Revisiting the Training of Logic Models of Protein Signaling Networks with a Formal Approach based on Answer Set Programming

A fundamental question in systems biology is the construction and training to data of mathematical models. Logic formalisms have become very popular to model signaling networks because their simplicity allows us to model large systems encompassing hundreds of proteins. An approach to train (Boolean) logic models to high-throughput phospho-proteomics data was recently introduced and solved using optimization heuristics based on stochastic methods. Here we demonstrate how this problem can be solved using Answer Set Programming (ASP), a declarative problem solving paradigm, in which a problem is encoded as a logical program such that its answer sets represent solutions to the problem. ASP has significant improvements over heuristic methods in terms of efficiency and scalability, it guarantees global optimality of solutions as well as provides a complete set of solutions. We illustrate the application of ASP with in silico cases based on realistic networks and data

Using answer set programming to integrate RNA expression with signalling pathway information to infer how mutations affect ageing.

A challenge of systems biology is to integrate incomplete knowledge on pathways with existing experimental data sets and relate these to measured phenotypes. Research on ageing often generates such incomplete data, creating difficulties in integrating RNA expression with information about biological processes and the phenotypes of ageing, including longevity. Here, we develop a logic-based method that employs Answer Set Programming, and use it to infer signalling effects of genetic perturbations, based on a model of the insulin signalling pathway. We apply our method to RNA expression data from Drosophila mutants in the insulin pathway that alter lifespan, in a foxo dependent fashion. We use this information to deduce how the pathway influences lifespan in the mutant animals. We also develop a method for inferring the largest common sub-paths within each of our signalling predictions. Our comparisons reveal consistent homeostatic mechanisms across both long- and short-lived mutants. The transcriptional changes observed in each mutation usually provide negative feedback to signalling predicted for that mutation. We also identify an S6K-mediated feedback in two long-lived mutants that suggests a crosstalk between these pathways in mutants of the insulin pathway, in vivo. By formulating the problem as a logic-based theory in a qualitative fashion, we are able to use the efficient search facilities of Answer Set Programming, allowing us to explore larger pathways, combine molecular changes with pathways and phenotype and infer effects on signalling in in vivo, whole-organism, mutants, where direct signalling stimulation assays are difficult to perform. Our methods are available in the web-service NetEffects: http://www.ebi.ac.uk/thornton-srv/software/NetEffects

A Method to Identify and Analyze Biological Programs through Automated Reasoning.

Predictive biology is elusive because rigorous, data-constrained, mechanistic models of complex biological systems are difficult to derive and validate. Current approaches tend to construct and examine static interaction network models, which are descriptively rich but often lack explanatory and predictive power, or dynamic models that can be simulated to reproduce known behavior. However, in such approaches implicit assumptions are introduced as typically only one mechanism is considered, and exhaustively investigating all scenarios is impractical using simulation. To address these limitations, we present a methodology based on automated formal reasoning, which permits the synthesis and analysis of the complete set of logical models consistent with experimental observations. We test hypotheses against all candidate models, and remove the need for simulation by characterizing and simultaneously analyzing all mechanistic explanations of observed behavior. Our methodology transforms knowledge of complex biological processes from sets of possible interactions and experimental observations to precise, predictive biological programs governing cell function

A Method to Identify and Analyze Biological Programs through Automated Reasoning.

Predictive biology is elusive because rigorous, data-constrained, mechanistic models of complex biological systems are difficult to derive and validate. Current approaches tend to construct and examine static interaction network models, which are descriptively rich but often lack explanatory and predictive power, or dynamic models that can be simulated to reproduce known behavior. However, in such approaches implicit assumptions are introduced as typically only one mechanism is considered, and exhaustively investigating all scenarios is impractical using simulation. To address these limitations, we present a methodology based on automated formal reasoning, which permits the synthesis and analysis of the complete set of logical models consistent with experimental observations. We test hypotheses against all candidate models, and remove the need for simulation by characterizing and simultaneously analyzing all mechanistic explanations of observed behavior. Our methodology transforms knowledge of complex biological processes from sets of possible interactions and experimental observations to precise, predictive biological programs governing cell function.G.M. holds a career development award from the Armenise Harvard foundation, and a Telethon-DTI career award. A.G.S. is a Medical Research Council Professor

Revision of Boolean Logical Models of Biological Regulatory Networks using Answer-Set Programming

Biological regulatory networks are one of the most prominent tools used to represent complex, regulatory cellular processes. Creating computational models of these networks is key to better comprehend the corresponding cellular processes, as they allow for the reproduction of known behaviors, the testing of hypotheses, and the identification of predictions in silico. However, given that the process of constructing and revising such models is mainly a manual one, it is prone to error, and would therefore benefit from automation. An attempt at solving this problem has already been made using a mixture of Answer Set Programming (ASP) and C++. The previous attempt automated the process of revising these models, by using ASP to verify whether a Boolean logical model of a biological regulatory network was consistent with a given set of experimental observations and, in case of inconsistencies, used C++ to implement an algorithm capable of searching for possible sets of repair operations to render the model consistent. In our work we propose an alternative solution for this problem, a solution that fully leverages ASP which, being a declarative language tailored for this type of difficult search problems, has demonstrated to be a great tool to use both for consistency checking as well as model repair. This is in view of the fact that ASP offers a more intuitive and elaboration-tolerant programming style, which facilitates the processes of understanding, and modifying the code behind the model revision process. This, coupled with the powerful and exhaustively optimized solving capabilities provided by the state of the art ASP system clingo, has shown that there is great potential in adopting a fully ASP-based approach to aid in the automation of the revision of Boolean logical models. In this thesis we present the tool that we have developed to automate the process of revising Boolean logical models of Biological Regulatory Network(s) (BRN), which uses ASP to search for inconsistencies and perform repairs on these models.As redes reguladoras biológicas são das ferramentas mais proeminentes usadas para representar processos celulares regulatórios complexos. A criação de modelos computacionais destas redes é fundamental para entender melhor os processos celulares correspondentes, pois permitem reproduzir comportamentos conhecidos, testar hipóteses e identificar previsões in silico. Porém, dado que o processo de construção e revisão destes modelos é principalmente manual, torna-se propenso a erros e, logo, beneficiaria de automação. Já foi feita uma tentativa de resolução deste problema usando uma mistura de Programação por Conjuntos de Resposta (ASP) com C++. A tentativa anterior automatizou o processo de revisão destes modelos, usando ASP para verificar se um modelo lógico booleano de uma rede regulatória é consistente com um determinado conjunto de observações experimentais e, caso inconsistências se verifiquem, é utilizado um algoritmo desenvolvido em C++ capaz de encontrar possíveis conjuntos de operações de reparo para tornar o modelo consistente. No nosso trabalho, propomos uma solução alternativa para este problema, que tira completo partido da utilização ASP que, sendo uma linguagem declarativa adaptada a este tipo de problemas de busca difíceis, demonstrou ser uma excelente ferramenta a utilizar tanto para a verificação da consistência como para a reparação de modelos. Tal deve-se ao facto de ASP oferecer um estilo de programação mais intuitivo e tolerante à elaboração, o que facilita os processos de compreensão, e a modificação do código por detrás do processo de revisão de modelos. Isto, juntamente com as poderosas e otimizadas capacidades de resolução de problemas de busca oferecidas pelo sistema ASP de última geração clingo, demonstrou que existe um grande potencial na adopção de um sistema totalmente baseado em ASP para ajudar na automatização da revisão destes modelos. Nesta tese apresentamos a ferramenta que desenvolvemos para automatizar o processo de revisão de modelos lógicos booleanos de redes reguladoras biológicas (BRN), que utiliza ASP para procurar inconsistências e efectuar reparações nestes modelos

Modelling timing in blood cancers

Dysregulation of biological processes in normal cells can lead to the abnormal growth of tumours. Oncogenesis requires the acquisition of advantageous mutations to expand in a fluctuating environment. Cancer cells gain these genetic and epigenetic alterations at different timing in their development, resulting in the formation of heterogeneous cell populations which interact and compete with each others inside tumours. At later stages, by escaping the immune system and acquiring malignant properties, some cancer cells manage to evade the primary tumour and spread in different organs to form metastases. Hence, tumour development in healthy tissues endure several biological changes whilst progressing and the order between these molecular and cellular events may modify prognosis. This thesis addresses the influence of biological event timing on blood cancer progression and clinical outcomes. It first investigates the therapeutic efficacy of p53 restoration in a lymphoma mouse model. While several therapy schedules are tested, all fail due to resistance emergence. Computational modelling establishes the cell dynamics in these tumours and how to use it to propose alternative treatment strategies. Data availability leads this work to explore the impact of molecular evolution in myeloid malignancies. Notably, one study has found that Myeloproliferative Neoplasms patients with both JAK2 and TET2 mutations have different disease characteristics with distinct mutation order. My analyses identify HOXA9 as a potential prognosis marker and biological switch responsible for patient stratification in these patients and in Acute Myeloid Leukemia. Additionally, a molecular network identifies the hematopoietic regulators involved in the branching evolution of Myeloproliferative Neoplasms. Further investigations of the Acute Myeloid Leukemia data show the possible involvement of APP, a gene associated to Alzheimer disease, in early cell fate commitment in hematopoiesis and in poor survival prognosis in undifferentiated leukemia when lowly expressed. Finally, this thesis examines the regulatory dynamics behind three clusters of Acute Myeloid Leukemia patients with distinct levels of HOXA9 and APP expression. By building a program inferring molecular motifs from biological observations, genes which may interact with HOXA9 and APP are identified.Microsoft Research and the MRC Cancer Unit

A systems biology approach to multi-scale modelling and analysis of planar cell polarity in drosophila melanogaster wing

This thesis was submitted for the degree of Doctor of Philosophy and awarded by Brunel University.Systems biology aims to describe and understand biology at a global scale where biological systems function as a result of complex mechanisms that happen at several scales. Modelling and simulation are computational tools that are invaluable for description, understanding and prediction these mechanisms in a quantitative and integrative way. Thus multi-scale methods that couple the design, simulation and analysis of models spanning several spatial and temporal scales is becoming a new emerging focus of systems biology. This thesis uses an exemplar – Planar cell polarity (PCP) signalling – to illustrate a generic approach to model biological systems at different spatial scales, using the new concept of Hierarchically Coloured Petri Nets (HCPN). PCP signalling refers to the coordinated polarisation of cells within the plane of various epithelial tissues to generate sub-cellular asymmetry along an axis orthogonal to their apical-basal axes. This polarisation is required for many developmental events in both vertebrates and non-vertebrates. Defects in PCP in vertebrates are responsible for developmental abnormalities in multiple tissues including the neural tube, the kidney and the inner ear. In Drosophila wing, PCP is seen in the parallel orientation of hairs that protrude from each of the approximately 30,000 epithelial cells to robustly point toward the wing tip. This work applies HCPN to model a tissue comprising multiple cells hexagonally packed in a honeycomb formation in order to describe the phenomenon of Planar Cell Polarity (PCP) in Drosophila wing. HCPN facilitate the construction of mathematically tractable, compact and parameterised large-scale models. Different levels of abstraction that can be used in order to simplify such a complex system are first illustrated. The PCP system is first represented at an abstract level without modelling details of the cell. Each cell is then sub-divided into seven virtual compartments with adjacent cells being coupled via the formation of intercellular complexes. A more detailed model is later developed, describing the intra- and inter-cellular signalling mechanisms involved in PCP signalling. The initial model is for a wild-type organism, and then a family of related models, permitting different hypotheses to be explored regarding the mechanisms underlying PCP, are constructed. Among them, the largest model consists of 800 cells which when unfolded yields 164,000 places (each of which is described by an ordinary differential equation). This thesis illustrates the power and validity of the approach by showing how the models can be easily adapted to describe well-documented genetic mutations in the Drosophila wing using the proposed approach including clustering and model checking over time series of primary and secondary data, which can be employed to analyse and check such multi-scale models similar to the case of PCP. The HCPN models support the interpretation of biological observations reported in literature and are able to make sensible predictions. As HCPN model multi-scale systems in a compact, parameterised and scalable way, this modelling approach can be applied to other large-scale or multi-scale systems.This study was funded by Brunel University

A Systems Medicine approach to multimorbidity. Towards personalised care for patients with Chronic Obstructive Pulmonary Disease

[eng] BACKGROUND: Multimorbidity (i.e. the presence of more than one chronic disease in the same patient) and comorbidity (i.e. the presence of more than one chronic disease in the presence of an index disease) are main sources of dysfunction in chronic patients and avoidable costs in conventional health systems worldwide. By affecting a majority of elderly population worldwide, multimorbidity prompts the need for revisiting the single disease approach followed by contemporary clinical practice and elaborate strategies that target shared mechanisms of associated diseases with the potential of preventing, decelerating or even halting multimorbid disease progression. However, our current understanding on disease interactions is rather limited, and although many disorders have been associated based on their shared molecular traits and their observed co-occurrence in different populations, no comprehensive approach has been outlined to translate this knowledge into clinical practice. The advent of novel measurement technologies (e.g. omics) and recent initiatives on digital health (e.g. registries, electronic health records) are facilitating access to an enormous amount of patient-related information from whole populations to molecular levels. State-of-the art computational models and machine learning tools demonstrate high potential for health prediction and together with systems biology are shaping the practicalities of systems medicine. Given the extremely long and expensive bench to clinics cycles of the biomedical sector, systems medicine promises a fast track approach where scientific evidence support clinical care, while simultaneously collected insights from daily clinical practice promote new scientific discoveries and optimize healthcare. The PhD thesis aims to explore multimorbidity from a systems medicine perspective on the concrete and practical use case of chronic obstructive pulmonary disease (COPD). COPD constitutes an ideal use case due to several factors, including: i) its high impact on healthcare and its ever-increasing burden; ii) its heterogeneous disease manifestations, and progress, often involving extra-pulmonary effects, including highly prevalent comorbidities (e.g. type 2 diabetes mellitus, cardiovascular disorders, anxiety-depression and lung cancer); and, iii) its well described systemic effects that are suggested associations with comorbidities in terms of underlying mechanisms. HYPOTHESIS: The central hypothesis of the PhD thesis builds on the emerging biological evidence that clustering of comorbid conditions, a phenomenon seen in complex chronic patients, could be due to shared abnormalities in relevant biological pathways (i.e. bioenergetics, inflammation and tissue remodelling). It is assumed that a systems understanding of the patient conditions may help to uncover the molecular mechanisms and lead to the design of preventive and targeted therapeutic strategies aiming at modulating patient prognosis. The PhD thesis focuses on non-pulmonary phenomena of COPD; that is, systemic effects and comorbidities, often observed in patients with COPD as a paradigm of complex chronic disease. OBJECTIVES: The general objective of the PhD thesis is threefold: i) to investigate molecular disturbances at body systems level that may lead to a better understanding of characteristic systemic effects and comorbidities of patients with COPD; ii) to analyse population level patterns of COPD comorbidities and investigate their role in the health risk of patients with COPD; and, iii) to explore technological strategies and tools that facilitate the transfer of the collected knowledge on comorbidity into clinical practice. MAIN FINDINGS: Firstly, the PhD thesis introduced a novel knowledge management tool for targeted molecular analysis of underlying disease mechanisms of skeletal muscle dysfunction in patients with COPD. Second, a network analysis approach was outlined to further study this systemic effect, as well as the causes of abnormal adaptation of COPD muscle to exercise training. Furthermore, this work together with three other studies also aimed to reveal the general underlying causes of comorbidity clustering in COPD, using different modelling approaches. Overarching outcome of these studies indicates abnormalities in the complex co-regulation of core biological pathways (i.e. bioenergetics, inflammation, oxidative stress and tissue remodelling) both on muscle and body systems level (blood, lung), which paves the way for the development of novel pharmacological and non-pharmacological preventive interventions on non- pulmonary phenomena in patients with COPD. Furthermore, results indicated strong relation of muscle related dysregulations to aerobic capacity, in opposed to pulmonary severity of COPD. These findings have far reaching potential in COPD care, starting from defining the need for better characterization of exercise performance in the clinic practice and the promotion of physical activity from early stages of the disease. This PhD thesis also generated outcomes with respect to the risk of multimorbidity in patients with COPD using a population health approach. The thesis validated that patients with COPD are in increased risk to co-occur with other diseases compared to non-COPD patients, regardless of the population and healthcare system specificities of different regions (i.e. Catalonia, US). These findings indicated the potential role of multimorbidity as a risk factor for COPD, that was evaluated in the PhD thesis by constructing health risk assessment models to predict unexpected medical events in patients with COPD. The promising performance of the models and the prominent role of multimorbidity in these models presented a powerful argument for its role in clinical staging of the disease and their potential in clinical decision support. CONCLUSIONS: The PhD thesis achieved main points of the general objectives, namely: i) to perform a systems analysis of patients with COPD by investigating molecular disturbances at body systems level leading to a better understanding of characteristic systemic effects and comorbidities of patient with COPD; ii) to analyse population level patterns of COPD comorbidities and investigate their role in the health risk of patients with COPD; and iii) to explore technological strategies and tools that facilitate the transfer of the collected knowledge on comorbidity into clinical practice. Accordingly, the following conclusions arise: 1. Non-pulmonary manifestations in patients with Chronic Obstructive Pulmonary Disease (COPD) have a major negative impact on: highly relevant clinical events, use of healthcare resources and prognosis. Accordingly, the following indications were made: a. Actionable insights on non-pulmonary phenomena should be included in the clinical staging of these patients in an operational manner. b. Management of patients with COPD should be revisited to incorporate an integrative approach to non-pulmonary phenomena. c. Innovative cost-effective interventions, and pharmacological and non- pharmacological treatments targeting prevention of non-pulmonary manifestations in patients with COPD should be developed, and properly assessed. 2. Abnormal co-regulation of core biological pathways (i.e. bioenergetics, inflammation, tissue remodelling and oxidative stress), both in skeletal muscle and at body systems level, are common characteristics of patients with COPD, which potentially play a major role in comorbidity clustering. 3. Consistent relationships between cardiovascular health, skeletal muscle dysfunction and clinical outcomes in patients with COPD was identified, which makes it a priority to characterize patient exercise performance and physical activity in the clinic, and to adopt early cardiopulmonary rehabilitation strategies to modulate prognosis and prevent comorbidity clustering in these patients. 4. Multimorbidity is a strong predictor of unplanned medical events in patients with COPD and shows high potential to be used for personalized health risk prediction and service workflow selection. 5. Personalized health risk prediction was identified as a high potential tool for the integration and transfer of scientific evidence on multimorbidity to daily clinical practice. Limiting factors of its present applicability were explored and implementation strategies based on cloud computing solutions were proposed.[cat] INTRODUCCIÓ: Tant la multimorbiditat (la presència de més d'una malaltia crònica en el mateix pacient), com la comorbiditat (la presència de més d'una malaltia crònica quan hi ha una malaltia de referència) són una font important de disfuncions en l’atenció sanitària dels pacients crònics i generen importants despeses evitables en sistemes de salut arreu del món. La multimorbiditat/comorbiditat afecta la majoria de població de més de 65 anys. El seu gran impacte sanitari i social fa necessària la revisió d’aspectes essencials de la pràctica mèdica convencional, molt enfocada al tractament de cada malaltia de forma aïllada. En aquest sentit, cal elaborar estratègies que considerin els mecanismes biològics comuns entre patologies, per tal de prevenir, retardar o fins i tot aturar la progressió del fenomen. Malauradament, el poc coneixement dels mecanismes biològics que modulen les interaccions entre malalties és un factor limitant important. Hi ha estudis sobre els mecanismes moleculars comuns entre malalties i s’han realitzat anàlisis poblacionals de la multimorbiditat, però no existeix encara una aproximació holística per tal de traduir aquest coneixement a la pràctica clínica. L’aparició de noves tecnologies òmiques, així com iniciatives recents en l’àmbit de la salut digital, han facilitat l'accés a una quantitat enorme d'informació dels pacients, tant a nivell poblacional com a nivell molecular. A més, les eines computacionals i d'aprenentatge automàtic existents estan demostrant un gran potencial predictiu que, conjuntament amb les metodologies de la biologia de sistemes, estan conformant els aspectes pràctics del desplegament de la medicina de sistemes. De forma progressiva, aquesta última esdevé una via efectiva per accelerar el rol de l’evidència científica com a suport a la atenció clínica. De forma recíproca, la digitalització sistemàtica de la pràctica clínica diària, permet la generació de noves descobertes científiques i la optimització de l’assistència sanitària. Aquesta tesis doctoral pretén explorar la multimorbiditat des d’una perspectiva de medicina de sistemes, considerant com a cas d'ús concret i pràctic la malaltia pulmonar obstructiva crònica (MPOC). La MPOC constitueix un cas d'ús ideal a causa de diversos factors: i) el seu alt impacte a nivell sanitari; ii) la heterogeneïtat en quant a manifestacions i progrés, sovint amb efectes extra-pulmonars, incloent de forma freqüent comorbiditats com la diabetis mellitus tipus 2, trastorns cardiovasculars, l'ansietat-depressió i el càncer de pulmó; i, iii) els efectes sistèmics de la malaltia pulmonar, que podrien presentar mecanismes biològics comuns a algunes comorbiditats. HIPÒTESIS: La hipòtesi central d’aquesta tesis doctoral considera que la multimorbiditat podria explicar-se per alteracions en les xarxes de regulació de mecanismes biològics rellevants com la bioenergètica, inflamació i remodelació de teixits. En aquest sentit, l’anàlisi holística del problema podria millorar la comprensió dels mecanismes moleculars que modulen les associacions entre malalties i, per tant, facilitar el disseny d'estratègies terapèutiques preventives i dirigides a modular el pronòstic dels pacients. Aquesta tesis doctoral estudia els fenòmens extra-pulmonars de la MPOC; és a dir, efectes sistèmics (disfunció del múscul esquelètic) i comorbiditats, com a paradigma de malalties cròniques complexes. OBJECTIUS: L'objectiu general d’aquesta tesis doctoral és triple: i) l’anàlisi holístic de pacients amb MPOC amb focus en la disfunció muscular i les comorbiditats; ii) avaluar el paper de les comorbiditats en el risc de salut dels pacients amb MPOC, tant a nivell poblacional com individual; i, iii) explorar estratègies tecnològiques i eines de salut digital que facilitin la transferència de coneixement a la pràctica clínica diària. RESULTATS: El primer manuscrit de la tesi descriu una nova eina de gestió del coneixement per l’anàlisi molecular dels mecanismes de disfunció del múscul esquelètic en pacients amb MPOC. També dins el primer objectiu de la tesi, s’efectua un anàlisi de xarxes orientat a la identificació de mòduls biològics explicatius de la disfunció muscular i de l’adaptació anòmala d’aquests malalts a l’entrenament físic, tal com es descriu en el segon manuscrit. Els tres articles següents exploren, des de diferents perspectives, l’impacte i mecanismes de les comorbiditats en els pacients amb MPOC. Els principals resultats d'aquests estudis indiquen una complexa i anormal regulació de vies biològiques principals, com es el cas de la bioenergètica, inflamació, estrès oxidatiu i remodelació de teixits, tant a nivell del múscul com a nivell sistèmic (sang, pulmó). Aquests resultats obren noves vies per a intervencions preventives, tant farmacològiques com no farmacològiques, sobre els fenòmens no pulmonars que presenten els pacients amb MPOC. Els resultats indiquen una associació de les alteracions musculars amb la capacitat aeròbica, i no pas amb la gravetat de la malaltia pulmonar. Aquestes troballes tenen un gran potencial en la millora de la gestió dels pacients amb MPOC, començant per la necessitat d’una millor caracterització de la capacitat aeròbica en la pràctica clínica i la promoció d'activitat física des de les primeres etapes de la malaltia. La tesi també ha generat resultats d’interès en relació amb el risc de multimorbiditat en pacients amb MPOC, mitjançant un enfocament de salut poblacional. Els resultats evidencien que els pacients amb MPOC presenten un risc mes elevat de comorbiditat que els pacients sense MPOC, independentment de les especificitats de la població i del sistema sanitari de les àrees analitzades (Catalunya, EUA). La tesi també demostra el paper de la multimorbiditat com a factor modulador del risc clínic dels pacients amb MPOC. Aquests resultats indiquen l’interès de l’ús de la multimobiditat en l’estadiatge dels pacients amb MPOC i en l’elaboració d’eines de suport al procés de decisió clínica. CONCLUSIONS: Aquesta tesi doctoral ha assolit els objectius generals plantejats i proposa les següents conclusions: 1. Les manifestacions no pulmonars en els pacients amb malaltia pulmonar obstructiva crònica (MPOC) tenen un impacte negatiu respecte a esdeveniments de gran rellevància clínica, ús de recursos sanitaris i pronòstic. En conseqüència, es fan les següents recomanacions: a. Els fenòmens no pulmonars de la MPOC s’haurien d’incloure de manera operativa en l’estadiatge d'aquests pacients. b. S’hauria de redefinir la gestió clínica dels pacients amb MPOC tot incorporant un enfocament holístic dels fenòmens no pulmonars. c. S’haurien de desenvolupar i avaluar correctament noves intervencions, farmacològiques i no farmacològiques, per a la prevenció de les manifestacions no pulmonars en pacients amb MPOC. 2. Les alteracions de la regulació de vies biològiques rellevants com la bioenergètica, inflamació, estrès oxidatiu i la remodelació de teixits a nivell del múscul esquelètic, i també a nivell sistèmic, s’observa en els pacients amb MPOC i pot tenir un paper important en les co-morbiditats. 3. Les relacions entre alteracions cardiovasculars, disfunció del múscul esquelètic i altres aspectes clínics dels pacients amb MPOC, indiquen la necessitat de caracteritzar la capacitat aeròbica i els nivells d'activitat física en la pràctica clínica, així com la implementació d’estratègies de rehabilitació cardiopulmonar en les primeres etapes de la malaltia, per tal de modular la prognosis dels malalts i prevenir l’aparició de comorbiditats. 4. La multimorbiditat és un bon predictor d’esdeveniments clínics rellevants en pacients amb MPOC i mostra un gran potencial per a personalitzar l’estimació de risc i la selecció de serveis. 5. La predicció de risc de forma personalitzada s’ha identificat com una eina amb molt potencial per a la gestió de la multimorbiditat en la pràctica clínica diària. S’han explorat els factors limitants de la seva aplicabilitat i s’han proposat estratègies d'implementació d’eines predictives adients, basades en solucions de computació en el núvol.[spa] INTRODUCCIÓN: Tanto la multimorbilidad (la presencia de más de una enfermedad crónica en un mismo paciente) como la comorbilidad (la presencia de más de una enfermedad crónica en presencia de una enfermedad de referencia) son una fuente importante de disfunciones en la atención sanitaria de los pacientes crónicos y generan importantes costes evitables en los sistemas de salud de todo el mundo. La multimorbilidad/comorbilidad afecta a la mayoría de la población de más de 65 años. Debido a su gran impacto sanitario y social, resulta necesaria la revisión de aspectos esenciales de la práctica médica convencional, muy enfocada en el tratamiento de cada enfermedad de forma aislada. En este sentido, es necesario elaborar estrategias que consideren mecanismos biológicos comunes entre patologías, con el fin de prevenir, retrasar o incluso detener la progresión del fenómeno. Desgraciadamente, el escaso conocimiento de los mecanismos biológicos que modulan las interacciones entre enfermedades es un factor limitante importante. Existen estudios sobre los mecanismos moleculares comunes entre enfermedades y se han realizados análisis poblaciones de la multimorbilidad, pero no existe aún una aproximación holística que permita traducir este conocimiento a la práctica clínica. La aparición de nuevas tecnologías ómicas, así como recientes iniciativas en el ámbito de la salud digital, han facilitado el acceso a una cantidad enorme de información sobre los pacientes, tanto a nivel poblacional como a nivel molecular. Además, las herramientas computacionales y de aprendizaje automático existentes demuestran un gran potencial predictivo que, conjuntamente con las metodologías de biología de sistemas, están conformando los aspectos prácticos de la medicina de sistemas. De manera progresiva esta última se está convirtiendo en una vía efectiva para acelerar el papel de la evidencia científica como soporte a la atención clínica. De forma recíproca, la digitalización sistemática de la práctica clínica diaria permite la generación de nuevos descubrimientos científicos y la optimización de la asistencia sanitaria. Esta tesis doctoral pretende explorar la multimorbilidad desde una perspectiva de medicina de sistemas, considerando como caso de uso concreto y práctico la enfermedad pulmonar obstructiva crónica (EPOC). La EPOC constituye un caso de uso ideal debido a diversos factores: i) su alto impacto a nivel sanitario; ii) la heterogeneidad en cuanto a manifestaciones y progreso, a menudo con efectos extra pulmonares, incluyendo de forma frecuente comorbilidades como la diabetes mellitus tipo 2, trastornos cardiovasculares, la ansiedad-depresión y el cáncer de pulmón; y, iii) los efectos sistémicos de la enfermedad pulmonar, que podrían presentar mecanismos biológicos comunes a algunas comorbilidades. HIPÓTESIS: La hipótesis central de esta tesis doctoral considera que la multimorbilidad podría explicarse por alteraciones en las redes de regulación de mecanismos biológicos relevantes como la bioenergética, inflamación y remodelación de tejidos. En este sentido, el análisis holístico del problema podría mejorar la comprensión de los mecanismos moleculares que modulan las asociaciones entre enfermedades y, por tanto, facilitar el diseño de estrategias terapéuticas preventivas y dirigidas a modular el pronóstico de los pacientes. Esta tesis doctoral estudia los fenómenos extra pulmonares de la EPOC; es decir, efectos sistémicos (disfunción del músculo esquelético) y comorbilidades, como paradigma de enfermedades crónicas complejas. OBJETIVOS: El objetivo general de esta tesis doctoral es triple: i) el análisis holístico de pacientes con EPOC focalizando en la disfunción muscular y la comorbilidades; ii) evaluar el papel de las comorbilidades en el riesgo de salud de los pacientes con EPOC, tanto a nivel poblacional como individual; y, iii) explorar estrategias tecnológicas y herramientas de salud digital que faciliten la transferencia de conocimiento a la práctica clínica diaria. RESULTADOS: El primer manuscrito de la tesis describe una nueva herramienta de gestión del conocimiento para el análisis molecular de los mecanismos de disfunción del músculo esquelético en pacientes con EPOC. Incluido en el primer objetivo de la tesis, se efectúa un análisis de redes orientado a la identificación de módulos biológicos que explican la disfunción muscular y la adaptación anómala de estos pacientes al entrenamiento físico, tal y cómo se describe en el segundo manuscrito. Los tres artículos siguientes exploran, desde perspectivas diferentes, el impacto y mecanismos de las comorbilidades en los pacientes con EPOC. Los principales resultados de estos estudios indican una compleja y anormal regulación de vías biológicas principales, como es el caso de la bioenergética, inflamación, estrés oxidativo y remodelación de tejidos, tanto a nivel del músculo como a nivel sistémico (sangre, pulmón). Estos resultados abren nuevas vías para intervenciones preventivas, tanto farmacológicas como no farmacológicas, sobre los fenómenos no pulmonares que presentan los pacientes con E