Support Meeting for Aspergillosis Patients LED BY GRAHAM ATHERTON SUPPORTED BY GEORGINA POWELL, DEBBIE KENNEDY & DEBORAH HAWKER NAC CENTRE MANAGER CHRIS HARRIS ADVANCES IN THE GENETICS OF SUSCEPTIBILTY TO CHRONIC PULMONARY ASPERGILLOSIS BY DR PAUL BOWYER, RESEARCH GROUP LEADER NATIONAL ASPERGILLOSIS CENTRE UHSM MANCHESTERFungal Research Trust
Programme 1pm Light lunch, Tea Coffee 1.30pm Paul Bowyer: Current research at the National Aspergillosis Centre 2pm Physiotherapy: Nebulisers 2.20pm Break: Social time, chat to staff 2.40pm NAC service information: Chris Harris 3pm Your requests for future meetings 3.10pm Meet the Team: Questions & Answers with Prof Denning 3.30pm Close
Aspergillus Research – Whats New? Paul Bowyer University of Manchester
How does the immune system stop fungal disease?The innate immune response is a complex multicellular process.Meet the cells....IMMUNE CELL: ROLE: DETECTS PATHOGENS, SNEAKS OFF AND PROGRAMS THE IMMUNE RESPONSE DENDRITIC CELL
IMMUNE CELL: ROLE: STOPS AND APPREHENDS KNOWN PATHOGENS MACROPHAGE IMMUNE CELL: ROLE: BRUTALLY ATTACKS THINGS NEUTROPHIL
How the immune system stops fungal disease: MACROPHAGEEPITHELIUM DENDRITIC CELL
How the immune system stops fungal disease: WHATS ALL THIS ERE THEN? MACROPHAGEEPITHELIUM I SAY CHAPS! DENDRITIC CELL
How the immune system stops fungal disease: OI! NOW THENOI!! MACROPHAGE OI!!! EPITHELIUM DENDRITIC CELL NEUTROPHILS
Adaptive Immunity – changes may lead to allergy
We recently used transcriptomics to look atdendritic cells from individuals with ABPA andchronic aspergillosis
Every cell in the body has the same DNA...But every cell is not the same – or we would all be blobs...
There are 25000 genes in each cell– but different cells use different sets of genesActive genes make RNAThe transcriptome is the RNA produced by the celland tells us everything that the cell is doing
Transcriptomics tells us which genesare active, and when...for ALL genes in the cell. £££££....
We took blood from individuals with ABPA, CPA, no disease or asthma From this we grew dendritic cells Then we split the cells into two groups - one was allowed to grow normally, the other had Aspergillus added. Then we made RNA and looked at the transcriptomesWhen we compare the difference between healthy cells and ABPA or CPA cellsOR when we look at how the cells respond to fungusWe can see everything the cells are doing and what makes the difference in disease
Individuals with ABPA or CPA:Do not produce enough C-lectin proteinsfrom their C-lectin genes. C-lectins bind to and sense the fungal cell. Without C-lectins the immune system cannot see the fungus
In conclusion: You cant fight what you cant see... Funded by: Mike Bromley Nicola Smith David Denning
Nebulisers – what we use and why Philip Langridge Specialist Physiotherapist Aspergillosis
Overview– What is a nebuliser?– What’s the difference between an inhaler and a nebuliser?– What medication goes into a nebuliser?– What sorts are there/ how do they work?– Cleaning/ maintainance
What is a nebuliser?• A device that converts liquids into a fine mist that can be inhaled and thus deposit in the lungs• A source of compressed gas (air or oxygen) drives the nebuliser• Can have mouthpiece or facemask (or through a ventilator)
Compressors–• Use compressedair as the Econoneb Use compressed air as the driving gas, at 6-8L/min. driving gas, at 6-8L/min.How it works: compressor as • Consider the– Air is“pump” that the the the drawn into drives compressor. nebuliser– It is driven through a filter . and through tubing to the nebuliser chamber. Portaneb– When it enters the nebuliser chamber it converts the liquid drug into a fine breathable mist, which the patient inhales.
What’s the difference between a nebuliser and an inhaler?– “Nebulisers are useful when large doses of inhaled drugs are needed when patients are too ill or otherwise unable to use handheld inhalers and when drugs are not available in that format for example antibiotics” (B T S 1997)– Salbutamol inhaler – 100mcg per puff– Salbutamol nebuliser solution – 2.5mg or 5 mg in 2.5ml solution
Size (of particle) matters!• Humungous in size are filtered in nose – 100 microns (1 micron = 0.001 millimeter )• Large in throat – 10 - 20 microns• Medium in small airways – 2 - 5 microns• Small in alveoli – 1 - 3 microns– (NB Aspergillus spores are very very small - 2-3 microns )
Nebulisation Time- (tell me when it’s over) Nebulisation to dryness is difficult to define. This maybe the time the nebuliser ‘spits’ intermittently or when no further aerosol has been emitted. It has been shown 80% of nebuliser drug is delivered in the first five minutes (O’Callaghan 1989)
Nebuliser performance – judgesopinion• When drug is delivered during respiratory cycle• Particle size/ where you want the drug to deposit• Respirable fraction….the percentage of respirable particles within the aerosol output (should be at least 50%)• Residual volume – Amount that never gets nebulised and delivered to the user
Nebuliser performance – public opinion• Cost of compressor, nebuliser• Servicing• Weight/ portability• Nebulisation time• Bottom line – does it do what you want it to do?• (does it help you more than it hinders you)
Cleaning Recommendations– Follow manufacturers instructions– Don’t let your rolling boil run dry in the pan!!!
Healthcare at Home• Introduction Why Selection process Who they are Why we use them Whats on offer and who qualifies
Why• Homecare was set up in November 2011 – Improve patient choice – Improve patient service – Improve ease of care by reducing hospital visits and waiting in pharmacy• to save VAT on high cost drugs – V- £30,000 per annum – P – £40,000 per annum – There is a delivery charge but it is affordable
Selection processThe decision to go forward and use a homecare service was explored and agreedThis then went out to tender whereby companies were allowed to apply to the Trust to be considered in the processThis process took several months before a decision was made
Requirements for applications9 companies were selected from this process and were invited to interview where they were required to demonstrate the following:• Ability to deliver the service• Safety and reliability with proven track record• Qualified staff
The Company - Healthcare at Home• Who are they? Healthcare at Home are a company who can provide the following: – Delivery of drugs – Nursing care – IV nursing care
Why Healthcare at HomeThey have a vast amount of experience in drug deliveryThey have a team of nurses available in most areas up and down the companyThey have a large team of people at their headquarters who can work closely with our team and monitor this process
What’s on offerDelivery of high cost drugs direct to patients homes – entirely optional and at your convenienceThis applies to Voriconazole Posaconazole Itraconazole solutionDelivery is made to all patients under the care of NAC providing funding is in place for the drugs
Who qualifies• Patients who are under the care of NAC• Patients who are on high cost drugs which are paid for by NCG or PCTIt makes no difference if you live local or distant the delivery can still be madeDeliveries are usually every two months dependant on your prescription
Advantages/disadvantages• Advantages: – Reduces the amount of visits for patients – Reduces travel for patients who live a long way – Removed problem of patients running out of medication – Patient choice – VAT savings
• Disadvantages: – Not experienced many at present – Some patients feel they would rather attend clinic – Weather may cause problems if very severe but again not experienced this yet.
Points to remember• Patients are still very much under our care• Should contact us with any concerns at any time• May require postal bloods in between visits• Still need to attend clinic• Can always attend in the interim if problems arise• Can withdraw from home delivery at any time
Going forward• Nursing care- will be discussed separately• IV’s at home – under discussion
Future meetingsFormat is for several smaller talks each month:1 invited speaker (external or internal)2 – 3 slots for one each of:PhysiotherapistService managementNursesDiagnosticsPatient involvement in ResearchPatient involvement in promoting awarenessYour feedbackMeet the Team
Future MeetingsRevisiting earlier subjects Damp homes & avoiding mould Nutrition Antifungal management Diagnostic services (tour of department?) NHS funding Genetic susceptibility to aspergillosis Lung function Clinical Q & A Allergens Physio
What else?Is there anything you would like to suggest as a subject? – remember it can be any part of the service and only has to be enough to fill 10-15minLeave suggestions (& criticisms) using forms provided – anonymously if you prefer.orEmail to email@example.comPhone 0161 291 5866 – leave message if no answer
Manchester Museum Science FestivalOctober 31st till November 5th 2012WE will be hosting an exhibition on fungal disease including LIFE art winners.
Changes at FRTFungal Research Trust = Fungal Infection Trust
FRT is changing its name to FITWhy?•FIT will continue to fund research exactly as FRT wasalways very successful at doing•FIT will also carry out a number of projects abroad toattempt to reach the many millions of infected peoplein countries like Africa & India via their governments.This is subject to quite separate funding from different sources.•Every £ raised for research in the UK for FIT will stillgo towards the same research funded by FRT.
When will FIT start?Within weeks FIT will become active and NEW initiatives will be carried out under that new nameFrom January 2013 FRT will have effectively transferred completely to FIT
Thank You“The best chance we have of beating this illness is to work together” Living with it, Working with it, Treating it Fungal Infection Trust