Mechanisms of NOD1-induced inflammation in vascular tissue

Blood vessels play a vital role in human disease including pathogen driven conditions such as septic shock and acute lung injury. In the innate immune system, host pattern recognition receptors (PRRs) recognise preserved pathogen associated molecular patterns (PAMPs) leading to cell activation. Previous work has shown that blood vessels respond to Gram negative bacteria via the PRRs Toll like receptor 4 (TLR4) and nucleotide oligomerisation domain 1 (NOD1). Indeed stimulation with a specific NOD1 agonist can induce vascular shock in rats (Cartwright, Murch et al. 2007). In humans however, the role of NOD1 in blood vessels is relatively unexplored. Accordingly, in this thesis I have sought to characterise the activity of NOD1 in rodent and human vascular tissue with comparison to TLR4 responses. I have shown that in rodents NOD1 is predominantly expressed and active in vascular cells and whole vessels. Crucially vessel organ culture suggests a predominant role for the endothelium in early responses to NOD1 and TLR4 agonists. I have then gone on to demonstrate induction of key inflammatory mediators by NOD1 agonists in human vessels and vascular cells, confirming the importance of the endothelium in this system. Finally I have used pharmacological tools to describe the signalling pathways downstream of NOD1 and TLR4 in endothelial cells including use of highly novel NOD1 pathway inhibitors. In conclusion, NOD1 is identified as an important PRR mediating inflammatory responses in rodent and human vascular tissue. The endothelium emerges as a key site for NOD1 mediated inflammation whilst the use of highly novel signalling inhibitors has enabled clear differentiation of NOD1 and TLR4 signalling. This suggests the possibility of selective targeting of NOD1 in human disease where disorders of the vasculature predominate

Exploring Chronic Respiratory Disease Care using Statistical Modelling and Routine Data

Chronic respiratory disease represents a significant burden to healthcare services and wider society. Patients benefit from early diagnosis and effective disease management, yet few patients in England are receiving the recommended levels of care. NHS services are increasingly under pressure from an ageing population, as well as disruption following the COVID-19 pandemic, raising important questions about how services can evolve to improve efficiency and standard of care. This thesis explores chronic respiratory disease care using two contrasting approaches. First, Chapters 2 and 3 utilise routinely collected health data from the Morecambe Bay area and provide insight into the impact of a local integrated care initiative. Spatio-temporal methodology is used to model referrals to outpatient respiratory clinics and a thorough data review is conducted to consider the challenge of measuring diagnostic quality. These studies exemplify different approaches to overcoming barriers encountered when using routine data for research purposes. Second, Chapters 4 and 5 apply a discrete-event microsimulation model for chronic obstructive pulmonary disease in the Canadian population to questions in the field of health economics and outcomes research. Simulated data is used to analyse the impact of interventions, both for identifying patients at an earlier stage in the disease progression and earlier initiation of more intensive pharmacotherapy to improve patient quality-of-life. The discussion points of these studies link to key NHS goals for respiratory disease. This thesis demonstrates the role of both routine and simulated data in healthcare research by providing insight into service utilisation, diagnostics, earlier detection of disease, and therapeutic management. However, neither approach is without limitations. Future research could focus on further developing methods for synthetic data, a means of using simulation to enhance the rich routine data landscape in England in order for research to be carried out in a safe and effective way

Quality control for multiple breath washout tests in multicentre bronchiectasis studies:Experiences from the BRONCH-UK clinimetrics study

Multiple Breath Washout (MBW) to measure Lung Clearance Index (LCI) is increasingly being used as a secondary endpoint in multicentre bronchiectasis studies. LCI data quality control or “over-reading” is resource intensive and the impact is unclear. Objectives: To assess the proportion of MBW tests deemed unacceptable with over-reading, and to assess the change in LCI (number of turnovers), LCI coefficient of variation (CV%) and tidal volume (VT) CV% results after over-reading. Methods: Data were analysed from 250 MBW tests (from 98 adult bronchiectasis patients) collected as part of the Bronch-UK Clinimetrics study in 5 UK centres. Each MBW test was over-read centrally using pre-defined criteria. MBW tests with <2 technically valid and repeatable trials were deemed unacceptable to include in analysis. In accepted tests, values for LCI, LCI CV% and VT CV% before and after over-reading, were compared. Results: Insufficient data was collected in 10/250 tests. With over-reading, 30/240 (12%) were deemed unacceptable to include in analysis. In those accepted tests, overall the change in LCI, LCI CV% and VT CV% with over-reading was not statistically significant. When MBW new sites were compared to MBW expert sites, the change in LCI with over-reading was significantly greater in MBW new sites (p = 0.047). Data suggests that over-reading could be important up to at least 12 months post initiation of MBW activity. Conclusion: MBW over-reading was important in this study as 12% of tests were considered unacceptable. Over-reading improved test result accuracy in sites new to MBW

Personalised asthma action plans for adults with asthma

BACKGROUND: A key aim of asthma care is to empower each person to take control of his or her own condition. A personalised asthma action plan (PAAP), also known as a written action plan, an individualised action plan, or a self-management action plan, contributes to this endeavour. A PAAP includes individualised self-management instructions devised collaboratively with the patient to help maintain asthma control and regain control in the event of an exacerbation. A PAAP includes baseline characteristics (such as lung function), maintenance medication and instructions on how to respond to increasing symptoms and when to seek medical help. OBJECTIVES: To evaluate the effectiveness of PAAPs used alone or in combination with education, for patient-reported outcomes, resource use and safety among adults with asthma. SEARCH METHODS: We searched the Cochrane Airways Group Specialised Register of trials, clinical trial registers, reference lists of included studies and review articles, and relevant manufacturers' websites up to 14 September 2016. SELECTION CRITERIA: We included parallel randomised controlled trials (RCTs), both blinded and unblinded, that evaluated written PAAPs in adults with asthma. Included studies compared PAAP alone versus no PAAP, and/or PAAP plus education versus education alone. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted study characteristics and outcome data and assessed risk of bias for each included study. Primary outcomes were number of participants reporting at least one exacerbation requiring an emergency department (ED) visit or hospitalisation, asthma symptom scores on a validated scale and adverse events (all causes). Secondary outcomes were quality of life measured on a validated scale, number of participants reporting at least one exacerbation requiring systemic corticosteroids, respiratory function and days lost from work or study. We used a random-effects model for all analyses and standard Cochrane methods throughout. MAIN RESULTS: We identified 15 studies described in 27 articles that met our inclusion criteria. These 15 included studies randomised a total of 3062 participants (PAAP vs no PAAP: 2602 participants; PAAP plus education vs education alone: 460 participants). Ten studies (eight PAAP vs no PAAP; two PAAP plus education vs education alone) provided outcome data that contributed to quantitative analyses. The overall quality of evidence was rated as low or very low.Fourteen studies lasted six months or longer, and the remaining study lasted for 14 weeks. When reported, mean age ranged from 22 to 49 years and asthma severity ranged from mild to severe/high risk. PAAP alone compared with no PAAPResults showed no clear benefit or harm associated with PAAPs in terms of the number of participants requiring an ED visit or hospitalisation for an exacerbation (odds ratio (OR) 0.75, 95% confidence interval (CI) 0.45 to 1.24; 1385 participants; five studies; low-quality evidence), change from baseline in asthma symptoms (mean difference (MD) -0.16, 95% CI -0.25 to - 0.07; 141 participants; one study; low-quality evidence) or the number of serious adverse events, including death (OR 3.26, 95% CI 0.33 to 32.21; 125 participants; one study; very low-quality evidence). Data revealed a statistically significant improvement in quality of life scores for those receiving PAAP compared with no PAAP (MD 0.18, 95% CI 0.05 to 0.30; 441 participants; three studies; low-quality evidence), but this was below the threshold for a minimum clinically important difference (MCID). Results also showed no clear benefit or harm associated with PAAPs on the number of participants reporting at least one exacerbation requiring oral corticosteroids (OR 1.45, 95% CI 0.84 to 2.48; 1136 participants; three studies; very low-quality evidence) nor on respiratory function (change from baseline forced expiratory volume in one second (FEV1): MD -0.04 L, 95% CI -0.25L to 0.17 L; 392 participants; three studies; low-quality evidence). In one study, PAAPs were associated with significantly fewer days lost from work or study (MD -6.20, 95% CI -7.32 to - 5.08; 74 participants; low-quality evidence). PAAP plus education compared with education aloneResults showed no clear benefit or harm associated with adding a PAAP to education in terms of the number of participants requiring an ED visit or hospitalisation for an exacerbation (OR 1.08, 95% CI 0.27 to 4.32; 70 participants; one study; very low-quality evidence), change from baseline in asthma symptoms (MD -0.10, 95% CI -0.54 to 0.34; 70 participants; one study; low-quality evidence), change in quality of life scores from baseline (MD 0.13, 95% CI -0.13 to 0.39; 174 participants; one study; low-quality evidence) and number of participants requiring oral corticosteroids for an exacerbation (OR 0.28, 95% CI 0.07 to 1.12; 70 participants; one study; very low-quality evidence). No studies reported serious adverse events, respiratory function or days lost from work or study. AUTHORS' CONCLUSIONS: Analysis of available studies was limited by variable reporting of primary and secondary outcomes; therefore, it is difficult to draw firm conclusions related to the effectiveness of PAAPs in the management of adult asthma. We found no evidence from randomised controlled trials of additional benefit or harm associated with use of PAAP versus no PAAP, or PAAP plus education versus education alone, but we considered the quality of the evidence to be low or very low, meaning that we cannot be confident in the magnitude or direction of reported treatment effects. In the context of this caveat, we found no observable effect on the primary outcomes of hospital attendance with an asthma exacerbation, asthma symptom scores or adverse events. We recommend further research with a particular focus on key patient-relevant outcomes, including exacerbation frequency and quality of life, in a broad spectrum of adults, including those over 60 years of age

Multiple breath washout in bronchiectasis clinical trials:is it feasible?

Background: Evaluation of Multiple Breath Washout (MBW) set-up including staff training, certification and central “over-reading” for data quality control is essential to determine the feasibility of MBW in future bronchiectasis studies. Aims: To assess the outcomes of a MBW training, certification and central over-reading programme. Methods: MBW training and certification was conducted in European sites collecting LCI data in the BronchUK clinimetrics and/or i-BEST-1 studies. The blended training programme included the use of an eLearning tool and a 1-day face-to-face session. Sites submitted MBW data to trained central over-readers who determined validity and quality. Results: Thirteen training days were delivered to 56 participants from 22 sites. 18/22 (82%) were MBW naïve. Participant knowledge and confidence increased significantly (p<0.001). By the end of the study recruitment, 15/22 sites (68%) had completed certification with a mean (range) time since training of 6.2 (3-14) months. In the BronchUK clinimetrics study, 468/589 (79%) tests met45 the quality criteria following central over-reading, compared with 137/236 (58%) tests in the i-BEST-1 study. Conclusions: LCI is feasible in a bronchiectasis multicentre clinical trial setting however, consideration of site experience in terms of training as well as assessment of skill drift and the need for re-training may be important to reduce time to certification and optimise data quality. Longer times to certification, a higher percentage of naive sites and patients with worse lung function may have contributed to the lower success rate in the i-BEST-1 study

Pathogen Sensing Pathways in Human Embryonic Stem Cell Derived-Endothelial Cells: Role of NOD1 Receptors.

Human embryonic stem cell-derived endothelial cells (hESC-EC), as well as other stem cell derived endothelial cells, have a range of applications in cardiovascular research and disease treatment. Endothelial cells sense Gram-negative bacteria via the pattern recognition receptors (PRR) Toll-like receptor (TLR)-4 and nucleotide-binding oligomerisation domain-containing protein (NOD)-1. These pathways are important in terms of sensing infection, but TLR4 is also associated with vascular inflammation and atherosclerosis. Here, we have compared TLR4 and NOD1 responses in hESC-EC with those of endothelial cells derived from other stem cells and with human umbilical vein endothelial cells (HUVEC). HUVEC, endothelial cells derived from blood progenitors (blood outgrowth endothelial cells; BOEC), and from induced pluripotent stem cells all displayed both a TLR4 and NOD1 response. However, hESC-EC had no TLR4 function, but did have functional NOD1 receptors. In vivo conditioning in nude rats did not confer TLR4 expression in hESC-EC. Despite having no TLR4 function, hESC-EC sensed Gram-negative bacteria, a response that was found to be mediated by NOD1 and the associated RIP2 signalling pathways. Thus, hESC-EC are TLR4 deficient but respond to bacteria via NOD1. This data suggests that hESC-EC may be protected from unwanted TLR4-mediated vascular inflammation, thus offering a potential therapeutic advantage

Real-world experience of nintedanib for progressive fibrosing interstitial lung disease in the UK

Background Nintedanib slows progression of lung function decline in patients with progressive fibrosing (PF) interstitial lung disease (ILD) and was recommended for this indication within the United Kingdom (UK) National Health Service in Scotland in June 2021 and in England, Wales and Northern Ireland in November 2021. To date, there has been no national evaluation of the use of nintedanib for PF-ILD in a real-world setting.Methods 26 UK centres were invited to take part in a national service evaluation between 17 November 2021 and 30 September 2022. Summary data regarding underlying diagnosis, pulmonary function tests, diagnostic criteria, radiological appearance, concurrent immunosuppressive therapy and drug tolerability were collected via electronic survey.Results 24 UK prescribing centres responded to the service evaluation invitation. Between 17 November 2021 and 30 September 2022, 1120 patients received a multidisciplinary team recommendation to commence nintedanib for PF-ILD. The most common underlying diagnoses were hypersensitivity pneumonitis (298 out of 1120, 26.6%), connective tissue disease associated ILD (197 out of 1120, 17.6%), rheumatoid arthritis associated ILD (180 out of 1120, 16.0%), idiopathic nonspecific interstitial pneumonia (125 out of 1120, 11.1%) and unclassifiable ILD (100 out of 1120, 8.9%). Of these, 54.4% (609 out of 1120) were receiving concomitant corticosteroids, 355 (31.7%) out of 1120 were receiving concomitant mycophenolate mofetil and 340 (30.3%) out of 1120 were receiving another immunosuppressive/modulatory therapy. Radiological progression of ILD combined with worsening respiratory symptoms was the most common reason for the diagnosis of PF-ILD.Conclusion We have demonstrated the use of nintedanib for the treatment of PF-ILD across a broad range of underlying conditions. Nintedanib is frequently co-prescribed alongside immunosuppressive and immunomodulatory therapy. The use of nintedanib for the treatment of PF-ILD has demonstrated acceptable tolerability in a real-world setting

111 A systematic review exploring factors associated with palliative care utilisation in patients with Idiopathic Pulmonary Fibrosis

Background Palliative care is being underutilised in patients with idiopathic pulmonary fibrosis (IPF). Barriers in accessing palliative care (PC) included prognostic uncertainty in IPF, lack of clarity regarding the role of PC and patients fear regarding the future.1 The aim of this review is to explain how PC is currently being utilised in IPF patients.Methods Medline and CINAHL were searched following a sensitive search strategy developed with a faculty librarian. Inclusion criteria included reporting PC utilisation in a health care setting as defined by WHO.2 Results From 245 search results, we included 12 articles. At a national and institutional level we found a PC utilisation of 0%-62% and 13.5%-36% respectively, with PC commencing 1 day – 1 month before death. PC was associated with in home and hospice death. PC utilisation did improve over time. Factors influencing PC utilisation include being older at the time of diagnosis with more severe comorbidities and residing closer to the institution. One cohort study highlighted patients receiving PC had more severe baseline disease which coincided with the centres focus on these measures. Many Cohort studies focused on the idea of a PC referral. Novel Education programmes, MDT approaches and decision aid tools all increased PC utilisation.Conclusion PC utilisation has shown high variability, with onset of care too late to derive maximal benefit, however utilisation has been improving over time. Structured approaches taken by individual centres did improve PC utilisation, however, more research is needed to understand the upward trend in PC utilisation. While some studies focused on the idea of a PC referral, centres should be aware that PC can be delivered by a range of healthcare professionals. Novel models of PC delivery have paved the way forward in increasing PC utilisation, therefore, more research should focus on developing these approaches.ReferencesKim JW, Atkins C, Wilson AM. Barriers to specialist palliative care in interstitial lung disease: a systematic review. BMJ Support Palliat Care. 2019 Jun;9(2):130–138. doi: 10.1136/bmjspcare-2018-001575. Epub 2018 Nov 21. PMID: 30464026.Who.int. 2022. Palliative care. [online] Available at: &lt;https://www.who.int/news-room/fact-sheets/detail/palliative-care&gt; [Accessed 19 August 2022]