individual characteristics. In addition, the current model can be applied to other TCEs and ICIs in different types of cancer to help assess plausible combination strategies and reduce the effort of clinical assessment. Although the knowledge gap between clinical trials and QSP modeling hinders application of these models in many respects, including the optimal selection of combination therapies, predicting toxicity, duration of response (DOR) and progression free survival, this gap will be filled as greater emphasis is placed on the collection of patient-centric biomarkers in current and future clinical trials.10.1136/jitc-2020-001141.supp2Supplementary data