Molecular picture of how antiviral drug molnupiravir works

A cryo-EM structure showing how the antiviral drug molnupiravir drug Read more

Straight to the heart: direct reprogramming creates cardiac “tissue” in mice

New avenues for a quest many cardiologists have pursued: repairing the damaged heart like patching a Read more

The future of your face is plastic

An industrial plastic stabilizer becomes a skin Read more

Molecular picture of how antiviral drug molnupiravir works

Scientists at the Max Planck Institute for Biophysical Chemistry in Germany have generated a structure showing how the antiviral drug molnupiravir drug works.

Molnupiravir was originally discovered by Emory’s non-profit drug development company DRIVE, and is now being developed by Merck. The drug, previously known as EIDD-2801, can be provided as a pill in an outpatient setting – potentially a step up in ease of distribution and convenience.

Molnupiravir is currently in clinical trials for non-hospitalized people with COVID-19 and at least one risk factor; results are expected later in the fall of 2021. Merck also recently began a prevention study for adults who live with a currently infected person. Previous small-scale studies conducted by Merck’s partner Ridgeback Biotherapeutics showed that the drug is safe and can reduce viral levels to undetectable in non-hospitalized people within five days.

The structure shows how the active form of molnupiravir interacts with the enzyme that makes new copies of the SARS-CoV-2 genome (RNA-dependent RNA polymerase). Incorporation of the active form of the drug into the RNA genome leads to mutations – so many that the virus can’t generate enough accurate copies of itself. Molnupiravir is likely to work in a similar way when deployed against other viruses such as influenza.

The cryo EM (cryo-electron microscopy) structure comes from Patrick Cramer’s group in Göttingen, along with chemists at the University of Würzburg, and was published in Nature Structural & Molecular Biology. Last year, Cramer’s group also generated a structure of the replicating viral RNA polymerase. The video below comes courtesy of the Max Planck Institute and Cramer’s lab.

The animation shows how the RNA-like building blocks of molnupiravir (M, yellow) form atypical pairings with adenine (A) and guanine (G) in the viral RNA. This leads to mutations in the viral RNA, interfering with efficient replication of SARS-CoV-2.
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Straight to the heart: direct reprogramming creates cardiac “tissue” in mice

Bypassing stem cells, Emory scientists can now create engineered heart tissue by directly reprogramming connective tissue cells in mice. The findings could provide new avenues for a quest many cardiologists have pursued: repairing the damaged heart like patching a roof. 

The results were published in Nature Biomedical Engineering

“This is the first study demonstrating direct tissue reprogramming from single adult cells from the body,” says senior author Young-sup Yoon, MD, PhD, professor of medicine at Emory University School of Medicine.

The research could potentially provide therapeutic options for millions of people with heart failure or other conditions. If heart muscle is damaged by a heart attack, the damaged or dead cells do not regenerate. Other scientists have shown they can create human heart tissue from induced pluripotent stem cells (example), but the Emory team showed that it is possible to avoid stem cells and the technologies required to create them, such as viruses. 

“Direct reprogramming into tissues that contain multiple cell types has not previously been reported, and it could open new pathways in the regenerative medicine field,” Yoon says. “It could serve as a platform for cell-based therapy by avoiding the problems of current stem cell-based approaches, and for disease modeling and drug development.”

First author Jaeyeaon Cho, PhD – currently at Yonsei University

Yoon is also part of the Wallace H. Coulter Department of Biomedical Engineering at Georgia Tech and Emory. First author Jaeyeaon Cho, PhD was a post-doctoral fellow at Emory and is currently a research assistant professor at Yonsei University College of Medicine in South Korea. Emory faculty members Rebecca Levit, MD and Hee Cheol Cho, PhD are co-authors on the paper.

Applying a combination of growth factors, regulatory microRNA and vitamins, the Emory researchers could create tissue that contains cardiac muscle, along with blood vessels containing endothelial cells and smooth muscle cells, and fibroblasts. In culture, the four cell types weave themselves together, bypassing any need to build heart tissue from separate components.

When transplanted onto the damaged heart of a mouse after a simulated heart attack, cells from the engineered tissue can migrate into the host heart, and improve its functioning. 

“In some previous studies, when a tissue patch composed of engineered cells and supportive biomaterials was transplanted to the damaged heart, there was little or no migration of cells from the patch to the host heart,” Yoon says.

From Cho et al. Nature Biomed Eng (2021). Migration of rCVT (reprogrammed cardiovascular tissue) into the host heart, 2 weeks after implantation. The white lines outline the heart muscle wall; only the implanted tissue fluoresces green, because of green fluorescent protein.

The critical elements of the direct reprogramming approach are microRNAs, which are “master keys” that control several genes at once. The researchers discovered the potential of one microRNA fortuitously; a pilot study examined the effect of applying several microRNAs active in the heart to fibroblasts. Unexpectedly, one of them generated endothelial cell and smooth muscle along with cardiac muscle cells.

The Emory researchers say that their engineered tissue does not exactly mimic natural heart tissue. The cardiac muscle cells do spontaneously contract, but they display immature characteristics. But after transplantation, the engrafted cells mature and integrate into the host heart. Over 16 weeks, the engrafted cells become indistinguishable from the host cardiac muscle cells. The researchers checked whether their transplanted tissue induced cardiac arrhythmias in the mice – a danger when introducing immature cells into the damaged heart — and they did not.

Yoon says it took almost 9 years to complete the project; an important next step is to test direct reprogramming with human cells.

This work was supported by grants from the National Heart Lung and Blood Institute (R01HL150877, R61HL 154116, R01HL125391) and a American Heart Association Transformative Project Award.

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The future of your face is plastic

Prolific drug discoverer and repurposer Jack Arbiser is at it again. Arbiser, an Emory dermatologist, has identified a new (but old) compound as a treatment for rosacea, a common skin condition involving redness and visible blood vessels on the face. Severe rosacea can lead to itching, pain, or thickening of the skin.

The compound is remarkable for two reasons: it is the same as Irganox 1010, an antioxidant plastic stabilizer used in industry for years, and it is a proteasome inhibitor.

The proteasome is the cell’s garbage disposal, and many kinds of proteins get tagged and thrown into it. Interfering with the disposal inhibits the inflammatory NFkB pathway. Oncologists may be familiar with the proteasome inhibitor bortezomib (a blockbuster drug known commercially as Velcade), used to treat multiple myeloma.

Arbiser has founded a company called Accuitis to develop the compound, called ACU-D1. Accuitis was funded by the Georgia Research Alliance. Accuitis’ web site notes that the compound “has the advantage of extensive toxicology testing in multiple animal species, as well as a safe record of human exposure for over 30 years.”

“ACU-D1 is a cream that works through a new mechanism of action that no current rosacea medications work through,” Arbiser told Dermatology Times. “Given the fact that there are no truly great treatments for rosacea, we are hoping that in the future our compound will be a first-in-class drug and become first-line therapy for rosacea.”

The results of a clinical trial for ACU-D1, conducted at the University of Louisville in Kentucky and Forefront Dermatology in San Antonio, were recently published in Journal of Drug in Dermatology.

This was a first-in-human study with 40 participants, lasting 12 weeks. It was not powered for a pivotal evaluation of ACU-D1’s efficacy. However, the drug showed a pronounced effect on people with severe rosacea. The trial used a Canfield imaging system imaging as a way of measuring skin irritation objectively, separately from the opinions of the investigators.

Canfield imaging of the face. From left to right: baseline, week 4, week 12

The drug appears to take effect after a couple weeks, showing maximum efficacy at one month. It also shows positive effects on redness, which is rare for a skin medication, Arbiser says. Few adverse effects were reported.

Arbiser says ACU-D1 could be an alternative to antibiotics, a common systemic treatment for rosacea. (Rosacea is partly an inflammatory response to microbes in the skin.) He is interested in studying ACU-D1’s efficacy for other inflammatory skin conditions such as eczema and psoriasis.

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Social isolation and the adolescent brain

We can’t read Emory neuroscientist Shannon Gourley’s papers on social isolation in adolescent mice, without thinking about how the COVID-19 pandemic is affecting children and teenagers. Much of the experimental work was completed before the pandemic began. Still, in the future, researchers will be studying the effects of the pandemic on children, in terms of depression and anxiety, or effects on relationships and education. They could look to neuroscience studies such as Gourley’s for insights into brain mechanisms.

What will the social isolation of the pandemic mean for developing brains?

In the brain, social isolation interferes with the pruning of dendritic spines, the structures that underly connections between neurons. One might think that more dendritic spines are good, but the brain is like a sculpture taking shape – the spines represent processes that are refined as humans and animals mature.

Mice with a history of social isolation have higher spine densities in regions of the brain relevant to decision-making, such as the prefrontal cortex, the Emory researchers found.

In a recently published review, Gourley and her co-authors, former graduate student Elizabeth Hinton and current MD/PhD Dan Li, say that more research is needed on whether non-social enrichment, such as frequent introduction of new toys, can compensate for or attenuate the effects of social isolation.

This research is part of an effort to view adolescent mental health problems, such as depression, obesity or substance abuse, through the prism of decision-making. The experiments distinguish between goal-oriented behaviors and habits. For humans, this might suggest choices about work/school, food, or maybe personal hygiene. But in a mouse context, this consists of having them poke their noses in places that will get them tasty food pellets, while they decode the information they have been given about what to expect. 

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COVID-triggered autoimmunity may be mostly temporary

In people with severe COVID-19, the immune system goes temporarily berserk and generates a wide variety of autoantibodies: proteins that are tools for defense, but turned against the body’s own tissues.

During acute infection, COVID-19 patients’ immune systems resemble those of people with diseases such as lupus or rheumatoid arthritis. However, after the storm passes, the autoantibodies decay and are mostly removed from the body over time, according to a study of a small number of patients who were hospitalized and then recovered. 

In a preprint posted on medRxiv, Emory immunologists provide a view of the spectrum of what COVID-generated autoantibodies react against, both during acute infection and later. Note: the results have not yet been published in a peer-reviewed journal.

The findings on COVID-19-triggered autoimmunity may have implications for both the treatment of acute infection and for long-haulers, in whom autoantibodies are suspected of contributing to persistent symptoms such as fatigue, skin rashes and joint pain.

During acute infection, testing for autoantibodies may enable identification of some patients who need early intervention to head off problems later. In addition, attenuation of autoantibody activity by giving intravenous immunoglobulin (IVIG) – an approach that has been tested on a small scale — may help resolve persistent symptoms, the Emory investigators suggest.

Researchers led by Ignacio Sanz, MD and Frances Eun-Hyung Lee, MD, isolated thousands of antibody-secreting cells from 7 COVID-19 patients who were in ICUs at Emory hospitals. They also looked for markers of autoimmunity in a larger group of 52 COVID-19 ICU patients.

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Detecting vulnerable plaque with a laser-induced whisper

A relatively new imaging technique called photoacoustic imaging or PAI detects sounds produced when laser light interacts with human tissues. Working with colleagues at Michigan State, Emory immunologist Eliver Ghosn’s lab is taking the technique to the next step to visualize immune cells within atherosclerotic plaques.

The goal is to more accurately spot vulnerable plaque, or the problem areas lurking within arteries that lead to clots, and in turn heart attacks and strokes. A description of the technology was recently published in Advanced Functional Materials

“I believe we are now closer to developing a more precise method to diagnose and treat life-threatening atherosclerotic plaques,” Ghosn says. “Our method could be deployed in combination with IVUS to significantly improve its accuracy and sensitivity, or it could be used non-invasively.”

From science fiction movies, we might think lasers come with a “pow” sound. Photoacoustic imaging is more like listening for a whisper: sounds associated with heat generated by a laser pulse when it is absorbed by tissue.

Earlier this year, the FDA approved a photoacoustic imaging system for detection of breast cancer. Several companies are developing photoacoustic imaging systems, and what we might call “plain vanilla” PAI is currently being tested on carotid artery plaque in clinical studies in Europe.

Ghosn’s approach, developed with biomedical engineer Bryan Smith at Michigan State, adds specificity by adding nanoparticle probes taken up by macrophages, the immune cells that accumulate within atherosclerotic plaques. The nanoparticles, administered before imaging, act as contrast agents.

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Multiple myeloma patients display weakened antibody responses to mRNA COVID vaccines

A new study reports weakened antibody responses to COVID-19 mRNA vaccines among most patients with multiple myeloma, a form of bone-marrow cancer associated with an immunocompromised state.

The research, published in the journal Leukemia, was carried out at the Institute for Myeloma and Bone Cancer Research (IMBCR) in California, in collaboration with Emory infectious diseases fellow Samuel Stampfer, MD, PhD.

Patients with smoldering myeloma, not requiring treatment, all achieved a good response to COVID-19 vaccination, whereas less than half of patients with active myeloma requiring treatment did. Specifically, only 45 percent of active patients fully responded to the mRNA vaccines, whereas less than a quarter showed a partial response and one-third did not respond to the vaccines above background antibody levels.

Serum samples from 103 multiple myeloma patients were obtained prior to vaccination and 2-3 weeks after administration of the first and second vaccines, and compared to a group of age‑matched healthy controls. Predictors of reduced antibody responses to the vaccines included: older age, impaired renal function, low lymphocyte counts, reduced uninvolved antibody levels, past first line of treatment, and those not in complete remission. Nearly two-thirds of patients who received the Moderna vaccine responded to a level thought to be clinically significant, whereas only approximately a quarter who received the Pfizer vaccine did.

“Based on these data, myeloma patients may need to continue social distancing following COVID-19 vaccination, and postvaccine antibody tests may help guide decisions regarding supplementary vaccination or antibody prophylaxis for this vulnerable population,” says Stampfer, who co-designed the clinical study, under the guidance of senior author James Berenson, MD, the Scientific and Medical Director of IMBCR.

“This study highlights the importance of recognizing the limitations of current vaccination approaches to COVID-19 for immunocompromised patients, and that new approaches will have to be developed to improve their protection from this dangerous infection,” Berenson says. “It also suggests that there may be clinically significant differences in the effectiveness of different COVID-19 vaccines for immune compromised patients. Until these advances occur, it means that myeloma patients will need to remain very careful even if they have been vaccinated through wearing their masks and avoiding contact with unvaccinated individuals.”.

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Precision medicine with multiple myeloma

“Precision medicine” is an anti-cancer treatment strategy in which doctors use genetic or other tests to identify vulnerabilities in an individual’s cancer subtype.

Winship Cancer Institute researchers have been figuring out how to apply this strategy to multiple myeloma, with respect to one promising drug called venetoclax, in a way that can benefit the most patients.

Known commercially as Venclexta, venetoclax is already FDA-approved for some forms of leukemia and lymphoma. Researchers had observed that multiple myeloma cells with one type of chromosomal DNA rearrangement tend to be sensitive to venetoclax. About 20 percent of multiple myelomas carry this rearrangement, called t(11;14).

“One of our main goals is to identify a better biomarker to predict patient response to venetoclax,” says Winship researcher Vikas Gupta, lead author of a paper published in Blood earlier this year.

Vikas Gupta, MD, PhD

Gupta works together with Winship hematologist Jonathan Kaufman and researcher Larry Boise, also associate director for education and training, to translate insights about myeloma cells into advances for patient care.

In a recent clinical trial led by Kaufman, a sizable fraction of people whose myelomas carried the t(11;14) rearrangement responded well to venetoclax, when their cancers were already refractory to other drugs. Another study that did not separate out myelomas with t(11;14) extended progression-free survival by almost a year.

However, venetoclax also was associated with increased mortality from infections, which led the FDA in 2019 to put the second study on hold temporarily. Other ongoing studies of venetoclax with multiple myeloma were affected.  It highlights the need to predict which patients would benefit from venetoclax – and which would not be likely to, for whom the drug may pose more risk.

In their paper, Winship investigators discovered that a set of cell markers predicted sensitivity to venetoclax better than t(11;14). These were markers for B cells, a type of white blood cell related to both multiple myeloma and some of the other forms of leukemia and lymphoma venetoclax is used to treat.

Gupta says that it was already possible to obtain myeloma cells from patients and test whether they are sensitive to venetoclax directly in the laboratory. But this isn’t practical for most clinics in cancer centers elsewhere.

“In contrast, the B cell phenotype can easily be assessed by flow cytometry, a technique that is routinely performed in clinical labs,” Gupta says. “So we are attempting to refine and validate our panel of flow cytometry markers, so that it can be used to easily and accurately predict which patients are sensitive to venetoclax.”

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Promiscuous protein droplets regulate immune gene activity

Biochemists at Emory are achieving insights into how an important regulator of the immune system switches its function, based on its orientation and local environment. New research demonstrates that the glucocorticoid receptor (or GR) forms droplets or “condensates” that change form, depending on its available partners.

The inside of a cell is like a crowded nightclub or party, with enzymes and other proteins searching out prospective partners. The GR is particularly well-connected and promiscuous, and has the potential to interact with many other proteins. It is a type of protein known as a transcription factor, which turns some genes on and others off, depending on how it is binding DNA.

These are fluorescent droplets of the glucocorticoid receptor (GR) in red, with a coregulator protein in green. When DNA is added, the co-regulator forms its own droplets on the surface of GR droplets. Image courtesy of Filipp Frank

“It is now thought that most transcription factors form or are recruited into condensates, and that condensation modulates their function,” says Filipp Frank, PhD, first author of the paper and a postdoctoral instructor in Eric Ortlund’s lab in the Department of Biochemistry. “What’s new is that we identified a DNA-dependent change in GR condensates, which has not been described for other transcription factors.”

The results are published in Proceedings of the National Academy of Sciences. Ortlund is a co-author of the paper, along with postdoctoral fellow Xu Liu, PhD.

Understanding how the GR works could help researchers find anti-inflammatory drugs with reduced side effects. The GR is the target for corticosteroid drugs such as dexamethasone, which is currently used to treat COVID-19 as well as allergies, asthma and autoimmune diseases.

Corticosteroids’ harmful side effects are thought to come from turning on genes involved in metabolism and bone growth, while their desired anti-inflammatory effects result from turning other inflammatory and immune system genes off. Researchers want to find alternatives that could separate those two functions.

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Neutrophils flood lungs in severe COVID-19

“First responder” cells called neutrophils are the dominant type of immune cells flooding the airways of people with severe COVID-19, according to a recent analysis of African-American patients in Emory hospitals.

The findings were posted on the preprint server Biorxiv prior to peer review.

Neutrophils are the most abundant immune cells in the blood, and usually the first to arrive at the site of a bacterial or viral infection. But in the lungs of severe COVID-19 patients, neutrophils camp out and release tissue-damaging enzymes, the new research shows. They also produce inflammatory messengers that induce more neutrophils to come to the lungs. 

Lung inflammation photo from NIEHS. Most of these dense small cells are neutrophils

This circulating cell type enters the lung and initiates a self-sustaining hyper-inflammation that leads to acute respiratory distress syndrome (ARDS), the leading cause of mortality in COVID-19, says lead author Eliver Ghosn assistant professor of medicine at Emory University School of Medicine.

“Our findings reveal novel therapeutic targets, and developing tactics to intervene could benefit severe patients in the ICU, particularly those that are most vulnerable,” Ghosn says. “We compared our lung data with matching blood samples for all the patients, and we were able to identify the subtype of neutrophils in the blood that is most likely to infiltrate the lungs of severe patients and cause ARDS.”

Somewhat counter-intuitively, Emory researchers had difficulty detecting SARS-CoV-2 infected cells in the upper airways of hospitalized patients. This result, consistent with findings by others, may explain why antiviral drugs such as remdesivir are ineffective once systemic inflammation has gained momentum; lung injury comes more from the influx of immune cells, such as neutrophils, rather than viral infection itself.

When Ghosn and his colleagues began examining immune cells in COVID-19, they found that almost all of the hospitalized patients they encountered were African-American. This highlights the racial disparities of the COVID-19 pandemic, especially in Georgia, and Ghosn’s team decided to “lean in” and focus on African-Americans. They collaborated closely with Eun-Hyung Lee’s lab at Emory to collect samples from hospitalized patients. 

“We believe these results can have broader implications and be applied to other demographics that suffer from similar lung pathology,” Ghosn says.

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