An intelligent management of integrated biomedical data for digital health via Network Medicine and its application to different human diseases

Personalized medicine aims to tailor the health care to each person’s unique signature leading to better distinguish an individual patient from the others with similar clinical manifestation. Many different biomedical data types contribute to define this patient’s unique signature, such as omics data produced trough next generation sequencing technologies. The integration of single-omics data, in a sequential or simultaneous manner, could help to understand the interplay of the different molecules thus helping to bridge the gap between genotype and phenotype. To this end, Network Medicine offers a promising formalism for multi-omics data integration by providing a holistic approach that look at the whole system at once rather than focusing on the single entities. This thesis regards the integration of various omics data following two different procedures within the framework of Network Medicine: A procedural multi-omics data integration, where a single omics was first selected to perform the main analysis, and then the other omics were used in cascade to molecularly characterize the results obtained in the main analysis. A parallel multi-omics data integration, where the result was given by the intersection of the results of each single-omics. The procedural multi-omics data integration was leveraged to study Colorectal and Breast Cancer. In the Colorectal Cancer case study, we defined the molecular signatures of a new subgroup of Colorectal Cancer possibly eligible for immune-checkpoint inhibitors therapy. Moreover, in the Breast Cancer case study we defined 11 prognostic biomarkers specific for the Basal-like subtype of Breast Cancer. Instead, the parallel multi-omics data integration was exploited to study COVID-19 and Chronic Obstructive Pulmonary Disease. In the COVID-19 case study, we defined a pool of drugs potentially repurposable for COVID-19. Whereas, in the Chronic Obstructive Pulmonary Disease case study, we discovered a group of differentially expressed and methylated genes that have a considerable biological specificity and could be related to the inflammatory pathological mechanism of Chronic Obstructive Pulmonary Disease

The new paradigm of Network Medicine to analyse breast cancer phenotypes

Breast cancer (BC) is a heterogeneous and complex disease as witnessed by the existence of different subtypes and clinical characteristics that poses significant challenges in disease management. The complexity of this tumor may rely on the highly interconnected nature of the various biological processes as stated by the new paradigm of Network Medicine. We explored The Cancer Genome Atlas (TCGA)-BRCA data set, by applying the network-based algorithm named SWItch Miner, and mapping the findings on the human interactome to capture the molecular interconnections associated with the disease modules. To characterize BC phenotypes, we constructed protein–protein interaction modules based on “hub genes”, called switch genes, both common and specific to the four tumor subtypes. Transcriptomic profiles of patients were stratified according to both clinical (immunohistochemistry) and genetic (PAM50) classifications. 266 and 372 switch genes were identified from immunohistochemistry and PAM50 classifications, respectively. Moreover, the identified switch genes were functionally characterized to select an interconnected pathway of disease genes. By intersecting the common switch genes of the two classifications, we selected a unique signature of 28 disease genes that were BC subtype-independent and classification subtype-independent. Data were validated both in vitro (10 BC cell lines) and ex vivo (66 BC tissues) experiments. Results showed that four of these hub proteins (AURKA, CDC45, ESPL1, and RAD54L) were over-expressed in all tumor subtypes. Moreover, the inhibition of one of the identified switch genes (AURKA) similarly affected all BC subtypes. In conclusion, using a network-based approach, we identified a common BC disease module which might reflect its pathological signature, suggesting a new vision to face with the disease heterogeneity

Network-driven strategies to integrate and exploit biomedical data

[eng] In the quest for understanding complex biological systems, the scientific community has been delving into protein, chemical and disease biology, populating biomedical databases with a wealth of data and knowledge. Currently, the field of biomedicine has entered a Big Data era, in which computational-driven research can largely benefit from existing knowledge to better understand and characterize biological and chemical entities. And yet, the heterogeneity and complexity of biomedical data trigger the need for a proper integration and representation of this knowledge, so that it can be effectively and efficiently exploited. In this thesis, we aim at developing new strategies to leverage the current biomedical knowledge, so that meaningful information can be extracted and fused into downstream applications. To this goal, we have capitalized on network analysis algorithms to integrate and exploit biomedical data in a wide variety of scenarios, providing a better understanding of pharmacoomics experiments while helping accelerate the drug discovery process. More specifically, we have (i) devised an approach to identify functional gene sets associated with drug response mechanisms of action, (ii) created a resource of biomedical descriptors able to anticipate cellular drug response and identify new drug repurposing opportunities, (iii) designed a tool to annotate biomedical support for a given set of experimental observations, and (iv) reviewed different chemical and biological descriptors relevant for drug discovery, illustrating how they can be used to provide solutions to current challenges in biomedicine.[cat] En la cerca d’una millor comprensió dels sistemes biològics complexos, la comunitat científica ha estat aprofundint en la biologia de les proteïnes, fàrmacs i malalties, poblant les bases de dades biomèdiques amb un gran volum de dades i coneixement. En l’actualitat, el camp de la biomedicina es troba en una era de “dades massives” (Big Data), on la investigació duta a terme per ordinadors se’n pot beneficiar per entendre i caracteritzar millor les entitats químiques i biològiques. No obstant, la heterogeneïtat i complexitat de les dades biomèdiques requereix que aquestes s’integrin i es representin d’una manera idònia, permetent així explotar aquesta informació d’una manera efectiva i eficient. L’objectiu d’aquesta tesis doctoral és desenvolupar noves estratègies que permetin explotar el coneixement biomèdic actual i així extreure informació rellevant per aplicacions biomèdiques futures. Per aquesta finalitat, em fet servir algoritmes de xarxes per tal d’integrar i explotar el coneixement biomèdic en diferents tasques, proporcionant un millor enteniment dels experiments farmacoòmics per tal d’ajudar accelerar el procés de descobriment de nous fàrmacs. Com a resultat, en aquesta tesi hem (i) dissenyat una estratègia per identificar grups funcionals de gens associats a la resposta de línies cel·lulars als fàrmacs, (ii) creat una col·lecció de descriptors biomèdics capaços, entre altres coses, d’anticipar com les cèl·lules responen als fàrmacs o trobar nous usos per fàrmacs existents, (iii) desenvolupat una eina per descobrir quins contextos biològics corresponen a una associació biològica observada experimentalment i, finalment, (iv) hem explorat diferents descriptors químics i biològics rellevants pel procés de descobriment de nous fàrmacs, mostrant com aquests poden ser utilitzats per trobar solucions a reptes actuals dins el camp de la biomedicina

Identifying therapeutic targets in glioma using integrated network analysis

Gliomas are the most common brain tumours in adult population with rapid progression and poor prognosis. Survival among the patients diagnosed with the most aggressive histopathological subtype of gliomas, the glioblastoma, is a mere 12.6 months given the current standard of care. While glioblastomas mostly occur in people over 60, the lower-grade gliomas afflict themselves upon individuals in their third and fourth decades of life. Collectively, the gliomas are one of the major causes of cancer-related death in individuals under fortyin the UK. Over the past twenty years, little has changed in the standard of glioma treatment and the disease has remained incurable. This study focuses on identifying potential therapeutic targets in gliomasusing systems-level approaches and large-scale data integration.I used publicly available transcriptomic data to identify gene co-expression networks associated with the progression of IDH1-mutant 1p/19q euploid astrocytomas from grade II to grade III and high-lighted hub-genes of these networks, which could be targeted to modulate their biological function. I also studied the changes in co-expression patterns between grade II and grade III gliomas and identified a cluster of genes with differential co-expression in different disease states (module M2). By data integration and adaptation of reverse-engineering methods, I elucidated master regulators of the module M2. I then sought to counteract the regulatory activity by using drug-induced gene expression dataset to find compounds inducing gene expression in the opposite direction of the disease signature. I proposed resveratrol as a potentially disease modifying compound, which when administered to patients with a low-grade disease could potentially delay glioma progression.Finally, I appliedanensemble-learning algorithm on a large-scale loss-of-function viability screen in cancer cell-lines with different genetic backgrounds to identify gene dependencies associated with chromosomal copy-number losses common intheglioblastomas. I propose five novel target predictions to be validated in future experiments.Open acces

Construction of gene regulatory networks using biclustering and bayesian networks

<p>Abstract</p> <p>Background</p> <p>Understanding gene interactions in complex living systems can be seen as the ultimate goal of the systems biology revolution. Hence, to elucidate disease ontology fully and to reduce the cost of drug development, gene regulatory networks (GRNs) have to be constructed. During the last decade, many GRN inference algorithms based on genome-wide data have been developed to unravel the complexity of gene regulation. Time series transcriptomic data measured by genome-wide DNA microarrays are traditionally used for GRN modelling. One of the major problems with microarrays is that a dataset consists of relatively few time points with respect to the large number of genes. Dimensionality is one of the interesting problems in GRN modelling.</p> <p>Results</p> <p>In this paper, we develop a biclustering function enrichment analysis toolbox (BicAT-plus) to study the effect of biclustering in reducing data dimensions. The network generated from our system was validated via available interaction databases and was compared with previous methods. The results revealed the performance of our proposed method.</p> <p>Conclusions</p> <p>Because of the sparse nature of GRNs, the results of biclustering techniques differ significantly from those of previous methods.</p

FAIR and bias-free network modules for mechanism-based disease redefinitions

Even though chronic diseases are the cause of 60% of all deaths around the world, the underlying causes for most of them are not fully understood. Hence, diseases are defined based on organs and symptoms, and therapies largely focus on mitigating symptoms rather than cure. This is also reflected in the most commonly used disease classifications. The complex nature of diseases, however, can be better defined in terms of networks of molecular interactions. This research applies the approaches of network medicine – a field that uses network science for identifying and treating diseases – to multiple diseases with highly unmet medical need such as stroke and hypertension. The results show the success of this approach to analyse complex disease networks and predict drug targets for different conditions, which are validated through preclinical experiments and are currently in human clinical trials

Protein–protein interactions and genetic diseases: The interactome

AbstractProtein–protein interactions mediate essentially all biological processes. Despite the quality of these data being widely questioned a decade ago, the reproducibility of large-scale protein interaction data is now much improved and there is little question that the latest screens are of high quality. Moreover, common data standards and coordinated curation practices between the databases that collect the interactions have made these valuable data available to a wide group of researchers. Here, I will review how protein–protein interactions are measured, collected and quality controlled. I discuss how the architecture of molecular protein networks has informed disease biology, and how these data are now being computationally integrated with the newest genomic technologies, in particular genome-wide association studies and exome-sequencing projects, to improve our understanding of molecular processes perturbed by genetics in human diseases. This article is part of a Special Issue entitled: From Genome to Function

Epidemiological and molecular associations between central nervous system disorders and cancer

The study of comorbidity is becoming a key topic in biomedical research, which is especially relevant in the context of population ageing. Comorbidity has profound implications for individuals, practitioners, and health care systems. As a consequence, increasing efforts are being made by the scientific community to characterize better how disorders relate to each other and to identify the factors producing these associations. Cancer and central nervous system (CNS) disorders are among the top leading causes of death and disease burden worldwide. In recent decades direct and inverse patterns of association between CNS disorders and cancer have been reported. However, observational studies have often found contrasting results. Consequently, evidence synthesis methods such as systematic reviews and meta-analysis have emerged as a critical tool to synthesize and evaluate the quality of the evidence regarding a specific research question. In addition, in the course of the Omics era, an unprecedented amount of information regarding the molecular bases of individual disorders has been produced, opening the door to the study of comorbidity from a molecular perspective through the identification of joint alterations in variants, genes, and biological processes. In the present thesis, we aimed to characterize the epidemiological and molecular associations between CNS disorders and cancer and to identify the potential role of their indicated medications. To this end, we first determined if CNS disorder patients presented an altered risk of subsequent cancer incidence and mortality by conducting systematic reviews and meta-analyses of observational studies. Second, we investigated if CNS disorders and cancers presented joint patterns of transcriptomic dysregulation using differential gene expression meta-analysis and weighed co-expression network analysis methods. Third, interactome-based methods and genetic correlations were employed to study the involvement of disease-associated genes and shared genetic variability. Finally, the impact of the medications indicated for the treatment of both sets of disorders in the reported comorbidities was assessed by the analysis of a large repository including information of cell lines treated with the indicated drugs. Our results suggest that patients suffering from neurodegenerative disorders are at a reduced risk of subsequent cancer incidence and mortality compared to controls. Autism spectrum disorder, bipolar disorder, and schizophrenia (SCZ) patients are at an increased risk of cancer mortality but not cancer incidence, whereas major depression patients presented an increased risk of cancer incidence and mortality. Several associations between CNS disorders and site-specific cancers were also identified. Significant direct and inverse patterns of transcriptomic dysregulation between CNS disorders and cancers were observed in our transcriptomic analyses, as well as the presence of joint alterations in several biological processes (i.e., cell cycle, apoptosis, immune system, and oxidative phosphorylation). Significant genetic correlations were also identified between CNS disorders and cancers, including those observed between Parkinson’s disease and melanoma and SCZ and breast cancer. Finally, several drugs indicated for the treatment of CNS disorders, such as antipsychotics, antidepressants, and acetyl-cholinesterase inhibitors were found to produce transcriptomic alterations that mimicked or reversed those found in some cancer types, indicating their potential role in the CNS and cancer comorbidity

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