Karl J. Staples

Background: Respiratory syncytial virus (RSV) causes substantial winter pressure on adult services. In the UK, RSV vaccination currently targets adults aged ≥75 years and care home residents; it remains uncertain whether this age criterion alone meaningfully discriminates risk of poor outcome among adults hospitalised with RSV. Methods: We pooled three UK hospital cohorts (one prospective, two retrospective) of adults admitted with acute respiratory infection (ARI) and PCR-confirmed RSV. The primary outcome was intensive care unit/high dependency unit (ICU/HDU) admission or all-cause mortality within 60 days. Prespecified predictors (age, sex and comorbidities) entered a least absolute shrinkage and selection operator (LASSO) penalised logistic regression; selected variables were refitted using standard logistic regression. Discrimination, calibration and decision-analytic performance were assessed using 1000-bootstrap internal validation and decision-curve analysis. Results: Among 334 adults, 37 (11.1%) experienced the primary outcome. An age-only rule mirroring current UK vaccine age-eligibility (≥75 years) demonstrated only modest discrimination (optimism-adjusted area under the receiver operating characteristic curve (AUC) 0.58, 95% CI 0.48 to 0.65) and a compressed distribution of predicted risks. A four-predictor model—including age, COPD, active/previous cancer and dementia—achieved higher discrimination AUC (0.77 (0.69 to 0.85)), a wider spread of predicted risks and the greatest net benefit across clinically plausible escalation thresholds (5–20%). Conclusions: In adults hospitalised with RSV-associated ARI, simple age-based heuristics—including the UK ≥75-year threshold—showed only modest ability to discriminate risk of ICU/HDU admission/60-day mortality once hospitalised. Comorbidity-inclusive approaches may provide more informative hospital-level risk stratification and warrant evaluation in future RSV vaccine-effectiveness and outcome studies. Any application requires external validation, more systematic RSV testing and comparison with physiology-based scores in larger, vaccinated cohorts.

Background: Macrolide antibiotics have immunomodulatory activity and when taken chronically reduce exacerbations of COPD. However, chronic use can cause bacterial resistance. EP395 (glasmacinal), a novel macrolide, is being developed as a treatment to reduce exacerbations of COPD without inducing antimicrobial resistance. Methods: In this double-blind, placebo-controlled, phase 2a trial ( NCT05572333 ), patients (≥45 years old, diagnosed with COPD for ≥2 years and stable on at least one maintenance inhaled therapy) were randomised (2:1) to EP395 or placebo daily for 12 weeks. The primary objective was safety, with key secondary objectives assessing pharmacodynamic effects of EP395. Results: A total of 61 patients were randomised (42 EP395, 19 placebo). A 12-week course of EP395 was well tolerated: no serious adverse events were considered related to EP395, and adverse events occurred in similar proportions in both groups (64.3% EP395, 63.2% placebo). Four patients were withdrawn due to adverse events (three EP395, one placebo). Sputum neutrophil elastase and myeloperoxidase, mediators of neutrophil activation, were reduced with EP395 (treatment difference (log scale): neutrophil elastase −0.415 ng·mL ⁻¹ , 95% CI −0.787 to −0.043 ng·mL ⁻¹ , p=0.030; myeloperoxidase −0.282 ng·mL ⁻¹ , 95% CI −0.640 to 0.076 ng·mL ⁻¹ , p=0.119). Relative changes in neutrophil elastase and myeloperoxidase from baseline with EP395 were 66% and 75%, respectively, of those observed with placebo. Exploratory 16S rRNA sequencing of sputum showed EP395 had no detectable effect on the lung microbiome, including the proportion of pathogenic Proteobacteria species. Conclusion: In patients with stable COPD, EP395 for 12 weeks was well tolerated, demonstrated selective anti-inflammatory activity and had no detectable effect on the lung microbiome.

COPD remains a leading cause of morbidity and mortality, with outcomes stagnating relative to other long-term conditions. Current diagnostic pathways rely on spirometry, which detects airflow obstruction only after irreversible small airway and parenchymal damage has accrued, whereas pathogenic processes begin decades earlier. This review examines how understanding early pathogenic processes could inform alternative approaches to diagnosis and treatment. We highlight the contribution of developmental and environmental exposures, genetic susceptibility and epigenetic modification to disease initiation. We outline how these convergent mechanisms drive structural and functional abnormalities undetectable by conventional diagnostics but measurable with novel techniques. Advanced imaging–parametric response mapping, hyperpolarised gas magnetic resonance imaging and computed tomography-based vascular metrics–can detect emphysema, small airways disease and vascular pruning before spirometric thresholds are reached. Physiological tools including forced oscillation techniques and capnography show promise for early detection in primary care and may be scalable, affordable alternatives to spirometry. Biofluid-based platforms, including exhaled breath analysis, extracellular matrix neo-epitopes and blood-based inflammatory signatures, offer noninvasive phenotyping and risk stratification, though require validation and pathway integration. We argue for a shift from a spirometry-centric model to a multidimensional diagnostic framework integrating imaging, molecular, physiological and biomarker data. Recent longitudinal evidence, including diagnostic schemas combining imaging with symptom burden, indicates that such approaches identify high-risk individuals missed by spirometry alone. Proactive COPD detection in its earliest stages is therefore an essential step to altering disease trajectory and improving patient outcomes, and it is time our community looks beyond spirometry to deliver this.

Introduction: Disease-modifying treatments such as monoclonal antibodies can be highly effective in chronic inflammatory diseases such as COPD, but often fail in clinical trials due to heterogeneity of inflammation and imperfect tools to stratify patients to select optimal therapeutic approaches. Molecular imaging provides the potential to transform precision medicine in this field. Methods: We developed and tested a novel molecular imaging platform using therapeutic monoclonal antibodies labelled with SPECT-CT detectable markers to quantify in vivo tumour necrosis factor (TNF) involved in chronic lung inflammation in humans. We undertook a proof-of-concept clinical study involving participants with COPD and healthy controls. Participants underwent SPECT-CT imaging at 6- and 24 h following injection of ^99m Tc-anti-TNF. Segmentation of lung regions and ^99m Tc-anti-TNF activity quantification was undertaken using novel semi-automated and AI-driven approaches. Results: A significant increase in normalised activity, representing increased TNF inflammatory activity, was seen between the two time-points in the COPD group (mean± sd : 64.88±31.04%, p=0.029) and not in healthy controls (35.38±34.33%, p=0.110). However, analysis at a single time-point revealed higher normalised activity in the healthy group. We demonstrated that pulmonary blood vessel density and degree of emphysema were strongly correlated with this activity signal and identified as confounding factors, highlighting the need to address differences in target-organ characteristics in COPD. Experimental methods to adjust for these factors were developed for organ-specific signal quantification. Conclusions: We report novel analysis techniques for molecular imaging of the human lung, presenting a platform which provides new insights into complex inflammatory disease and future precision medicine approaches.

The human respiratory tract virome is an underexplored component of the microbiome that includes eukaryotic viruses, bacteriophages and archaeal viruses. The respiratory virome represents a dynamic and heterogeneous ecosystem, shaped by host, environmental and microbial factors. Advances in metagenomic sequencing have expanded our understanding of virome composition, dynamics and potential roles in health and disease. Despite increasing interest, virome research remains fragmented and often secondary to bacteriome studies. Challenges in study design, genomic characterisation and interpretation limit consistent conclusions. This review summarises current knowledge of the respiratory virome in health and across acute and chronic respiratory diseases, including acute respiratory infection, asthma, COPD, cystic fibrosis and bronchiectasis. While each condition is distinct, they share features of airway inflammation and immune dysregulation where the virome may act as a modifier or marker. Across these syndromes, emerging evidence highlights the consistent detection of respiratory viruses including potential commensals, such as Anelloviridae, and the often-overlooked role of bacteriophages. We also discuss the concept of viral dark matter, where large proportions of sequence data remain unclassified, potentially representing novel viral taxa. Technical and conceptual challenges are evaluated, alongside recent methodological innovations such as meta-transcriptomics and viral enrichment protocols. We outline how standardised, multi-omic and longitudinal approaches are urgently needed to clarify the virome's functional role, interactions with immunity and microbial communities and its utility as a biomarker or therapeutic target.

Background: Influenza virus particularly affects those with chronic lung conditions such as Chronic Obstructive Pulmonary Disease (COPD). Airway epithelial cells are the first line of defense and primary target of influenza infection and release extracellular vesicles (EVs). EVs can transfer of biological molecules such as microRNAs (miRNAs) that can modulate the immune response to viruses through control of the innate and adaptive immune systems. The aim of this work was to profile the EV miRNAs released from bronchial epithelial cells in response to influenza infection and discover if EV miRNA expression was altered in COPD.Methods: Influenza infection of air-liquid interface (ALI) differentiated BCi-NS1.1 epithelial cells were characterized by analyzing the expression of antiviral genes, cell barrier permeability and cell death. EVs were isolated by filtration and size exclusion chromatography from the apical surface wash of ALI cultured bronchial epithelial cells. The EV miRNA cargo was sequenced and reads mapped to miRBase. The BCi sequencing results were further investigated by RT-qPCR and by using healthy and COPD primary epithelial cells.Results: Infection of ALI cultured BCi cells with IAV at 3.6 x 10⁶ IU/ml for 24 h led to significant upregulation of anti-viral genes without high levels of cell death. EV release from ALI-cultured BCi cells was confirmed using electron microscopy and detection of known tetraspanin EV markers using western blot and the ExoView R100 platform. Differential expression analyses identified 5 miRNA that had a fold change of >0.6: miR-155-5p, miR-122-5p, miR-378a-3p, miR-7-5p and miR-146a-5p (FDR<0.05). Differences between EV, non-EV and cellular levels of these miRNA were detected. Primary epithelial cell release of EV and their miRNA cargo was similar to that observed for BCi. Intriguingly, miR-155 expression was decreased in EVs derived from COPD patients compared to EVs from control samples.Conclusion: Epithelial EV miRNA release may be a key mechanism in modulating the response to IAV in the lungs. Furthermore, changes in EV miRNA expression may play a dysfunctional role in influenza-induced exacerbations of COPD. However, further work to fully characterize the function of EV miRNA in response to IAV in both health and COPD is required.

Introduction: Reduced antibiotic consumption due to better self-management could change the profile of bacteria present in the airway, which might benefit the health of chronic obstructive pulmonary disease patients. To test this, we planned to use sputum samples already being collected from Colour-COPD trial patients for mechanistic work. The trial will test whether a sputum colour chart is non-inferior to usual self-management, and has a primary outcome of chronic obstructive pulmonary disease-specific hospital admission. Secondary outcomes include antibiotic consumption and quality of life. Since only half of exacerbations of chronic obstructive pulmonary disease (acute exacerbation of chronic obstructive pulmonary disease) are bacterial, and sputum colour has a good positive predictive value for bacterial presence, it is likely that our intervention will reduce antibiotic consumption. The main route by which our intervention could improve patient outcomes is that it could alter the airway microbiome, and subsequent pathological processes; this add-on study tried to assess that concept. Methods: We used all sputum samples submitted by Colour-COPD trial patients and processed and stored them for microbiome and cytokine analyses. Sputum plugs were split with one-half being diluted in phosphate-buffered saline, dispersed using glass beads and stored for quantitative polymerase chain reaction/16S analysis. The second portion was dispersed using sequential phosphate-buffered saline and dithiothreitol treatment, generating supernatants and cytospins. Analysis of the microbial patterns, which would have been obtained from the respiratory microbiome, will be compared to antibiotic consumption for acute exacerbation of chronic obstructive pulmonary disease (days/year) steroid load (days/year and mg/year), acute exacerbation of chronic obstructive pulmonary disease rate, forced expiratory volume in 1 second and longitudinally within individuals to determine the impact of frequent courses of antibiotics at group and individual level. This work will now be completed outside the duration of this award. Selected inflammatory markers linked to neutrophilic and eosinophilic inflammation were planned to be measured, but this work was abandoned when the study was terminated early. Results and study limitations: The trial was stopped prematurely due to low recruitment. This was due to a combination of insufficient trial sites, the impact of COVID-19 on research infrastructure and a reduced rate of acute exacerbation of chronic obstructive pulmonary disease during the COVID-19 pandemic, which affected eligibility in primary care sites, in particular. Since analysis of the microbiome was planned to occur only after trial results, this was abandoned within this award at the termination of the trial. However, since the research questions remained, could be answered in other ways, and patients had consented to the use of their samples for the proposed work, alternative ways to collect samples and fund microbiome analyses were sought. We are now at a point where we expect to have sufficient samples to have adequate power to answer two of our research questions by the time the trial ends, and will conduct their analysis thereafter. Conclusion: Although we are not able to address our objectives of describing the airway microbiome in a primary care chronic obstructive pulmonary disease population, and describing the relationship between antibiotic consumption and changes in airway microbiome during the term of the award, we were able to learn lessons about matching mechanistic work to trials. Future work: We stored samples for a separately funded study to meet our objectives. Funding: This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Efficacy and Mechanism Evaluation (EME) programme as award number NIHR130938.

Background: Respiratory viral infections (RVIs) are a significant cause of morbidity and hospital admission worldwide. However, the management of most viral infection-associated diseases remains primarily supportive. The recent COVID-19 pandemic has underscored the urgent need for a deeper understanding of RVIs to improve patient outcomes and develop effective treatment strategies. The Understanding Infection, Viral Exacerbation and Respiratory Symptoms at Admission-Longitudinal Study is an observational study which addresses this need by investigating the heterogeneity of RVIs in hospitalised adults, aiming to identify clinical and biological predictors of adverse outcomes. This study aims to bridge critical knowledge gaps in the clinical course and the economic impact of RVIs by characterising the phenotypic diversity of these infections and their recovery patterns following hospital admission and thus assisting with the optimal design of future interventional studies. Methods and analysis: This prospective longitudinal observational study (V.6, 20 September 2023) will be conducted across multiple UK secondary care sites from August 2022 onwards, with an aim to enrol 1000 participants testing positive for RVI. Adults admitted with respiratory symptoms who test positive for RVIs via the BioFire® FilmArray® System or other validated diagnostic PCR tests will be enrolled. The data collected include patient demographics, clinical history, comorbidities and symptoms experienced prior to, during and after hospitalisation with follow-up after discharge at weeks 1, 2, 4, 8, 12 and 26. In addition, biological samples are collected at multiple time points during the hospital stay. The primary endpoints are to study the impact of different RVIs and identify predictors of disease progression and length of stay. Secondary endpoints include time to recovery and healthcare cost. Exploratory endpoints focus on biomarker profiles associated with virus type and clinical outcomes. Ethics and dissemination: The study protocol received ethical approval from the relevant committees (English Ethics Reference Number: 22/WM/0119; Scottish Ethics Reference Number: 22-SS-0101, 20/09/2023). For patients who lack the capacity to consent, the study complies with the Mental Capacity Act 2005, using a consultee process where a family member, carer or an independent clinician may provide assent on behalf of the patient. Data from all the study centres will be analysed together and disseminated through peer-reviewed journals, conference presentations and workshops. The study group will ensure that participants and their families are informed of the study findings promptly and in an accessible format. Trial registration number: ISRCTN49183956 .

Background: The role of eosinophils in COPD and their utility as biomarkers for cytokine targeting monoclonal therapies remains unclear. We investigated the distribution of eosinophils across different tissue compartments in COPD and analysed gene expression to understand the possible mechanistic drivers of eosinophilic inflammation in COPD. Methods: Blood and BAL from ex-smoking volunteers with mild/moderate COPD (n = 31) and healthy ex-smoking controls (n = 20), and bronchial biopsy tissue in a subcohort (n = 19 and n = 8, respectively) was analysed. Differentially-expressed genes (DEGs) were characterised using RNASeq. Proteomic analysis of BAL was conducted using mass-spectrometry. Results: COPD subjects had more eosinophils in blood and lung tissue compared to controls, with increased eosinophil protein CLC/Galectin-10 in BAL. However, peripheral blood eosinophil counts related poorly to numbers in lung tissue (rho = -0.09192, p = 0.3541) or proportions in BAL (rho = 0.01762, p = 0.4632). Tissue IL-5Rα expression was higher in frequent exacerbators and related to tissue eosinophils, but not peripheral blood eosinophils. Higher blood eosinophils were associated with DEGs that differed with compartment. Higher tissue eosinophil levels were associated with IL-13-induced DEGs including POSTN in bronchial brushes and CCL26 in bronchial biopsies. Gene-set enrichment analysis on data from brushings revealed significant enrichment of IL-4/IL-13, but not IL-5, pathways associated with eosinophil presence. Conclusion: Eosinophilic lung inflammation is related to exacerbation frequency, but lung eosinophils are not predicted by blood eosinophil counts in COPD. Our data suggest IL-13-mediated pathways may be responsible for the presence of tissue eosinophils in COPD. Further work to establish more predictive biomarkers of lung eosinophil biology are required to unlock this axis to optimised treatment.