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Favre P, Maquer G, Henderson A, Hertig D, Ciric D, Bischoff JE. In Silico Clinical Trials in the Orthopedic Device Industry: From Fantasy to Reality? Ann Biomed Eng 2021; 49:3213-3226. [PMID: 33973129 PMCID: PMC8110242 DOI: 10.1007/s10439-021-02787-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 04/24/2021] [Indexed: 11/24/2022]
Abstract
The orthopedic device industry relies heavily on clinical evaluation to confirm the safety, performance, and clinical benefits of its implants. Limited sample size often prevents these studies from capturing the full spectrum of patient variability and real-life implant use. The device industry is accustomed to simulating benchtop tests with numerical methods and recent developments now enable virtual "in silico clinical trials" (ISCT). In this article, we describe how the advancement of computer modeling has naturally led to ISCT; outline the potential benefits of ISCT to patients, healthcare systems, manufacturers, and regulators; and identify how hurdles associated with ISCT may be overcome. In particular, we highlight a process for defining the relevant patient risks to address with ISCT, the utility of a versatile software pipeline, the necessity to ensure model credibility, and the goal of limiting regulatory uncertainty. By complementing-not replacing-traditional clinical trials with computational evidence, ISCT provides a viable technical and regulatory strategy for characterizing the full spectrum of patients, clinical conditions, and configurations that are embodied in contemporary orthopedic implant systems.
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Affiliation(s)
| | - Ghislain Maquer
- Zimmer Biomet, Sulzerallee 8, 8404 , Winterthur, Switzerland
| | - Adam Henderson
- Zimmer Biomet, Sulzerallee 8, 8404 , Winterthur, Switzerland
| | - Daniel Hertig
- Zimmer Biomet, Sulzerallee 8, 8404 , Winterthur, Switzerland
| | - Daniel Ciric
- Zimmer Biomet, Sulzerallee 8, 8404 , Winterthur, Switzerland
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102
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Van Asten JGMV, Fung MT, Oomens CWJ, Bader DL, Worsley PR. A combined experimental and computational approach to evaluate microclimate control at the support surface interface. J Tissue Viability 2021; 30:395-401. [PMID: 34030943 DOI: 10.1016/j.jtv.2021.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 03/23/2021] [Accepted: 04/23/2021] [Indexed: 11/28/2022]
Abstract
Temperature and humidity conditions at the interface between a support surface and the skin, termed microclimate, has been implicated in the development of pressure ulcers. Support surface technologies have been developed to control microclimate conditions, although only a few standard test methods exist to evaluate their performance. This study describes a combined experimental-computational approach to analyzing microclimate control systems. The study used a modified physical model protocol to evaluate two specific support surface systems involving a spacer fabric cover with i) no air flow and ii) an active fan. The physical model deposited moisture at a controlled rate for 25 min, and the microclimate conditions under the model and the surrounding area were monitored for 24 h. Using the experimental data as boundary conditions, a finite element model was developed using mass transport principles, which was calibrated using experimental results. Model inputs included mass density and mass diffusivity, resulting in an estimated absolute humidity change over time. The physical model tests revealed distinct differences between the support surfaces with and without active airflow, with the former having little effect on local humidity levels (RH>75% for 24hr). By contrast, there was a spatial and temporal change in microclimate with the active fan, with sensors positioned towards the source of airflow reaching ambient conditions within 24hr. The computational model was refined to produce comparable results with respect to both the spatial distribution of microclimate and the change in values over time. The combined experimental and computation approach was able to distinguish distinct difference in microclimate change between two support surface designs. The approach could enable the efficient evaluation of different mattress design principles to aid decision making for personalized support surface solutions, for the prevention of pressure ulcers.
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Affiliation(s)
- J G M V Van Asten
- Department of Biomedical Engineering, Eindhoven University of Technology, the Netherlands
| | - M-T Fung
- Department of Biomedical Engineering, Eindhoven University of Technology, the Netherlands
| | - C W J Oomens
- Department of Biomedical Engineering, Eindhoven University of Technology, the Netherlands
| | - D L Bader
- Department of Biomedical Engineering, Eindhoven University of Technology, the Netherlands; School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, UK
| | - P R Worsley
- School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, UK.
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103
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Kreuzer SM, Briant PL, Ochoa JA. Establishing the Biofidelity of a Multiphysics Finite Element Model of the Human Heart. Cardiovasc Eng Technol 2021; 12:387-397. [PMID: 33851325 DOI: 10.1007/s13239-021-00538-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 04/05/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Accelerating development of new therapeutic cardiac devices remains a clinical and technical priority. High-performance computing and the emergence of functional and complex in silico models of human anatomy can be an engine to accelerate the commercialization of innovative, safe, and effective devices. METHODS An existing three-dimensional, nonlinear model of a human heart with flow boundary conditions was evaluated. Its muscular tissues were exercised using electrophysiological boundary conditions, creating a dynamic, electro-mechanical simulation of the kinetics of the human heart. Anatomic metrics were selected to characterize the functional biofidelity of the model based on their significance to the design of cardiac devices. The model output was queried through the cardiac cycle and compared to in vivo literature values. RESULTS For the kinematics of mitral and aortic valves and curvature of coronary vessels, the model's performance was at or above the 95th percentile range of the in vivo data from large patient cohorts. One exception was the kinematics of the tricuspid valve. The model's mechanical use environment would subject devices to generally conservative use conditions. CONCLUSIONS This conservative simulated use environment for heart-based medical devices, and its judicious application in the evaluation of medical devices is justified, but careful interpretation of the results is encouraged.
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Affiliation(s)
- Steven M Kreuzer
- Mechanical Engineering Practice, Exponent, Inc., 1075 Worcester St, Natick, MA, 01760, USA
| | - Paul L Briant
- Mechanical Engineering Practice, Exponent, Inc., 149 Commonwealth Drive, Menlo Park, CA, 94025, USA
| | - Jorge A Ochoa
- Biomedical Engineering and Sciences Practice, Exponent, Inc., 1250 S Capital of Texas Hwy, Bldg. 3, Ste. 400, Austin, TX, 78746, USA.
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104
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Patterson EA, Whelan MP, Worth AP. The role of validation in establishing the scientific credibility of predictive toxicology approaches intended for regulatory application. ACTA ACUST UNITED AC 2021; 17:100144. [PMID: 33681540 PMCID: PMC7903516 DOI: 10.1016/j.comtox.2020.100144] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 09/15/2020] [Accepted: 11/04/2020] [Indexed: 12/14/2022]
Abstract
The role of validation in establishing the credibility of predictive methods is discussed. Various assessment frameworks for predictive methods have evolved independently, being developed by different communities. A set of seven credibility factors is proposed as a method-agnostic means of comparing the various assessment frameworks. It is hoped this will facilitate communication and cross-disciplinary collaboration between method developers and users.
New approaches in toxicology based on in vitro methods and computational modelling offer considerable potential to improve the efficiency and effectiveness of chemical hazard and risk assessment in a variety of regulatory contexts. However, this presents challenges both for developers and regulatory assessors because often these two communities do not share the same level of confidence in a new approach. To address this challenge, various assessment frameworks have been developed over the past 20 years with the aim of creating harmonised and systematic approaches for evaluating new methods. These frameworks typically focus on specific methodologies and technologies, which has proven useful for establishing the validity and credibility of individual methods. However, given the increasing need to compare methods and combine their use in integrated assessment strategies, the multiplicity of frameworks is arguably becoming a barrier to their acceptance. In this commentary, we explore the concepts of model validity and credibility, and we illustrate how a set of seven credibility factors provides a method-agnostic means of comparing different kinds of predictive toxicology approaches. It is hoped that this will facilitate communication and cross-disciplinarity among method developers and users, with the ultimate aim of increasing the acceptance and use of predictive approaches in toxicology.
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Affiliation(s)
| | | | - Andrew P Worth
- European Commission, Joint Research Centre (JRC), Ispra, Italy
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105
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van Riel NAW, Tiemann CA, Hilbers PAJ, Groen AK. Metabolic Modeling Combined With Machine Learning Integrates Longitudinal Data and Identifies the Origin of LXR-Induced Hepatic Steatosis. Front Bioeng Biotechnol 2021; 8:536957. [PMID: 33665185 PMCID: PMC7921164 DOI: 10.3389/fbioe.2020.536957] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 12/16/2020] [Indexed: 11/23/2022] Open
Abstract
Temporal multi-omics data can provide information about the dynamics of disease development and therapeutic response. However, statistical analysis of high-dimensional time-series data is challenging. Here we develop a novel approach to model temporal metabolomic and transcriptomic data by combining machine learning with metabolic models. ADAPT (Analysis of Dynamic Adaptations in Parameter Trajectories) performs metabolic trajectory modeling by introducing time-dependent parameters in differential equation models of metabolic systems. ADAPT translates structural uncertainty in the model, such as missing information about regulation, into a parameter estimation problem that is solved by iterative learning. We have now extended ADAPT to include both metabolic and transcriptomic time-series data by introducing a regularization function in the learning algorithm. The ADAPT learning algorithm was (re)formulated as a multi-objective optimization problem in which the estimation of trajectories of metabolic parameters is constrained by the metabolite data and refined by gene expression data. ADAPT was applied to a model of hepatic lipid and plasma lipoprotein metabolism to predict metabolic adaptations that are induced upon pharmacological treatment of mice by a Liver X receptor (LXR) agonist. We investigated the excessive accumulation of triglycerides (TG) in the liver resulting in the development of hepatic steatosis. ADAPT predicted that hepatic TG accumulation after LXR activation originates for 80% from an increased influx of free fatty acids. The model also correctly estimated that TG was stored in the cytosol rather than transferred to nascent very-low density lipoproteins. Through model-based integration of temporal metabolic and gene expression data we discovered that increased free fatty acid influx instead of de novo lipogenesis is the main driver of LXR-induced hepatic steatosis. This study illustrates how ADAPT provides estimates for biomedically important parameters that cannot be measured directly, explaining (side-)effects of pharmacological treatment with LXR agonists.
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Affiliation(s)
- Natal A W van Riel
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands.,Department of Vascular Medicine, Amsterdam UMC, Amsterdam, Netherlands.,Maastricht Centre for Systems Biology, Maastricht University, Maastricht, Netherlands
| | - Christian A Tiemann
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Peter A J Hilbers
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Albert K Groen
- Department of Vascular Medicine, Amsterdam UMC, Amsterdam, Netherlands.,Department of Laboratory Medicine, University Medical Center Groningen, Groningen, Netherlands
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106
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Sorguven E, Bozkurt S, Baldock C. Computer simulations can replace in-vivo experiments for implantable medical devices. Phys Eng Sci Med 2021; 44:1-5. [PMID: 33559037 DOI: 10.1007/s13246-021-00978-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2021] [Indexed: 01/10/2023]
Affiliation(s)
- Esra Sorguven
- Thermo Fluid Mechanics Research Centre, University of Sussex, Brighton, BN1 9RH, UK
| | - Selim Bozkurt
- Institute of Cardiovascular Science, University College London, London, WC1E 6DD, UK
| | - Clive Baldock
- Research and Innovation Division, University of Wollongong, Wollongong, NSW, 2522, Australia.
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107
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Russo G, Pennisi M, Fichera E, Motta S, Raciti G, Viceconti M, Pappalardo F. In silico trial to test COVID-19 candidate vaccines: a case study with UISS platform. BMC Bioinformatics 2020; 21:527. [PMID: 33308153 PMCID: PMC7733700 DOI: 10.1186/s12859-020-03872-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 11/09/2020] [Indexed: 02/07/2023] Open
Abstract
Background SARS-CoV-2 is a severe respiratory infection that infects humans. Its outburst entitled it as a pandemic emergence. To get a grip on this outbreak, specific preventive and therapeutic interventions are urgently needed. It must be said that, until now, there are no existing vaccines for coronaviruses. To promptly and rapidly respond to pandemic events, the application of in silico trials can be used for designing and testing medicines against SARS-CoV-2 and speed-up the vaccine discovery pipeline, predicting any therapeutic failure and minimizing undesired effects. Results We present an in silico platform that showed to be in very good agreement with the latest literature in predicting SARS-CoV-2 dynamics and related immune system host response. Moreover, it has been used to predict the outcome of one of the latest suggested approach to design an effective vaccine, based on monoclonal antibody. Universal Immune System Simulator (UISS) in silico platform is potentially ready to be used as an in silico trial platform to predict the outcome of vaccination strategy against SARS-CoV-2. Conclusions In silico trials are showing to be powerful weapons in predicting immune responses of potential candidate vaccines. Here, UISS has been extended to be used as an in silico trial platform to speed-up and drive the discovery pipeline of vaccine against SARS-CoV-2.
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Affiliation(s)
- Giulia Russo
- Department of Drug Sciences, University of Catania, 95125, Catania, Italy
| | - Marzio Pennisi
- Computer Science Institute, DiSIT, University of Eastern Piedmont, 15125, Alessandria, Italy
| | | | - Santo Motta
- National Research Council of Italy, 00185, Rome, Italy
| | - Giuseppina Raciti
- Department of Drug Sciences, University of Catania, 95125, Catania, Italy.
| | - Marco Viceconti
- Department of Industrial Engineering, Alma Mater Studiorum - University of Bologna, 40136, Bologna, Italy
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108
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Biomechanical modelling of the facet joints: a review of methods and validation processes in finite element analysis. Biomech Model Mechanobiol 2020; 20:389-401. [PMID: 33221991 PMCID: PMC7979651 DOI: 10.1007/s10237-020-01403-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 11/04/2020] [Indexed: 12/13/2022]
Abstract
There is an increased interest in studying the biomechanics of the facet joints. For in silico studies, it is therefore important to understand the level of reliability of models for outputs of interest related to the facet joints. In this work, a systematic review of finite element models of multi-level spinal section with facet joints output of interest was performed. The review focused on the methodology used to model the facet joints and its associated validation. From the 110 papers analysed, 18 presented some validation of the facet joints outputs. Validation was done by comparing outputs to literature data, either computational or experimental values; with the major drawback that, when comparing to computational values, the baseline data was rarely validated. Analysis of the modelling methodology showed that there seems to be a compromise made between accuracy of the geometry and nonlinearity of the cartilage behaviour in compression. Most models either used a soft contact representation of the cartilage layer at the joint or included a cartilage layer which was linear elastic. Most concerning, soft contact models usually did not contain much information on the pressure-overclosure law. This review shows that to increase the reliability of in silico model of the spine for facet joints outputs, more needs to be done regarding the description of the methods used to model the facet joints, and the validation for specific outputs of interest needs to be more thorough, with recommendation to systematically share input and output data of validation studies.
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109
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Tarricone R, Ciani O, Torbica A, Brouwer W, Chaloutsos G, Drummond MF, Martelli N, Persson U, Leidl R, Levin L, Sampietro-Colom L, Taylor RS. Lifecycle evidence requirements for high-risk implantable medical devices: a European perspective. Expert Rev Med Devices 2020; 17:993-1006. [PMID: 32975149 DOI: 10.1080/17434440.2020.1825074] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION The new European Union (EU) Regulations on medical devices and on in vitro diagnostics provide manufacturers and Notified Bodies with new tools to improve pre-market and post-market clinical evidence generation especially for high-risk products but fail to indicate what type of clinical evidence is appropriate at each stage of the whole lifecycle of medical devices. In this paper we address: i) the appropriate level and timing of clinical evidence throughout the lifecycle of high-risk implantable medical devices; and ii) how the clinical evidence generation ecosystem could be adapted to optimize patient access. AREAS COVERED The European regulatory and health technology assessment (HTA) contexts are reviewed, in relation to the lifecycle of high-risk medical devices and clinical evidence generation recommended by international network or endorsed by regulatory and HTA agencies in different jurisdictions. EXPERT OPINION Four stages are relevant for clinical evidence generation: i) pre-clinical, pre-market; ii) clinical, pre-market; iii) diffusion, post-market; and iv) obsolescence & replacement, post-market. Each stage has its own evaluation needs and specific studies are recommended to generate the appropriate evidence. Effective lifecycle planning requires anticipation of what evidence will be needed at each stage.
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Affiliation(s)
- Rosanna Tarricone
- Department of Social and Political Science, Bocconi University , Milan, Italy.,SDA Bocconi School of Management , Milan, Italy.,SDA Bocconi School of Management, Centre for Research on Health and Social Care Management (CERGAS) , Milan, Italy
| | - Oriana Ciani
- SDA Bocconi School of Management, Centre for Research on Health and Social Care Management (CERGAS) , Milan, Italy.,Institute of College and Medicine, University of Exeter, South Cloisters, St Luke's Campus , Exeter, UK
| | - Aleksandra Torbica
- Department of Social and Political Science, Bocconi University , Milan, Italy.,SDA Bocconi School of Management , Milan, Italy
| | - Werner Brouwer
- Erasmus School of Health Policy & Management (ESHPM), Erasmus University Rotterdam , Rotterdam, PA, The Netherlands
| | - Georges Chaloutsos
- Biomedical Engineering Department, Onassis Cardiac Surgery Centre & Director , Athens, Greece
| | - Michael F Drummond
- Professor of Health Economics, Centre for Health Economics, University of York , York, UK
| | - Nicolas Martelli
- Associate Clinical Professor, Hôpital Européen Georges Pompidou , Paris, France
| | - Ulf Persson
- IHE, Swedish Institute for Health Economics , Lund, Sweden
| | - Reiner Leidl
- Institute of Health Economics and Healthcare Management, Helmholtz Zentrum München - German Research Center for Environmental Health (Gmbh) , Neuherberg, Germany
| | - Les Levin
- Chief Executive Officer & Scientific Officer, EXCITE International , Canada
| | - Laura Sampietro-Colom
- Deputy Director of Innovation, Head of Health Technology Assessment Unit at Hospital Clinic Barcelona , Spain
| | - Rod S Taylor
- Institute of Health and Wellbeing, University of Glasgow , Glasgow, UK
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110
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In-silico human electro-mechanical ventricular modelling and simulation for drug-induced pro-arrhythmia and inotropic risk assessment. PROGRESS IN BIOPHYSICS AND MOLECULAR BIOLOGY 2020; 159:58-74. [PMID: 32710902 PMCID: PMC7848595 DOI: 10.1016/j.pbiomolbio.2020.06.007] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 06/08/2020] [Accepted: 06/28/2020] [Indexed: 12/28/2022]
Abstract
Human-based computational modelling and simulation are powerful tools to accelerate the mechanistic understanding of cardiac patho-physiology, and to develop and evaluate therapeutic interventions. The aim of this study is to calibrate and evaluate human ventricular electro-mechanical models for investigations on the effect of the electro-mechanical coupling and pharmacological action on human ventricular electrophysiology, calcium dynamics, and active contraction. The most recent models of human ventricular electrophysiology, excitation-contraction coupling, and active contraction were integrated, and the coupled models were calibrated using human experimental data. Simulations were then conducted using the coupled models to quantify the effects of electro-mechanical coupling and drug exposure on electrophysiology and force generation in virtual human ventricular cardiomyocytes and tissue. The resulting calibrated human electro-mechanical models yielded active tension, action potential, and calcium transient metrics that are in agreement with experiments for endocardial, epicardial, and mid-myocardial human samples. Simulation results correctly predicted the inotropic response of different multichannel action reference compounds and demonstrated that the electro-mechanical coupling improves the robustness of repolarisation under drug exposure compared to electrophysiology-only models. They also generated additional evidence to explain the partial mismatch between in-silico and in-vitro experiments on drug-induced electrophysiology changes. The human calibrated and evaluated modelling and simulation framework constructed in this study opens new avenues for future investigations into the complex interplay between the electrical and mechanical cardiac substrates, its modulation by pharmacological action, and its translation to tissue and organ models of cardiac patho-physiology.
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111
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Machine learning methods to support personalized neuromusculoskeletal modelling. Biomech Model Mechanobiol 2020; 19:1169-1185. [DOI: 10.1007/s10237-020-01367-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 07/08/2020] [Indexed: 12/19/2022]
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112
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Russo G, Reche P, Pennisi M, Pappalardo F. The combination of artificial intelligence and systems biology for intelligent vaccine design. Expert Opin Drug Discov 2020; 15:1267-1281. [PMID: 32662677 DOI: 10.1080/17460441.2020.1791076] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION A new body of evidence depicts the applications of artificial intelligence and systems biology in vaccine design and development. The combination of both approaches shall revolutionize healthcare, accelerating clinical trial processes and reducing the costs and time involved in drug research and development. AREAS COVERED This review explores the basics of artificial intelligence and systems biology approaches in the vaccine development pipeline. The topics include a detailed description of epitope prediction tools for designing epitope-based vaccines and agent-based models for immune system response prediction, along with a focus on their potentiality to facilitate clinical trial phases. EXPERT OPINION Artificial intelligence and systems biology offer the opportunity to avoid the inefficiencies and failures that arise in the classical vaccine development pipeline. One promising solution is the combination of both methodologies in a multiscale perspective through an accurate pipeline. We are entering an 'in silico era' in which scientific partnerships, including a more and more increasing creation of an 'ecosystem' of collaboration and multidisciplinary approach, are relevant for addressing the long and risky road of vaccine discovery and development. In this context, regulatory guidance should be developed to qualify the in silico trials as evidence for intelligent vaccine development.
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Affiliation(s)
- Giulia Russo
- Department of Drug Sciences, University of Catania , Catania, Italy
| | - Pedro Reche
- Department of Immunology, Universidad Complutense De Madrid, Ciudad Universitaria , Madrid, Spain
| | - Marzio Pennisi
- Computer Science Institute, DiSIT, University of Eastern Piedmont , Italy
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