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Emerging treatment options for hemophilia, including gene therapy, modified factor products, antibody-based products, and other nonreplacement therapies, are in development or on their way to marketing authorization. For proof of efficacy, annual bleeding rates (ABRs) have become an increasingly important endpoint in hemophilia trials. We hypothesized that ABR analyses differ substantially between and within medicinal product classes and that the ABR observation period constitutes a major bias. For ABR characterization, an internal factor VIII (FVIII) treatment database has been built based on confidential clinical trial data submitted to the Paul-Ehrlich-Institut (PEI). Furthermore, anonymized data from 46 trial protocols submitted for review to the PEI were analyzed (FVIII replacement, n = 27; antibody-based, n = 12; and gene therapy, n = 7) for methodology. Definitions of bleeding episodes and ABR observational periods differed substantially in clinical trials. In the initial observation phase, individual ABRs of patients, treated prophylactically for 1 year, vary by about 40% (P < 0.001), which finally led to a significant reduction of the ABR group mean by 20% (P < 0.05). Furthermore, the high variance in ABRs constitutes a major challenge in statistical analyses. In conclusion, considerable heterogeneity and bias in the ABR estimation in clinical trials was identified, which makes it substantially more difficult to compare the efficacy of different treatment regimens and products. Thus, awareness of the important pitfalls when using ABR as a clinical outcome is needed in the evaluation of hemophilia therapies for patients, physicians, regulators, and health technology assessment agencies.

Due to the outbreak of the coronavirus disease 2019 (COVID-19) pandemic, clinical trial (CT) research for efficacy and safety evaluation of convalescent plasma (CP) accelerated globally. In trial planning and approval, clinical researcher and regulatory agencies worldwide are challenged by limited evidence from the use of convalescent plasma in previous outbreaks of viral diseases and by different possible study approaches. We analyzed CT designs to identify potential opportunities for data aggregation and to facilitate generation of decision-relevant evidence.

There is a broad range of factor products approved in Germany for haemophilia A treatment. Since the introduction of recombinant coagulation factor VIII (FVIII) products in the 1990s, there has been substantial debate whether there is a difference in inhibitor incidence between single FVIII products or product classes. Neither haemophilia registries nor clinical studies, including a randomised controlled clinical trial, provided a consistent and definite answer. The reasons were mainly related to methodological challenges in conducting controlled studies in a rare disease. In this analysis, the most relevant epidemiological challenges and main problems were examined, including study bias, potential overlap of individual studies and advanced development of therapy and methods in the course of time. Meta-analyses on two levels showed that therapies using recombinant products resulted in different event rates when compared to plasma-derived products. These results are accompanied by substantial study heterogeneity evidenced by Cochran’s Q tests. Only three studies have been identified that meet the standards of current clinical guidance. To finally resolve this ongoing and disputable safety issue of replacement therapy, collaboration among registry owners, academia and regulators must be fostered.

Aims The benefit of the β1-adrenergic receptor (β1-AR) agonist dobutamine for treatment of acute heart failure in peripartum cardiomyopathy (PPCM) is controversial. Cardiac STAT3 expression is reduced in PPCM patients. Mice carrying a cardiomyocyte-restricted deletion of STAT3 (CKO) develop PPCM. We hypothesized that STAT3-dependent signalling networks may influence the response to β-AR agonist treatment in PPCM patients and analysed this hypothesis in CKO mice. Methods and results Follow-up analyses in 27 patients with severe PPCM (left ventricular ejection fraction ≤25%) revealed that 19 of 20 patients not obtaining dobutamine improved cardiac function. All seven patients obtaining dobutamine received heart transplantation (n = 4) or left ventricular assist devices (n = 3). They displayed diminished myocardial triglyceride, pyruvate, and lactate content compared with non-failing controls. The β-AR agonist isoproterenol (Iso) induced heart failure with high mortality in postpartum female, in non-pregnant female and in male CKO, but not in wild-type mice. Iso induced heart failure and high mortality in CKO mice by impairing fatty acid and glucose uptake, thereby generating a metabolic deficit. The latter was governed by disturbed STAT3-dependent signalling networks, microRNA-199a-5p, microRNA-7a-5p, insulin/glucose transporter-4, and neuregulin/ErbB signalling. The resulting cardiac energy depletion and oxidative stress promoted dysfunction and cardiomyocyte loss inducing irreversible heart failure, which could be attenuated by the β1-AR blocker metoprolol or glucose-uptake-promoting drugs perhexiline and etomoxir. Conclusions Iso impairs glucose uptake, induces energy depletion, oxidative stress, dysfunction, and death in STAT3-deficient cardiomyocytes mainly via β1-AR stimulation. These cellular alterations may underlie the dobutamine-induced irreversible heart failure progression in PPCM patients who frequently display reduced cardiac STAT3 expression.

Toxin A (TcdA) and B (TcdB) from Clostridium difficile enter host cells by receptor-mediated endocytosis. A prerequisite for proper toxin action is the intracellular release of the glucosyltransferase domain by an inherent cysteine protease, which is allosterically activated by inositol hexaphosphate (IP6). We found that in in vitro assays, the C-terminally-truncated TcdA1–1065 was more efficient at IP6-induced cleavage compared with full-length TcdA. We hypothesized that the C-terminally-located combined repetitive oligopeptides (CROPs) interact with the N-terminal part of the toxin, thereby preventing autoproteolysis. Glutathione-S-transferase (GST) pull-down assays and microscale thermophoresis confirmed binding between the CROPs and the glucosyltransferase (TcdA1–542) or intermediate (TcdA1102–1847) domain of TcdA, respectively. This interaction between the N- and C-terminus was not found for TcdB. Functional assays revealed that TcdB was more susceptible to inactivation by extracellular IP6-induced cleavage. In vitro autoprocessing and inactivation of TcdA, however, significantly increased, either by acidification of the surrounding milieu or following exchange of its CROP domain by the homologous CROP domain of TcdB. Thus, TcdA CROPs contribute to the stabilization and protection of toxin conformation in addition to function as the main receptor binding domain.

In order to determine the microRNA expression pattern in normal basal and luminal breast epithelium and to analyze the relationship of this expression pattern to different breast cancer subtypes, laser-microdissected luminal and basal cells isolated from plastic surgery tissue samples were used for comprehensive expression profiling, measuring 664 microRNAs by low-density TaqMan arrays. In a test (n = 5) and validation set (n = 9) 10 differentially expressed microRNAs were identified by TaqMan RT-qPCR. These microRNAs were studied in laser-microdissected cells of luminal A (n = 5), luminal B (n = 5), basal-like subtypes of breast cancer (n = 10), and malignant myoepithelioma of the breast (n = 10). From 116 microRNAs unequivocally expressed in normal breast epithelial cells, we identified 8 basal microRNAs (let7c, miR-125b, miR-126, miR-127-3p, miR-143, miR-145, miR-146b-5p, and miR-199a-3p), preferentially expressed in normal basal cells, exceeding luminal cells by a factor from 4 to 1000. All of these microRNAs were also found to be significantly elevated in malignant myoepithelioma but not in basal-type of breast cancer. Two members of the miR-200 family (miR-200c and miR-429) were predominantly luminal. Both microRNAs were expressed in the luminal and basal type of breast cancer in contrast to malignant myoepithelioma, which revealed significantly lower levels potentially contributing to its mesenchymal phenotype. In conclusion, normal luminal and basal mammary epithelial cells exhibit a different microRNA expression profile. Malignant myoepithelioma seems to exhibit a basal pattern of microRNA expression, whereas the so-called basal-like breast cancer is clearly different and reveals a luminal type pattern.

Despite their near sequence identity, actin isoforms cannot completely replace each other in vivo and show marked differences in their tissue-specific and subcellular localization. Little is known about isoform-specific differences in their interactions with myosin motors and other actin-binding proteins. Mammalian cytoplasmic β- and γ-actin interact with nonsarcomeric conventional myosins such as the members of the nonmuscle myosin-2 family and myosin-7A. These interactions support a wide range of cellular processes including cytokinesis, maintenance of cell polarity, cell adhesion, migration, and mechano-electrical transduction. To elucidate differences in the ability of isoactins to bind and stimulate the enzymatic activity of individual myosin isoforms, we characterized the interactions of human skeletal muscle α-actin, cytoplasmic β-actin, and cytoplasmic γ-actin with human myosin-7A and nonmuscle myosins-2A, -2B and -2C1. In the case of nonmuscle myosins-2A and -2B, the interaction with either cytoplasmic actin isoform results in 4-fold greater stimulation of myosin ATPase activity than was observed in the presence of α-skeletal muscle actin. Nonmuscle myosin-2C1 is most potently activated by β-actin and myosin-7A by γ-actin. Our results indicate that β- and γ-actin isoforms contribute to the modulation of nonmuscle myosin-2 and myosin-7A activity and thereby to the spatial and temporal regulation of cytoskeletal dynamics. FRET-based analyses show efficient copolymerization abilities for the actin isoforms in vitro. Experiments with hybrid actin filaments show that the extent of actomyosin coupling efficiency can be regulated by the isoform composition of actin filaments.

Mutations in sarcomeric actins have been linked to various skeletal and cardiac myopathies. In contrast, only a small number of mutations in the cytoplasmic isoforms β-actin and γ-actin have been identified and linked to disease processes. Here, we describe the characterization of disease-related human β-actin mutants R183W and E364K. Mutation R183W is associated with developmental malformations, deafness and dystonia. The residue is located in subdomain 4 in the nucleotide binding cleft and participates in forming a gate-like structure for the nucleotide. Mutation E364K was found in a patient with neutrophil dysfunction. E364 is a surface residue in subdomain 1. We produced both mutants in Sf9 cells and characterized their properties in vitro. The midpoints of the thermal transition Tm, which correspond to the temperatures at which half of all protein molecules are in the native state and the remaining half is in the denatured state, are unaffected by the mutations suggesting proper folding and normal protein stability. Both mutants display increased affinity for DNase-I indicating conformational changes in subdomain 2 that appear to alter the binding interface between monomers. Activated neutrophils are highly motile phagocytic cells and they are thus highly sensitive to changes that affect actin polymerization and F-actin stability. We observed reduced rates of nucleotide exchange and elongation velocities during polymerization for R183W and E364K β-actin. Mutation R183W accelerates ATP hydrolysis by F-actin. R183W β-actin shows impaired ability to activate non-muscle myosin 2A ATPase.