Hoang Linh Nguyen1, Pham Dang Lan1,2, Nguyen Quoc Thai1,3, Daniel A Nissley4, Edward P O'Brien5,6,7, Mai Suan Li8. 1. Life Science Lab, Institute for Computational Science and Technology, Quang Trung Software City, Tan Chanh Hiep Ward, District 12, Ho Chi Minh City, Vietnam. 2. Faculty of Physics and Engineering Physics, VNUHCM-University of Science, 227, Nguyen Van Cu Street, District 5, Ho Chi Minh City, Vietnam. 3. Dong Thap University, 783 Pham Huu Lau Street, Ward 6, Cao Lanh City, Dong Thap, Vietnam. 4. Department of Statistics, University of Oxford, Oxford OX1 2JD, United Kingdom. 5. Department of Chemistry, Pennsylvania State University, University Park, Pennsylvania 16802, United States. 6. Bioinformatics and Genomics Graduate Program, The Huck Institutes of the Life Sciences, Pennsylvania State University, University Park, Pennsylvania 16802, United States. 7. Institute for Computational and Data Sciences, Pennsylvania State University, University Park, Pennsylvania 16802,United States. 8. Institute of Physics, Polish Academy of Sciences, al. Lotnikow 32/46, 02-668 Warsaw, Poland.
Abstract
The 2019 novel coronavirus (SARS-CoV-2) epidemic, which was first reported in December 2019 in Wuhan, China, was declared a pandemic by the World Health Organization in March 2020. Genetically, SARS-CoV-2 is closely related to SARS-CoV, which caused a global epidemic with 8096 confirmed cases in more than 25 countries from 2002 to 2003. Given the significant morbidity and mortality rate, the current pandemic poses a danger to all of humanity, prompting us to understand the activity of SARS-CoV-2 at the atomic level. Experimental studies have revealed that spike proteins of both SARS-CoV-2 and SARS-CoV bind to angiotensin-converting enzyme 2 (ACE2) before entering the cell for replication. However, the binding affinities reported by different groups seem to contradict each other. Wrapp et al. (Science 2020, 367, 1260-1263) showed that the spike protein of SARS-CoV-2 binds to the ACE2 peptidase domain (ACE2-PD) more strongly than does SARS-CoV, and this fact may be associated with a greater severity of the new virus. However, Walls et al. (Cell 2020, 181, 281-292) reported that SARS-CoV-2 exhibits a higher binding affinity, but the difference between the two variants is relatively small. To understand the binding mechnism and experimental results, we investigated how the receptor binding domain (RBD) of SARS-CoV (SARS-CoV-RBD) and SARS-CoV-2 (SARS-CoV-2-RBD) interacts with a human ACE2-PD using molecular modeling. We applied a coarse-grained model to calculate the dissociation constant and found that SARS-CoV-2 displays a 2-fold higher binding affinity. Using steered all-atom molecular dynamics simulations, we demonstrate that, like a coarse-grained simulation, SARS-CoV-2-RBD was associated with ACE2-PD more strongly than was SARS-CoV-RBD, as evidenced by a higher rupture force and larger pulling work. We show that the binding affinity of both viruses to ACE2 is driven by electrostatic interactions.
The 2019 novel coronavirus (SARS-CoV-2) epidemic, which was first reported in December 2019 in Wuhan, China, was declared a pandemic by the World Health Organization in March 2020. Genetically, SARS-CoV-2 is closely related to SARS-CoV, which caused a global epidemic with 8096 confirmed cases in more than 25 countries from 2002 to 2003. Given the significant morbidity and mortality rate, the current pandemic poses a danger to all of humanity, prompting us to understand the activity of SARS-CoV-2 at the atomic level. Experimental studies have revealed that spike proteins of both SARS-CoV-2 and SARS-CoV bind to angiotensin-converting enzyme 2 (ACE2) before entering the cell for replication. However, the binding affinities reported by different groups seem to contradict each other. Wrapp et al. (Science 2020, 367, 1260-1263) showed that the spike protein of SARS-CoV-2 binds to the ACE2 peptidase domain (ACE2-PD) more strongly than does SARS-CoV, and this fact may be associated with a greater severity of the new virus. However, Walls et al. (Cell 2020, 181, 281-292) reported that SARS-CoV-2 exhibits a higher binding affinity, but the difference between the two variants is relatively small. To understand the binding mechnism and experimental results, we investigated how the receptor binding domain (RBD) of SARS-CoV (SARS-CoV-RBD) and SARS-CoV-2 (SARS-CoV-2-RBD) interacts with a humanACE2-PD using molecular modeling. We applied a coarse-grained model to calculate the dissociation constant and found that SARS-CoV-2 displays a 2-fold higher binding affinity. Using steered all-atom molecular dynamics simulations, we demonstrate that, like a coarse-grained simulation, SARS-CoV-2-RBD was associated with ACE2-PD more strongly than was SARS-CoV-RBD, as evidenced by a higher rupture force and larger pulling work. We show that the binding affinity of both viruses to ACE2 is driven by electrostatic interactions.
The 2019 novel coronavirus
(SARS-CoV-2) was first reported in Wuhan,
China, in December 2019. The severe acute respiratory syndrome disease
caused by this virus is named COVID-19.[2] The rapid spread of SARS-CoV-2 worldwide led the World Health Organization
to declare a pandemic on March 11, 2020.[2] As of May 8, 2020, more than 3.9 million cases of infection and
about 271 thousand deaths were recorded, and thousands more are struggling
for their lives in hospitals across the globe.Clinical symptoms
of Covid-19 include respiratory illness and pneumonia.[3] This pathogen is known as a member of the genus
β-coronavirus, which refers to severe acute coronavirus respiratory
syndrome (SARS-CoV)[4,5] causing a global epidemic in more than 25 countries
in 2002 and 2003. SARS-CoV-26 is genetically close to the
old variant SARS-CoV, but the number of confirmed cases and deaths
from Covid-19 has significantly exceeded the 2002 to 2003 SARS cases
in only a few months,[7] and an initial review
suggests that its reproductive rate is likely higher than that of
SARS.[7]Coronaviruses belong to the
single-strand-envelope RNA virus family
that can be classified into four genera.[8] Both SARS-CoV and SARS-CoV-2 belong to the β genus. Coronaviruses
are spherical in shape with protruding molecules from the viral surface
called spike (S) proteins.[9] During entry
of the viral molecule into the host cell, the S protein is responsible
for host binding through interaction with the receptor and for fusion
of the viral and cellular membranes. In the prefusion stage, the S
protein is split into two subunits S1 and S2, which noncovalently
bind to each other.[10] Subunit S1 binds
to the receptor binding domain (RBD), and S2 mediates the fusion of
the viral and cellular membranes. In the case of SARS-CoV, domain
B of S1 directly interacts with angiotensin-converting enzyme 2 (ACE2)
of the host cell attaching the virion to the cell surface.[11−13] In addition, the injection of SARS-CoV through ACE2 may exacerbate
acute pulmonary failure.[14] Therefore, characterizing
the molecular mechanism of the interaction between the S protein and
the ACE2 receptor plays an important role in understanding the process
of β-coronavirusinfection.Using the cryo-EM technique,
Wrapp et al. obtained the structure
of the SARS-CoV-2 S protein in the prefusion state.[15] They found that the S protein of SARS-CoV-2 resembles the
S of SARS-CoV. Experimental studies showed that like SARS-CoV, SARS-CoV-2
also uses ACE2 as a receptor to enter cells.[16,17] Comparing the conformations of the SARS-CoV and SARS-CoV-2 at their
interface with humanACE2, Yan et al. found a similarity between the
receptor binding domains of SARS-CoV and SARS-CoV-2 upon binding to
ACE2.[18] However, there are some differences
between their structures at the interface that can distinguish the
binding affinity of two viral proteins. Wrapp et al.[15] showed that the S protein of SARS-CoV-2 binds to the ACE2
peptidase domain (ACE2-PD) with a binding affinity clearly higher
than that of SARS-CoV. The dissociation constant KD of SARS-CoV-2 is 14.7 nM, 10–20 times lower than
that of SARS-CoV[12,15] (Table ). This result appears to contradict Walls
et al.,[17] who reported that KD is about an order of magnitude smaller and the difference
between two variants is also smaller (KD ≈ 1.2 and 5 nM for SARS-CoV-2 and SARS-CoV-2, respectively)
(Table ). Therefore,
understanding the binding mechanism and differences in experimental
data obtained by different groups is of great interest. This problem
is also important because the binding of the S protein to the host
receptor is crucial to understanding why a new virus spreads faster
than the old one at the atomic level.
Table 1
KD (nM)
of SARS-CoV-2 and SARS-CoV Obtained by Experiment and Simulationa
reference
SARS-CoV-2
SARS-CoV
KD(SARS-CoV)/KD(SARS-CoV-2)
Wrapp et al.,[12,15] exp
14.7
150–300
10.2–20.4 times
Walls et al.,[17] exp
1.2 ± 0.1
5.0 ± 0.1
4.2 times
our simulation
2.7
6.7
2.5 times
Relative KD values are shown in the last column. Error
bars were not
reported in Wrapp et al.[12,15]
Relative KD values are shown in the last column. Error
bars were not
reported in Wrapp et al.[12,15]In this paper we considered the
interaction of S proteins with
humanACE2 by combining coarse-grained and all-atom steered molecular
dynamics (SMD) simulations. All-atom models would be an ideal choice
for evaluating KD, but achieving good
sampling for large complexes of S protein and ACE2 is computationally
challenging, prompting us to use coarse-grained models. Because coarse-grained
modeling does not preserve many atomic details, SMD simulations were
carried out to clarify the binding mechanism.For clarity, we
will use the following abbreviations: SARS-CoV-RBD
and SARS-CoV-2-RBD denote the receptor binding domain of SARS-CoV
and SARS-CoV-2, respectively, whereas ACE2-PD refers to the peptidase
domain of humanACE2. With these abbreviations, the interaction of
two viruses with the host receptor is simply defined as the interaction
of SARS-CoV-RBD and SARS-CoV-2-RBD with ACE2-PD. The binding affinity
of the two complexes will be accessed by mechanical pulling to separate
SARS-CoV-RBD and SARS-CoV-2-RBD from ACE2-PD (Figure ).
Figure 1
(Top panel) Spike protein sequence and relative
locations of different
regions: RBD, receptor binding domain; SD1, subdomain 1; SD2, subdomain
2; FP, fusion peptide; HR1, heptad repeat 1; HR2, heptad repeat 2;
TM, transmembrane regions; IC, intracellular domain. (Middle panel)
Structures of the complex of ACE2-PD with SARS-CoV-RBD (left, PDB
ID 2AJF) and
SARS-CoV-2-RBD (right, PDB ID 6VW1). The arrow indicates the direction along
which external force is applied in the SMD simulation. (Bottom panel)
The vectors of individual hydrogen bonds in the interface are highlighted
in red, and the total vector (as in the middle panel) is black.
(Top panel) Spike protein sequence and relative
locations of different
regions: RBD, receptor binding domain; SD1, subdomain 1; SD2, subdomain
2; FP, fusion peptide; HR1, heptad repeat 1; HR2, heptad repeat 2;
TM, transmembrane regions; IC, intracellular domain. (Middle panel)
Structures of the complex of ACE2-PD with SARS-CoV-RBD (left, PDB
ID 2AJF) and
SARS-CoV-2-RBD (right, PDB ID 6VW1). The arrow indicates the direction along
which external force is applied in the SMD simulation. (Bottom panel)
The vectors of individual hydrogen bonds in the interface are highlighted
in red, and the total vector (as in the middle panel) is black.Coarse-grained umbrella sampling simulations for
SARS-CoV-2 indicate KD ≈ 7 nM,
roughly 3 times less than that
of SARS-CoV, implying that the new virus binds to humanACE2 slightly
more strongly than the old one, and this difference in the binding
affinity is not as significant as shown by the experiment of Wrapp
et al.[15] Our result is consistent with
Walls et al.,[17] who reported that KD of SARS-CoV-2 is about 4 times less than that
of SARS-CoV (Table ).Using SMD simulations, we demonstrated that a higher rupture
force
(Fmax in the force–extension profile)
and more pulling work are required to unbind SARS-CoV-2-RBD from ACE2-PD
than to unbind SARS-CoV-RBD, which suggested that, in agreement with
the experiment of Wrapp et al.,[15] SARS-CoV-2
binds to ACE2 more strongly than does SARS-CoV. The binding affinity
was shown to be driven by electrostatic interactions. This finding
may have implications in drug design strategies in which potential
drugs should be compounds that can weaken the electrostatic interaction
between ACE2-PD and RBD of the virus.
Materials and Methods
Initial
Structures of SARS-CoV-2-RBD and SARS-CoV-RBD Bound
to ACE2-PD
The structure of ACE2-PD in complex with SARS-CoV-2-RBD
was retrieved from Protein Data Bank (PDB) file PDB ID 6VW1, while the structure
of ACE2-PD complexed with SARS-CoV-RBD has PDB ID 2AJF(19) (Figure ). The PDB structures of SARS-CoV-2-RBD and SARS-CoV-RBD do not resolve
12 residues at the N-terminus and 8 residues at the C-terminus, respectively.
The missing residues were added using the Modeler software package.[20]
Choice of Pulling Direction in the SMD Simulation
The
choice of pulling direction is not unique. Nevertheless, we chose
the direction so that stretching along it would break the maximum
number of HBs because by trial we found that it was almost perpendicular
to the two parts of the two proteins interacting at the interface
if we consider these two parts to be parallel planes. Our choice was
also based on the fact that the complex is stabilized by hydrogen
bonds (HBs) between the two subunits.Using Pymol software,
we represent each HB between two monomers as a unit vector with two
possible directions. The directions of the individual vectors should
be chosen so that the sum of all the vectors is maximized (Figure ). We have 10 and
12 vectors for SARS-CoV-RBD and SARS-CoV-2-RBD, respectively. Their
total vector is shown in Figure , and the external force in the SMD simulation was
directed along it.
Steered Molecular Dynamics
Molecular
dynamics-based
methods such as molecular mechanics Poisson–Boltzmann or the
generalized Born surface area (MM-PB/GBSA),[21] thermodynamics integration,[22] free-energy
perturbation,[23] and umbrella sampling[24] are methods that can be used to estimate the
binding free energy. However, for large systems, such as the two complexes
studied here, these methods are not practical due to insufficient
sampling. Therefore, we use the SMD method, which is computationally
fast but still reliable in predicting relative binding affinities.[25−29]The simulations were performed using the GROMACS 2018.6 package,[30] and the AMBER-f99SB-ILDN force field with water
molecules was modeled using TIP3P.[31] In
the SMD simulations, a spring is attached from one side to a dummy
atom and from the other side to the center of mass (CoM) of SARS-CoV-2-RBD
or SARS-CoV-RBD. The dummy atom is then pulled from its initial position
along the direction of the maximum total vector with a constant speed v covering a distance Δzc = vt at time t. Hence, the elastic
force experienced by the chain is F = k(Δz – vt), where Δz is the displacement of the chain’s atom
connected to the spring in the direction of pulling. As in the case
of AFM experiments,[32] in this work we chose k = 600 kJ/mol/nm2. In order to check the robustness
of the results against pulling speed, we performed the simulation
for three values of v = 5, 1.5, and 0.5 nm/ns. In
the SMD simulation, RBD of the viral S protein was pulled, while ACE2-PD
was considered to be the reference molecule. To prevent ACE2-PD from
shifting during pulling, we restrained the Cα atoms of the residues,
the COM of which is at a distance of more than 1.2 nm from the COM
of any RBD residues of the viral S protein. A cutoff of 1.2 nm was
chosen because the same cutoff was also used for nonbonded interactions.
A harmonic potential with a spring constant of 1000 kJ/mol/nm2 was applied to the restrained Cα atoms.Both
complexes were solvated in a box of 19 × 18 × 18
nm3 so that there was enough space to pull the viral protein.
COM of the complex is located at the 9, 9, 9 nm position. Counter
ions were added to neutralize the system. The energy of the system
was minimized using the steepest-descent algorithm. The system was
then equilibrated in the NVT and NPT ensembles with 1 and 5 ns MD
simulations, respectively. The production run was performed in the
NPT ensemble at temperature T = 300 K and 1 bar
of pressure, which were achieved by employing the v-rescale and Parrinello–Rahman
algorithms.[33,34] Bond lengths were constrained
using the LINCS algorithm,[35] allowing to
use a time step of 2 fs. The neighbor list was updated every 10 ps.
The long-range electrostatic interaction was calculated using the
particle mesh Ewald (PME) method.[36]
Hydrogen
Bonds
For analysis purposes, a hydrogen bond
is considered to be present when the distance between the donor atom
and acceptor atom is ≤3.5 Å and the angle between the
acceptor–H-donor atoms is ≥135°.
Nonbonded Contact
A nonbonded contact is considered
to be present when the distance between two Cα atoms is <6.5
Å.
Pulling Work
The pulling work is calculated using the
trapezoidal rulewhere N is
the number of steps and F and x are the pulling
force and coordination of the COM of RBD at step i, respectively.
Coarse-Grained Model
Coarse-grained
(CG) Go model simulations
were performed using a previously published procedure.[37] In this model, each amino acid is represented
by a single interaction site centered on the Cα atom position.
The energy of a given conformation of this model is calculated asThe first
term corresponds
to the bond distance energy to hold two neighboring Cα interaction
sites at a distance of r0 = 3.8 Å.
The second term is the bond angle energy which employs a double-well
potential that can adopt angles representative of either α or
β structures of proteins.[38] The next
term is the standard dihedral angle potential with the sum of four
terms used to approximate each virtual dihedral among four successive
Cα interaction sites. Electrostatic interactions were modeled
on the basis of Debye–Huckel theory with a Debye screening
length of lD = 10 Å. Lysine and arginine
residues are assigned a charge of +e, glutamate and
aspartate are assigned a charge of −e, and
all other residues are assigned a charge of 0e. The
12–10–6 potential was used for van der Waals attractive
interactions.[39] This potential favors the
native contacts defined as in conventional Go models. Native contacts
were defined on the basis of an experimental crystal structure as
previously described,[37] and their energy
sets are based on a training set of single-domain proteins.[40] Native contacts between the RBD of the S protein
and ACE2 were defined in the same way as intradomain contacts.The value of ϵNC, which sets the depth of the energy
minimum for a native contact, is calculated to be ϵNC = nϵHB + ηϵ.
Here, ϵHB, and ϵ represent energy contributions arising from hydrogen
bonding and van der Waals contacts between residues i and j identified from the all-atom structure of
the protein, respectively. n is the number of hydrogen bonds formed between residues i and j, and ϵHB = 0.75
kcal/mol. The value of ϵ is based on the Betancourt–Thirumalai pairwise potential.[41] The scaling factor η is determined to
reproduce protein stability, and its values will be given below.
Tuning the Native State Stability of Coarse-Grained Structure
The strength of the nonbonded contact energies in terms of van
der Waals interactions was multiplied by a number η to tune
the native state stability of the protein structures. Two different
η values, named respectively ηintra and ηinter for contacts within
a monomer or between monomers in a complex, were determined. For single-domain
stability, we employ an average η value taken from the previous
training set.[40] The goal is to find the
minimum η that results in a protein model that is folded at
least 98% of the time during a 500 ns simulations. The choice of the
“98% folded” criterion for selecting the value of η
is heuristic on the basis of the following justification. If, at equilibrium
at 310 K, a protein is in the folded state 98% of the time, then the
folding probability is PF = 0.98 and the
unfolding probability is PU = 0.02. Using
the equation ΔG = −kBT ln(PF/PU), we obtain the difference in free energy
between the folded and unfolded states ΔG ≈
4kBT, which is a reasonable
for a protein. Thus, it is heuristic but has a physical basis.We ran simulations of SARS-CoV and ACE2 using different η values
of 1.114, 1.359, and 1.916 (corresponding to η = ⟨η⟩
class, ⟨η⟩ class +22%, or ⟨η⟩
class + 72% using the mixed α/β structures[37]). For each value of η, ten 500 ns Langevin
dynamics simulations at 310 K were run using a friction coefficient
of 0.050 ps–1, an integration time step of 0.015
ps, and the SHAKE algorithm applied to covalent bonds. Single domains
of SARS-CoV or ACE2 were considered to be folded in a simulation frame
when their fraction of native contacts is greater than 0.69. ηintra = 1.359 is the lowest value that
stabilizes both monomeric structures. To determine a minimum η
for the interprotein interactions, ten 100 ns Langevin dynamics simulations
were carried out for hetero structures of SARS-CoV and ACE2 using
different overall averaged η values of 1.235, 1.507, and 2.124
(corresponding to ⟨η⟩overall, ⟨η⟩overall + 22%, and ⟨η⟩overall + 72%[37]). The strength of the interfacial
interactions affects the stability of the heterodimer state. The whole
structure is considered to be stable if the interaction energy between
SARS-CoV and ACE2 is negative and the COM between the two proteins
stays within 1.5 Å of the X-ray COM distance (∼9.5 Å)
during the simulations. With these criteria, we find ηinter = 1.235 is the minimum value that keeps the dimer
in its bound form. Different experiments give different values of
the dissociation constant for the SARS-CoV systems binding to ACE2.
Wrapp et al.[15] reported a value of 14.7
nM for the SARS-CoV-2 complex, much lower than the 150–300
nM value for the SARS-CoV complex reported by Kirchdoerfer et al.,[12] while Walls et al.[17] measured a similar KD for both systems
of only a few nM. Although these experiments result in different dissociation
constant values, they all agree that KD should be on the level of nM.As explained in the Method section,
the choice of ηintra and ηinter is
based on the requirement that the proteins in our CG models are stable
folders. However, in order to reproduce the experimental result, i.e., KD is on the order of nM, we should tune these
parameters. We can show that the best way to achieve this goal is
to change ηintra while keeping ηinter fixed.Using ηintra = 1.359
and ηinter = 1.235 as discussed
above, we obtained KD ≈ 100 μM
for the two systems.
These KD values are too large in comparison
to the experimental data; therefore, we ran additional simulations
in which we fix η at 1.235 and search for a reasonable ηintra. We found that ηintra = 1.8 results in KD on the order of
nM for both the SARS-CoV and SARS-CoV-2 complexes.
Chemistry at Harvard
Macromolecular Mechanics (CHARMM) version c35b5[42] was used for all coarse-grained protein simulations.
REX-US simulations were carried out using the CoM distance of interface
residues as the reaction coordinate. The initial structure of the
CoV-ACE2 complex is first aligned along the z axis
of the local coordinate system and umbrella windows generated by translating
ACE2 by 0.5 Å increments along the z dimension
up to a CoM distance of 100 Å for a total of 182 windows. A harmonic
restraint was applied to the CoM of each monomer to the target umbrella
distance using a force constant of 7 kcal/Å.[2] For each umbrella window, Langevin dynamics simulations
were then run at 310 K using a frictional coefficient of 0.050 ps–1, an integration time step of 0.015 ps, and the SHAKE
algorithm applied to covalent bonds. Every 5000 integration time steps
a Hamiltonian replica exchange was attempted between neighboring windows.
In total, 10 000 exchanges (∼750 ns of simulation time)
were attempted, with the first 1000 attempted exchanges discarded
to allow equilibration. The 650 ns were then used for analysis. Acceptance
ratios between neighboring umbrellas were between 0.42 and 0.57.
Method for Determining Dissociation Constant KD from REX-US Simulation
Taking [CoV-ACE2], [CoV],
and [ACE2] to be the concentrations of bound complex CoV-ACE2, unbound
CoV, and unbound ACE2, respectively, the probability of bound (Pb) and unbound states (Pu)[43] can be expressed asSince we are simulating only
a dimer, [CoV] = [ACE2].The dissociation constant KD is thenWe can then express the dissociation
constant as a function of Pb, Pu, and [CoV] aswhere [CoV] is the equilibrium
concentration of monomers as given byCoefficient C0 = 1660 is constant of proportionality to convert
to
units of molarity. Namely, in eq , V(r*) is measured in Å2, and the unit of concentration [CoV] is M. V(r*) is the simulation volume in which free monomers
exist. Since we have radial symmetry in these simulations, it is a
function of the maximum radius r* that we simulated
between the separated monomers.To determine the probability Pb, one
has to integrate the potential of mean force (PMF) which can be calculated
from REX-US simulations aswhere G3D(r⃗) as the 3D potential of mean
force (3D-PMF).Using the CoM as the order parameter in our
simulations, we make
the simplifying assumption that the PMF is spherically symmetric,
allowing us to replace ∫0ρ3D(r⃗) dr⃗ with ∫04πr2ρ1D(r) dr where r is the radial
distance in spherical coordinates and eq becomesG1D(r) is the 1D PMF, which
we calculate from the replica
exchange simulations using the histogram-free formulation of the WHAM
equations.[44]rb is the CoM distance threshold separating bound and unbound states. rb is defined as corresponding to the peak of
the 1D-PMF (Figure ). The numerical integration of eq is carried out using the trapezoidal rule. Pu is then computed as 1 – Pb, and the dissociation constant is computed using eq .
Figure 8
(Top) One-dimensional potential of mean force
(1D-PMF) of SARS-CoV
(black curve) and SARS-CoV-2 (red curve). Results were obtained by
applying the WHAM analysis method for 750 ns REX-US simulations. (Bottom) KD curves as a function of r* corresponding to the change in the total free monomer concentration
from eq . Pb and KD were determined at r* = 105 Å.
Results and Discussion
Initial
Structures of SARS-CoV-RBD and SARS-CoV-2-RBD in Complex
with ACE2-PD
The networks of HBs and nonbonded contacts (NBCs)
between ACE2-PD and RBD of the S proteins in the initial structures
used for SMD simulation are shown in Figure . The binding regions of the two complexes
are similar, including residues 24–42, 79–83, and 329–354
(Figure ). The superimposition
of two complexes (Figure S1) also confirms
this observation. The number of ACE2 residues that form HB and NBC
with SARS-CoV and SARS-CoV-2 is 12 and 14, respectively, suggesting
that the binding of SARS-CoV-2 with ACE2 is stronger than that of
SARS-CoV.
Figure 2
Networks of interchain HBs (green) and NBCs (red) of the initial
structures used in SMD simulation. Residue indexes of the viral protein
are highlighted in pink and blue, and those for ACE2, in black and
green. The numbering of residues is the same as in PDB structures
with the chain names shown in parentheses.
Networks of interchain HBs (green) and NBCs (red) of the initial
structures used in SMD simulation. Residue indexes of the viral protein
are highlighted in pink and blue, and those for ACE2, in black and
green. The numbering of residues is the same as in PDB structures
with the chain names shown in parentheses.Since the residues of RBD of the two S proteins are numbered differently,
the superimposition (Figure S1) allows
us to determine residues at equivalent positions that form HB and
NBC with ACE2-PD (Figure ). We can show that SARS-CoV-2-RBD binds to ACE2-PD in three
regions and SARS-CoV-RBD binds in two regions. The first region contains
residues R426, Y436, Y484, T486, T487, G488, and Y491 in SARS-CoV,
while in SARS-CoV-2 these residues are Y449, Y496, Q498, T500, G502,
and Y505 (Figure S1). Yan et al. suggested
that replacing R426, Y484, Y436, and T487 in SARS-CoV with N439, Q498,
Y449, and N501 could alter the binding affinity between viral proteins
and humanACE2.[18] The second region, where
both viral proteins have HB and NBC with ACE2, consists of L472, N473,
A475, and Y491 in SARS-CoV, while in SARS-CoV-2 this region has three
residues: F486, N487, and Y489.In the third region (G416, V417,
Y453, R454, L455, F456, Q493,
and Y473 for SARS-CoV-2 and N479, D480, V404, R441, Y442, L443, and
F460 for SARS-CoV), only SARS-CoV-2 forms contacts with ACE2. In general,
SARS-CoV-2 and SARS-CoV form 17 NBCs with ACE2, but the number of
HBs of SARS-CoV-2 (12 HBs) is greater than that of SARS-CoV (10 HBs).
This result implies that SARS-CoV-2 binds to ACE2 more strongly than
does SARS-CoV.
SARS-CoV-2-RBD Binds to ACE2-PD More Strongly
Than Does SARS-CoV-RBD:
SMD Results
The force–time profiles, obtained in the
SMD simulation for the two complexes, are shown in Figure . Obviously, RBD of SARS-CoV-2
requires more force and time to unbind compared to the case of SARS-CoV.
Averaging over five trajectories, we obtained the rupture force Fmax = 751.2 ± 42.5 and 588.2 ± 53.4
pN at v = 0.5 nm/ns for SARS-CoV-2 and SARS-CoV,
respectively (Table ). The nonequilibrium work Wneq performed
by dissociating SARS-CoV-2 with ACE2 (132.1 ± 3.7 kcal/mol) is
also higher than that of SARS-CoV (97.9 ± 3.0 kcal/mol) (Table ). As shown in previous
studies,[25,27] the greater the pulling work and the rupture
force, the higher the binding affinity. Therefore, our SMD results
indicate that SARS-CoV-2-RBD binds more strongly to ACE2-PD than does
SARS-CoV-RBD. These results are consistent with the experiment of
Wrapp et al.,[15] reporting that ACE2 is
associated with SARS-CoV-2 with an affinity 10–20 times higher
than with SARS-CoV. However, our assessment of dissociation constant KD using coarse-grained modeling (see below)
and an experiment of Walls et al.[17] showed
that although the old virus exhibits a lower binding affinity the
difference between the two variants is not significant.
Figure 3
Representative force–time profiles, obtained
for v = 5, 1.5, and 0.5 nm/ns.
Table 2
Nonequilibrium Work, Wneq, and Rupture
Force, Fmax, Obtained in the SMD Simulation
for v = 0.5, 1.5,
and 5 nm/nsa
v = 0.5 mn/ns
v = 5 mn/ns
v = 1.5 mn/ns
no salt
150 mM salt
S protein
Wneq (kcal/mol)
Fmax (pN)
Wneq (kcal/mol)
Fmax (pN)
Wneq (kcal/mol)
Fmax (pN)
Wneq (kcal/mol)
Fmax (pN)
SARS-CoV-2
398.5 ± 5.7
1369.2 ± 93.7
231.9 ± 9.1
960.4 ± 43.2
132.1 ± 3.7
751.2 ± 42.5
135.0 ± 4.9
753.1 ± 63.8
SARS-CoV
263.8 ± 5.1
982.1 ± 45.2
124.8 ± 8.4
626.7 ± 51.8
97.9 ± 3.0
588.2 ± 53.4
98.6 ± 10.3
637.3 ± 65.9
For v = 0.5
nm/ns, an additional simulation was performed at a salt concentration
of 150 mM. The errors represent standard deviations.
For v = 0.5
nm/ns, an additional simulation was performed at a salt concentration
of 150 mM. The errors represent standard deviations.Representative force–time profiles, obtained
for v = 5, 1.5, and 0.5 nm/ns.In order to show that our main conclusion is independent of the
pulling speed, we carried out the SMD simulations at v = 1.5 and 5 nm/ns (Figure ). As expected,[27,45] the rupture force and
nonequilibrium work increase with increasing v, but
for both pulling speeds, Fmax and Wneq of SARS-CoV-2-RBD are higher than those
for SARS-CoV-RBD (Table ). Thus, the fact that SARS-CoV-2 binds to ACE2 more strongly than
does SARS-CoV is evidence that it is robust against pulling speed.
In what follows, we report the results obtained for the lowest speed, v = 0.5 nm/ns.In order to investigate the effect
of salt concentration on the
SMD results, we performed additional simulations with a physiological
salt concentration of 150 mM and a pulling speed of 0.5 nm/ns. Within
the error bars, Fmax and the nonequilibrium
work computed from these simulations are similar to values computed
without salt (Table ), which indicate that salt at the physiological concentration does
not affect the SMD results.
Binding of SARS-CoV-RBD and SARS-CoV-2-RBD
to ACE2-PD is Driven
by Electrostatic Interactions
The time dependence of the
total nonbonded interaction energy (electrostatic and van der Waals
(vdW)) between ACE2-PD and RBD of two S proteins is shown in Figure . Because the systems
are large, the interaction energy does not vanish even when the distance
between the COMs of two subunits is >8 nm. The interaction between
ACE2 and SARS-CoV-2-RBD is stronger than in the case of SARS-CoV,
supporting the fact that the complex of SARS-CoV-2 and ACE2 is more
stable than that of its partner, SARS-CoV.
Figure 4
(Left) Time dependence
of the total nonbonded interaction energy
(electrostatic and vdW) of SARS-CoV and SARS-CoV-2 in complex with
ACE2 and a pulling speed of 0.5 nm/ns. (Right) Time dependence of
the electrostatic and vdW interaction energies of two complexes. The
results were obtained by averaging over five trajectories and a time
window of 0–7000 ps.
(Left) Time dependence
of the total nonbonded interaction energy
(electrostatic and vdW) of SARS-CoV and SARS-CoV-2 in complex with
ACE2 and a pulling speed of 0.5 nm/ns. (Right) Time dependence of
the electrostatic and vdW interaction energies of two complexes. The
results were obtained by averaging over five trajectories and a time
window of 0–7000 ps.Averaging over five trajectories, we find that the electrostatic
interaction is significantly stronger than vdW interactions (Figure , right; Table ) for both heterodimers,
implying that the binding of the novel and old viruses to ACE2 is
driven by the electrostatic interaction. At pH 7.4 used in this work,
the total charges of SARS-CoV-2-RBD and SARS-CoV-RBD are +3 and +2e, respectively, leading to a stronger electrostatic interaction
between the former and ACE2-PD compared to the latter. In addition,
within the error bars, the vdW interaction of ACE2 and SARS-CoV-2
is also stronger than that of the SARS-CoV complex (Figure and Table ).
Table 3
Nonbonded Interaction
Energies (kcal/mol)
Obtained by Averaging over Five Trajectories and a Time Window of
0–7000 psa
interaction
energy (kcal/mol)
SARS-CoV
SARS-CoV-2
electrostatic
–620.39 ± 2.53
–791.41 ± 2.44
van der Waals
–75.56 ± 0.98
–84.48 ± 0.54
total
–695.95 ± 3.51
–875.89 ± 2.98
The pulling
speed is v = 0.5 nm/ns. Errors represent standard
deviations.
The pulling
speed is v = 0.5 nm/ns. Errors represent standard
deviations.To confirm the
finding that electrostatic interaction dominates
the vdW interaction, we did the following. As follows from Figure , positively charged
residues R1, K403, R408, R439, and K452 of SARS-CoV-2-RBD have a strong
electrostatic interaction, and the total nonbonded interaction (vdW
and electrostatic) with ACE2-PD is lower than or equal to −200
kcal/mol. We mutated these five residues with neutral alanine. For
the mutant (R1A, K403A, R408A, R439A, and K452A), we carried out five
SMD runs at a pulling speed of 0.5 nm/ns and obtained Fmax and work values of 671.7 ± 49.3 pN and 96.4 ±
8.5 kcal/mol, respectively (Table ). Within the error bars, these values are similar
to 588.2 ± 53.4 pN and 98.6 ± 10.3 kcal/mol of the old SARS-CoV-RBD
(Table ), which implies
that the electrostatic interaction plays a key role in the association
of the S protein with human cells. In general, the replacement of
positively charged residues with neutral alanine weakens the binding
of viral RBD to ACE2-PD.
Figure 6
Energy of the nonbonded interaction between the residues
of RBD
of S proteins and ACE2-PD. Residues that have an energy below −100
kcal/mol are shown in blue, while red indicates residues with an energy
above 100 kca/mol. Other residues are in black. In the case of SARS-CoV-2,
charged residues R1, K403, R408, R439, and K452 have a total nonbonded
interaction below −200 kcal/mol. Results were obtained by averaging
over five trajectories and a time window of 0–7000 ps. Pulling
speed v = 0.5 nm/ns.
SARS-Co-RBD Is More Flexible Than SARS-Co-2-RBD
The
RMSF (root-mean-square fluctuation) profile of the residues of RBD
of S glycoproteins is different for the two variants (Figure ). In SARS-CoV, there are three
regions with significant RMSF: the blue and magenta regions are located
on the border with ACE2-PD, and the cyan region is in contact with
solvent molecules but not with ACE2-PD. In SARS-CoV-2, the red, yellow,
and blue regions, which are located at the interface with ACE2, have
significant RMSFs (Figure ). The 380–420 region strongly fluctuates in SARS-CoV
but not in SARS-CoV-2. Three other regions with high RMSFs are highlighted
in cyan, magenta, and yellow. They have contact with solvent molecules
but not with ACE2. Overall, having a lower RMSF, SARS-Co-RBD is more
flexible in complex with ACE2 than is SARS-CoV-2-RBD (Figure ), supporting the increased
binding affinity of the novel virus to the receptor cell.
Figure 5
RMSF of the
residues of viral RBD S proteins, obtained in the SMD
simulation with v = 0.5 nm/ns. The regions with high
RMSFs are shown with colored bands. Blue refers to the area where
the RBD residues are in contact with ACE2-PD. The results were obtained
by averaging over five trajectories and a time window of 0–7000
ps.
RMSF of the
residues of viral RBD S proteins, obtained in the SMD
simulation with v = 0.5 nm/ns. The regions with high
RMSFs are shown with colored bands. Blue refers to the area where
the RBD residues are in contact with ACE2-PD. The results were obtained
by averaging over five trajectories and a time window of 0–7000
ps.The RMSF (root-mean-square fluctuation)
profiles of the residues
of viral RBD proteins are different for the two viruses (Figure ). In SARS-CoV, there
are five regions with a significant RMSF and only the blue region
is located on the border with ACE2-PD, while the other regions are
in contact with solvent molecules but not with ACE2-PD. In SARS-CoV-2,
the two blue regions, which are located at the interface with ACE2,
have significant RMSFs (Figure ). A few residues at the C-terminus have very strong fluctuations
because they are entirely located in the bulk. The 394–420
region strongly fluctuates in SARS-CoV (red region) but not in SARS-CoV-2.
Three other regions of SARS-CoV-2 with high RMSFs are highlighted
in cyan, magenta, and yellow. They have contact with solvent molecules
but not with ACE2.Averaging over all residues we obtained RMSFs
of 1.04 and 1.08
Å for SARS-CoV and SARS-CoV-2, respectively. However, for residues
that are in contact with ACE2-PD the mean RMSF for SARS-CoV (1.53
Å) is higher than that for SARS-Cov-2 (1.27 Å). Thus, having
a higher RMSF, SARS-CoV-RBD is more flexible in complex with ACE2
than is SARS-CoV-2-RBD (Figure ). This may support the increased binding affinity of the
novel virus to the receptor cell.
Role of Specific Residues
of ACE2-PD
The contributions
of ACE2-PD residues to the energy of the nonbonded interaction with
RBD of the S protein have similar profiles for the two complexes (Figure S2). This is expected because in both
complexes ACE2-PD has the same sequence and its structures are highly
overlapped (Figure S1). In general, the
interaction energies of individual ACE2-PD residues in complex with
SARS-CoV-2 are lower than in SARS-CoV, which is consistent with the
results obtained for the rupture force and nonequilibrium work.
Role of Specific Residues of RBD of S Proteins
The
interaction energy profiles of the viral protein residues with ACE2-PD
(Figure ) show that regions 425–460 of SARS-CoV-RBD
and 450–475 of SARS-CoV-2-RBD contain many residues that attract
ACE2-PD strongly. However, in both RBDs there is no specific segment
that dominates the interaction between the two monomers because prominent
residues are distributed discretely over the entire sequences (Figure ). These distributions
are almost identical in SARS-CoV-RBD and SARS-CoV-2-RBD. For both
viral S proteins, RBD residues that have medium interaction with ACE2-PD
are located in the region of 460–500. Therefore, there is no
specific region of SARS-CoV-2-RBD that can play a dominant role in
the difference between the two variants in their propensity to bind
to humanACE2-PD.Energy of the nonbonded interaction between the residues
of RBD
of S proteins and ACE2-PD. Residues that have an energy below −100
kcal/mol are shown in blue, while red indicates residues with an energy
above 100 kca/mol. Other residues are in black. In the case of SARS-CoV-2,
charged residues R1, K403, R408, R439, and K452 have a total nonbonded
interaction below −200 kcal/mol. Results were obtained by averaging
over five trajectories and a time window of 0–7000 ps. Pulling
speed v = 0.5 nm/ns.In order to understand the role of the residues that are different
for SARS-Cov and SARS-Cov-2 at the interface, we superimposed the
structures of two complexes as shown in Figure , where a list of
these residues in three regions is given in the upper panel. For example,
in region 1 they are R426, Y436, Y484, and T487 for SARS-Cov and R439,
Y449, Q498, and N501 for SARS-Cov-2. Yan et al. suggested that these
sequence variations may result in differences in the binding affinity
with ACE2,[18] but the corresponding interaction
energy was not obtained. We verified this assumption by calculating
the interaction energy of individual residues using the SMD simulation.
In general, SARS-CoV-2-RBD residues have a stronger nonbonded interaction
with ACE2 than their counterparts in SARS-CoV-RBD. (See the numbers
in parentheses next to each residue in Figure .) The difference in the interaction energy
of one pair is insignificant compared to the total interaction energy
(Figure and Table ). Using the numbers
shown in Figure ,
we can show that the contribution of all of the selected residues
to the interaction energy difference is about −82.8 kcal/mol,
which is significant compared to the total energy difference between
the SARS-CoV-2 and SARS-CoV complexes (about −179.9 kcal/mol, Table ). Thus, our SMD results
confirm the previous assumption[18] that
variations in the sequence of RBD at the border with ACE2 significantly
affect the binding affinity.
Figure 7
(Upper panel) List of the residues that are
different for SARS-Cov
and SARS-Cov-2 in three regions denoted by boxes at the interface.
(Middle panel, left) Interface with three regions enclosed in boxes.
For the SARS-CoV system, the viral protein is shown in cyan, and magenta
highlights ACE2-PD. For the SARS-CoV-2 system, the viral protein and
ACE2-PD are highlighted in orange and green, respectively. The bottom
and middle panels (right) refer to regions 1, 2, and 3. The residues
of the viral protein in SARS-CoV and SARS-CoV-2 are highlighted in
teal and orange, respectively. The numbers in parentheses denote the
mean nonbonded interaction energies between these residues and ACE2-PD
(kcal/mol). Results were obtained by averaging over five trajectories
and a time window of 0–7000 ps. Pulling speed v = 0.5 nm/ns.
(Upper panel) List of the residues that are
different for SARS-Cov
and SARS-Cov-2 in three regions denoted by boxes at the interface.
(Middle panel, left) Interface with three regions enclosed in boxes.
For the SARS-CoV system, the viral protein is shown in cyan, and magenta
highlights ACE2-PD. For the SARS-CoV-2 system, the viral protein and
ACE2-PD are highlighted in orange and green, respectively. The bottom
and middle panels (right) refer to regions 1, 2, and 3. The residues
of the viral protein in SARS-CoV and SARS-CoV-2 are highlighted in
teal and orange, respectively. The numbers in parentheses denote the
mean nonbonded interaction energies between these residues and ACE2-PD
(kcal/mol). Results were obtained by averaging over five trajectories
and a time window of 0–7000 ps. Pulling speed v = 0.5 nm/ns.
Estimation of the Difference
in Binding Affinity between SARS-CoV
and SARS-CoV2 to Human ACE
Combining Jarzynski’s equality[46,47] and SMD, we can determine the absolute binding affinity, but this
approach is not reliable for our large systems because a huge number
of SMD trajectories are required.[48] Therefore,
in this section, we calculate the dissociation constant KD for both complexes using CG-MD replica exchange umbrella
sampling. We used the same set of η value as described in the Materials and Methods for both single-domain and
dimer simulations.To ensure the sampling was converged, we
constructed 1D-PMF profiles for different time windows including 75–400,
400–750, and 75–750 ns. Since these profiles are nearly
identical for the three windows tested (Figure S3), we conclude that the quantities we calculated represent
equilibrium values, and we report the results obtained for the widest
window of 75–750 ns for further analyses (Figure , upper panel).(Top) One-dimensional potential of mean force
(1D-PMF) of SARS-CoV
(black curve) and SARS-CoV-2 (red curve). Results were obtained by
applying the WHAM analysis method for 750 ns REX-US simulations. (Bottom) KD curves as a function of r* corresponding to the change in the total free monomer concentration
from eq . Pb and KD were determined at r* = 105 Å.As seen from 1D-PMF profiles (Figure ), a barrier separating the bound and unbound
regimes occurs at a CoM distance of rb ≈ 28 Å for both complexes, while the most stable bound
state is near the native-state CoM distance of ∼10 Å.
To determine KD, we calculated Pb at different r* values (eq ) and then used eq to calculate KD. Figure (lower panel) plots KD as a function
of the distance r*. As seen in this figure, KD increases with the increase in r* and tends to converge at large r* as expected
because physically KD should not depend
on r*. To calculate KD, we need to determine a cutoff value of r* above
which the interaction between CoV and ACE2 disappears. We can show
that for both complexes the cutoff is r* ≈
105 Å, and we use this value for estimating KD. Substituting r* = 105 Å into eq , we obtained Pb = 0.9956 and 0.9972 for the SARS-CoV and SARS-CoV-2
complexes, respectively (Figure , lower panel). Using eq , we obtained the free monomer concentrations [CoV]
= 3.0 μM and [CoV-2] = 1.9 μM. Finally, using eq and Figure , we obtained KD = 6.7 and 2.7 nM for the dissociation constants of SARS-CoV and
SARS-CoV-2 complexes, respectively, which implies that both viruses
tightly bind to humanACE2. This result is also consistent with the
SMD results in which SARS-CoV-2 binds to ACE2-PD better than SARS-CoV.Using the surface plasmon resonance technique for SARS-CoV-2, Wrapp
et al.[15] obtained KD = 14.7 nM, and while using biolayer interferometry, Walls
et al.[17] obtained KD = 1.2 ± 0.1 nM (Table ; note that error bars were not reported in Wrapp et
al.). The difference between them is probably related to experimental
techniques, and the result of the latter group is closer to our value
of 2.7 nM. More importantly, the relative binding affinities reported
by three groups are different. For SARS-CoV, Wrapp et al.[15] and Kirchdoerfer et al.[12] reported KD ≈ 150–300
nM, which is 10–20 times greater than that of SARS-CoV-2, implying
that the old virus is much more weakly associated with ACE2 than the
new virus.Walls et al.[17] advocated
that KD of SARS-CoV is roughly 4 times
larger than KD of SARS-CoV-2, while our
simulation yields
an approximately 2 times larger value (Table ). Therefore, contrary to Wrapp et al. the
experimental and theoretical results of these groups show that SARS-CoV-2
binds to the host cell slightly more strongly than does SARS-CoV.
We can estimate the binding free energy using the relation ΔGbind = −kBT ln(KD), where KD is measured in M. Since at room temperature kBT ≈ 0.592 kcal/mol,
differences in KD of 2- and 4-fold result
only in differences in ΔGbind of
about 0.4 and 0.8 kcal/mol, respectively, which once again confirms
that both in vitro(17) and in silico experiments provided a small difference in the
binding affinities of the two viruses.It should be noted that
the difference in binding free energies
of 1 to 2 kcal/mol is practically within the calculation error. Consequently,
the difference in ΔGbind of approximately
0.4 kcal/mol obtained with coarse-grained umbrella sampling is marginal.
However, the result shown in Figure correctly reflects the tendency that SARS-CoV-2 binds
more strongly with the host cell than does SARS-CoV.
Conclusions
Recent experiments have shown that both SARS-CoV and SARS-CoV-2
bind strongly to ACE2 with a KD of 1–100
nM, which allow them to invade host cells. Both the experiment of
Walls et al.[17] and our simulation show
that with a lower KD, SARS-CoV-2 binds
more strongly than SARS-CoV, but the difference is small in terms
of differential binding free energies. In contrast, a large difference
between the two S proteins was observed by Wrapp et al.,[12,15] which partially helps us to understand why the Wuhan virus spreads
faster. Moreover, due to high-binding-affinity human organs which
are rich in ACE2 in the oral and nasal mucosa, the lungs, skin, lymph
nodes, stomach, small intestine, colon, thymus, bone marrow, kidneys,
spleen, liver, and brain can be easily infected.[49] Because the binding of the virus to host cells is the first
important step in the infection process, preventing S protein from
interacting with ACE2 is one of the strategies to stop a viral outbreak.
Therefore, this protein is a primary target for developing potential
drugs to combat the pandemic.[50]The
result obtained for the rupture force and nonequilibrium work
using all-atom SMD simulations indicates that the RBD of the new virus
binds more tightly than the old one. Because this method can predict
only the relative binding affinity, KD cannot be determined and compared with the experiment. However,
the SMD approach has advantages over the experiment and coarse-grained
modeling and allows us to characterize the binding process in atomic
detail and demonstrate that the electrostatic interaction is more
important than the vdW interaction in stabilizing the studied heterodimers.Recent experiments[51] have shown that
many antibodies, such as CR3022, bind to SARS-CoV but not to SARS-CoV-2.
It would be interesting to study this phenomenon using molecular simulations
because a deep understanding of the underlying structural origin of
binding affinities is useful for the development of new monoclonal
antibodies (as candidate therapeutics) that can specifically bind
to SARS-CoV-2 RBD.
Authors: Mahmoud Al Ahmad; Lillian J A Olule; Mohammed Meetani; Farrukh Amin Sheikh; Rahima Al Blooshi; Neena G Panicker; Farah Mustafa; Tahir A Rizvi Journal: IEEE J Sel Top Signal Process Date: 2021-12-09 Impact factor: 7.695
Authors: Marwa Houssein; Aya El Asir Al Hossainy; Jana Al Soussi; Jana El Batch; Lana El-Samadi; Sherine El Imam; Rawan Fakih; Hoda Dakdouk; Mahmoud Khalil Journal: Health Sci Rev (Oxf) Date: 2022-07-10