Class of 2016 Abstract / Objectives: To assess the relationship between adherence to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines for the management of chronic obstructive pulmonary disease (COPD) exacerbations and the corresponding 30-day, all-cause readmissions rate in a community hospital. Methods: A retrospective chart review was conducted on patients admitted with the primary diagnosis of a COPD exacerbation. Medications administration records relevant to the GOLD guidelines were examined as separate independent variables in relation to a readmission within 30 days of discharge. Additional factors examined included: demographic data, resident of a long-term care facility, pre-index hospitalization, pulmonary consult, vaccines, length of stay (LOS), discharge medications, and follow-up appointments. Results: Electronic health records of 120 patients were reviewed and divided into non-readmitted patients (n = 65, mean age 73.4 ± 10.1 years), all-cause readmissions (n = 55, mean age 70.15 ± 9.69 years), and COPD-related readmissions (n = 21, mean age 70.7 ± 11.1 years). Patients with heart failure (p = 0.024), a LOS >5 days (p = 0.045), a pre-index hospitalization (p = 0.001), or who were long-term care residents (p = 0.024) experienced more all-cause readmissions. Females experienced less all-cause readmissions (p = 0.035). Significantly more patients with a pre-index hospitalization had a COPD-related readmission (p = 0.027). Lastly, adherence to the GOLD treatment parameters was not significantly different across all groups. Conclusions: COPD is a complex disease and adherence to the GOLD guidelines during an exacerbation is unlikely to significantly impact 30-day readmission rates.

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第22883号 / 医博第4677号 / 新制||医||1048(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 平井 豊博, 教授 川上 浩司, 教授 椛島 健治 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

Idiopathic pulmonary fibrosis (IPF) is one of the most aggressive and severe interstitial lung diseases (ILDs) for which there is no cure. IPF is characterized by an excessive accumulation of fibroblasts which secrete an abundance of extracellular proteins such as collagen. These processes lead to repetitive tissue scarring and fibrosis in the lung parenchyma. As a result, lungs become rigid limiting oxygen intake and gas exchange. Once diagnosed, IPF is fatal within 2-3 years. There is no known cause or proven treatment that significantly improves outcomes. Although the cause is unknown, the current model of IPF suggests that an overactive epithelial repair mechanism caused by genetic and epigenetic factors as well as environmental exposures is responsible for the chronic fibrosis and scarring characteristic of IPF. The transforming growth factor beta (TGF-B) signaling pathway has been implicated as a major contributor in activating this chronic fibrosis. An upstream activator of the TGF-B pathway, avB6, has been identified as a potential therapeutic target. My collaborators in Dr. David Baker's lab at the University of Washington have created a novel avB6 integrin inhibitor (BP2_disulf) whose efficacy in improving IPF outcomes has yet to be tested. In my study, I test the ability of BP2_disulf to combat IPF through the use of the standard IPF murine model and translatable end points like non-invasive uCT scans, pulmonary function tests, bronchoalveolar lavage fluid (BALF) profiles, and histology. With these methods, I demonstrate that intraperitoneal injection of BP2_disulf in bleomycin-injured mice has the ability to decrease rate of fibrotic progression and pulmonary function decline compared to mice treated with bleomycin alone. These results prove that BP2_disulf is a promising therapeutic not only for IPF but other ILDs as well. Further efficacy validation and investigation into an aerosolized delivery method will advance this drug to clinical trials and make it accessible to those in need.

Les mutations du gène codant pour la protéine C (SP-C) du surfactant pulmonaire (SFTPC) sont à l’origine de pathologies interstitielles chroniques du nourrisson, de l’enfant mais également de l’adulte. Une importante hétérogénéité phénotypique est cependant observée, y compris au sein d’une même famille. Par un épissage alternatif, le gène SFTPC permet la synthèse de deux isoformes du précurseur protéique de SP-C (proSP-C) pour aboutir à la protéine mature après plusieurs modifications post-traductionnelles. Les conséquences des mutations de SFTPC sur l'homéostasie du surfactant ne sont pas clairement élucidées, mais il semble que le mauvais repliement de la protéine soit une caractéristique commune. A l’issue de nos travaux antérieurs, nous avons mis en évidence un effet de certaines mutations et de polymorphismes sur l’épissage de SFTPC faisant ainsi varier significativement l’expression de chacune des deux isoformes protéiques, sans qu’à l’heure actuelle nous ne connaissions le rôle de chacune dans la synthèse de la protéine SP-C mature. Notre projet, s’inscrivant dans la continuité de mon master 2, a pour but de mieux comprendre les mécanismes physiopathologiques pré et post-transcriptionnels associés aux variations de SFTPC et leurs conséquences sur le développement des pneumopathies interstitielles. Le premier axe de notre projet repose sur l’étude in vitro (lignées cellulaires) et in vivo (modèle murin, ARN des patients) des variations de chacun des isoformes. Dans un second axe, nous souhaitons poursuivre l'étude de facteurs pouvant influencer le phénotype des patients porteurs de mutations du gène SFTPC, qu'ils soient d'origine externes (infections virales et bactériennes ou environnementaux comme le tabac) ou génétique. Collectivement, ces études nous permettrons de fournir une signature moléculaire pour cette maladie et d’identifier de nouvelles cibles thérapeutiques afin d’en améliorer le pronostic mais également la prise en charge et la qualité de vie des patients. / Surfactant pathologies linked to mutations in the SFTPC gene, via autosomal dominant transmission, are most commonly associated with diffuse interstitial diseases in infants, children and adults, and may also be responsible for acute respiratory distress syndrome in newborns. They are most often accompanied by a high morbidity and mortality rate, thus rendering early diagnosis essential for ideal intervention and support. Mutations in the SFTPC gene lead to alveolar and intracellular accumulation of an abnormal form of the precursor protein SP-C (ProSP-C), which is responsible for the resulting tissue damage. However, the pathophysiological mechanisms are not yet completely deciphered. The gene encodes two isoforms of ProSP-C from three alternative transcripts. The expression level of each is currently unknown and the vast majority of studies evaluating the effect of mutations are performed on only one isoform. Incidentally, our preliminary results on the analysis of RNA extracted from bronchoalveolar washing, both from control subjects and patients harboring a mutation, show that the all three SFTPC transcripts are expressed and that the presence of a mutation is associated with a variation in the expression levels of the transcripts. The aim of my project is to study the expression level of SFTPC transcripts and ProSP-C isoforms from the heterologous expression of the SFTPC gene (exons and introns) in cell lines. I will beanalyzing the post-translational maturation profile of these pro-proteins and evaluating the effect of the mutations on their expression and maturation in both our cellular models and in vivo with two Knock-in mice models.A better understanding of the pathophysiology of genetic abnormalities associated with mutations in the SFTPC gene will not only greatly contribute to earlier management of patients, but also it will help in modifying the progression of lung injury and its prognosis.

Chronic obstructive lung disease is among the leading causes of adult hospital admissions and readmissions in the United States. Preventing acute exacerbations is the primary approach in therapy. Combinations of smoking cessation, pulmonary rehabilitation, vaccinations and inhaled and oral medications may all reduce the overall risk of acute exacerbations. When prevention is unsuccessful, treatment of exacerbations often does not require hospitalization but can be safely executed in the outpatient setting. In the patient who does not require mechanical ventilation or who manifests respiratory acidosis, oxygen supplementation, frequent short-acting inhaled bronchodilators, oral corticosteroids and often antibiotics can abort the decompensation and sometimes return the patient to his or her pre-attack baseline lung function. Several models exist for delivering this care in the ambulatory setting. Follow-up care after an exacerbation has resolved is important, though there are few hard data suggesting which approach is best in this setting.

No description available.

Preterm birth (<37 weeks) is the world’s principal cause of death of children <5 years of age. Bronchopulmonary dysplasia (BPD) is the most common complication of preterm birth. BPD is characterized by an arrest in alveolar and vascular development within the lung. It is a multifactorial disease, caused by a combination of supplemental oxygen, mechanical ventilation, and inflammation. BPD is also an independent risk factor for abnormal neurodevelopment. The link between BPD and abnormal neurodevelopment is poorly understood and there are currently no effective cures for these complications. We hypothesized that a crucial cell population for brain development, i.e., the neural progenitor cell (NPC) is functionally impaired in BPD and that this impairment is associated with abnormal neurodevelopment. Based on our previous findings, we also predicted that human umbilical cord-mesenchymal stromal cell (UC-MSC) extracellular vesicles (EVs), could mitigate both the lung and brain injuries in experimental BPD. We utilized several animal models of BPD, across multiple species, to determine the effects of hyperoxia, mechanical ventilation, and inflammation on the developing lungs and brain. We also utilized UC- MSC therapy to mitigate these injuries. We discovered that hyperoxia exposure damages the developing lungs as well as the brain, leading to cerebrovascular and NPC impairments, as well as reduced neurogenesis. These impairments were associated with neurobehavioural deficits in adulthood. Furthermore, we found that inflammation in combination with mechanical ventilation and hyperoxia also impairs NPC function. Importantly, we demonstrated that UC-MSC EVs can reduce inflammation, improve vascular growth, restore lung growth, and mitigate impairments in NPC self-renewal. This work highlights novel mechanisms of BPD-associated abnormal neurodevelopment and offers potential regenerative medicine therapies to alleviate these outcomes for this vulnerable population.

京都大学 / 新制・課程博士 / 博士(医学) / 甲第23782号 / 医博第4828号 / 新制||医||1057(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 羽賀 博典, 教授 波多野 悦朗, 教授 溝脇 尚志 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

<p>The focus of this thesis was the role of fibrocytes in chronic lung disease. These bone marrow derived cells have been identified in the lung and the circulation in patient samples and animal models of lung injury. However, the precise mechanistic role of the fibrocyte is still to be elucidated.</p> <p>Live assessment of lung changes in animal models of chronic lung disease allows for real time observation of changes, and gives a readout which can be translated to humans who undergo similar tests. In this thesis, we adapted an existing model of lung injury, and delivered a discrete treatment to a single lung lobe while monitoring its successful delivery.</p> <p>I also developed a robust system to examine the relationship between fibrocyte response, and cytokine expression previously identified in chronic lung disease. We found a connection between cytokine expression and fibrocyte mobilisation. Our model showed that fibrocyte mobilisation in the presence of existing lung injury does not improve and rather can worsen existing lung injury. This was a significant finding as it confirms the role of the fibrocyte as a participator or conductor in fibrogenesis and it suggests that this cell may play a role in the development of chronic lung diseases.</p> <p>Finally, we contributed to the ongoing characterisation of the fibrocyte as a prospective biomarker. We confirmed the cell’s identity by characterising it by its known markers and biological characteristics. We also identified the presence of this cell in chronic lung disease and linked its presence to disease progression.</p> / Doctor of Philosophy (Medical Science)

Cigarette smoke contributes to 90% of lung cancer cases and 80% of COPD cases. These concerns loom large as lung cancer represents 13% of all cancer deaths and estimates report by 2020 COPD will be the third leading cause of death in the world. The master regulator of the ER stress response, IRE-1, in the context of cigarette smoke exposure lacks study. Interestingly, its downstream pathways are activated. In fact, the 2014 Surgeon General’s report on the health consequences of smoking highlighted the endoplasmic reticulum (ER) stress response as a potential mechanism leading to the development of lung cancer and Chronic Obstructive Pulmonary Disorder (COPD). Following acute cigarette smoke exposure, mouse lung homogenates exhibited increased levels of XBP-1 along with downstream mediators of IRE-1 activation— GRP-78 and CHOP. Specifically observing macrophages, an important immune cell and source of acute inflammation, cigarette smoke induced activation of IRE-1/XBP-1 pathway through splicing of XBP-1 mRNA. However, upon assaying for pro-inflammatory cytokines we were unable to determine that cigarette smoke directly caused inflammation in vitro. Furthermore, cigarette smoke inhibited the activation of M2 macrophages, an anti-inflammatory and tissue healing subset seen through CCL18 inhibition. A majority of M2 and M1 macrophage markers were decreased from IRE-1/XBP-1 inhibition. This suggests a different phenotype than classical M1 or M2 polarization being induced by cigarette smoke. In addition, it suggests the IRE-1/XBP-1 pathway having a robust role in controlling gene expression and balance of cellular proteomics. / Thesis / Master of Science (MSc) / Cigarette smoke exposure damages the lungs and over time places the user at risk for increased infections, progressive decreases in lung function and cancer. A specific cell of the immune system and found in the lungs, macrophages or “Big Eater” cells, responds first by picking up debris and responding to harmful foreign substances by releasing proteins signaling the immune system to become activated. Within all animal cells, an organelle called the Endoplasmic Reticulum (ER) manufactures a third of proteins produced allowing the cell to adapt to foreign substances, including cigarette smoke. Cigarette smoke could cause the ER, a plastic organelle, to change in size and function at a heightened level due to activation of a sensing protein integrated in the ER, Inositol Requiring Enzyme-1 (IRE-1). Both activation of the ER and cigarette smoke causes macrophages to behave as “tissue-healing” or M2 subsets that release factors promoting reconstruction of the lungs; alternatively, M1 macrophages fight diseases and promote further inflammation. Using genetic analysis of macrophages exposed to cigarette smoke in culture dishes and analyzing the proteins secreted, we determined cigarette smoke inhibits M1 macrophages and the “tissue-healing” subset, while increasing adhesion molecule expression. Overall, cigarette smoke affected the polarization of M1 and M2 phenotype, analyzed through proteins and genes expression. We observed an increase in sXBP-1, indicative of IRE-1/XBP-1 pathway activation, from cigarette smoke extract exposure in macrophages. However, the use of IRE-1 inhibitors increased ER stress markers while affecting M1 and M2 markers. This suggests ER compensation from the use of inhibiting one arm of the ER stress response.