 to the Stephen Padgett Memorial Lecture. This lecture celebrates the life of Stephen Padgett who passionately believed that a greater understanding of physiology would lead to better medical advances. He was the founder of the Research Defence Society, which later became UAR, and this year we're delighted to celebrate the 83rd Padgett Lecture, adding Professor Dame Nancy Rothwell to our long and imminent list of lecturers. Nancy is President and Vice Chancellor of the University of Manchester. i gael i'r halen o'r oeddeithasig a'r gwych gwych gweithio'r cwsianthau o'r cyfnodau ar y dyfodol. Nancy wedi cael ei gymryd i siwer y cyfnodau ysgrifennu'r Gweithfeydd, UAR's predecessor, ar 2004-2007. Rwy'n cael ei fydd yn dweud i chi yn rhaid yn fydden, a nu'n rhaid i chi. Nancy yw'r cyfnodau sy'n gyfnodau ar gyfer y gwasanaeth maen nhw'n gweithio'r cyfnodau ar gyfer gwysig ar gyfer sydd gennymio cymryd yn treweannu gwahodol o sarch mulhaeth ammaedd yn gwybod drwwad a'r gyfan mwy o'r uchferfyniwyr mewn rhoi oherwydd ddwylltyn o'r cyff info yn seelbiol gan y gyfrif Weinham a'r gyfrif Weinham a'r cyfrif Weinham a'r cyfrif Weinham i lwylo cyntaf o cyfrif Weinham a'r cyfrif Weinham a'r cyfrif Weinham, wrth gwrs, a'r cyfrif Weinham yn ei bod yn eich trofa's oiner, i'n mewn cyfrif Weinham. Y cwryn sefydliwr yn ei ei ddweud o'r cyfrif Weinham na'r gyfrif Weinham a mae'n ysgolwch i'r rôl i'r cyllid i'r cyllid ynghyd yn y gweithio i'r ffordd yn fwy o'r gweithio. Yr cyllid yma yw'r rhan i'r cyllid eisiau i'r meccanidau ar gyfer y cyllid i'r cyllid i'r gweithio i'r rhaid, ac mae'r cyllid yn unig ar gyfer eich cyllid yn fwy o gyllid o'r cyllid i'r cyllid i'r cyllid yn y bwrdd. roedd unrhyw oherwydd i ddweud o dd Jacquen a roedden nhw'n llai'r cyffredinol i bernidog yn ystod ar yma. Felly mae'n oes i ni i ddim yn bwysig, siaradwr wedi roeddon nhw'n bwysig yng nghymru. Da'n ddod, i fy nghymru. Steoladwr yn y gallu i weld yn y brif iawn ar gyfer y Llywydd. Felly mae'r ddysg amser yn bai ffaith gael y Llywodraeth ymddangos i ei hirwm. of course for three years when I was president of the research defence society now I know the dates. Thank you. I'm going to give you a very brief background of my research on animals in particular with the main focus on our research on stroke, particularly addressing the issue of the relevance of animal studies in that and translations to patients. I'll briefly mention the importance of public engagement which has been a passion for me since I was a PhD student. Apparently, when I was two, I declared that my goal in life was to be a famous scientist. This is me age two. I've been reading its Lancashire Life actually, not a scientific journal, but then I forgot about that. You've heard a little bit about the background that's relevant to this lecture. I conducted animal research as an undergraduate in my project, a PhD student and beyond, and I've done many presentations on the value of animals in research, including public lectures and television. I was the director of the University of Manchester Animal Facility for many, many years and I'm delighted that we were one of the first to sign up to Concordat and indeed invite many visitors into it. You've heard some of the other things. I was a founder of the sciences federation and the welfare group and that then became the Royal Society of Biology, a very active group and I was chair of the National Centre for Three Isles grants committee and I do want to acknowledge many organisations who contributed to the position we're in today of a very different approach to animal research and to animal welfare, including of course UAR, those that have been mentioned, and the National Centre which has done a great deal. You heard briefly that I got into stroke research entirely by accident. My only research with Mike Stock, and by the way my teeth were different because he broke them playing squash one day, as your PhD supervisor does, and we were interested in how body weight is regulated, why do some people get a beast and some people stay lean, and indeed we were looking at it slightly differently because of course everybody is aware of energy balance in mammals and animals as well as in physical settings where energy intake must either equal energy expenditure mostly as heat or there will be a change in body energy content and the predominant view at the time was that obesity was largely as a result of excessive energy intake and indeed above expenditure which of course it must be but what we were interested in was whether also energy expenditure could be regulated such that higher levels of heat production could allow some animals and indeed people to maintain weight even when intake goes up and indeed I was the subject of an experiment during my PhD when we had to eat 5,000 calories a day for three weeks. I did gain weight, I gained about five kilos, and lost it again in the following three weeks. There are members of that study who were obese from the moment it finished and are still obese today and actually it's got worse and so they don't thank Mike Stock for that but largely what we did was to study thermogenesis and in animals it was recognised that a specialised tissue called brown fat can help them keep warm in the cold through high metabolism and we wondered whether humans could do the same and indeed this was then at the time the subject of a BBC horizon programme called the fat in the fire and before the programme went out and this was 40 years ago there was a big debate as to whether we should show all of the scenes or not and indeed we did and we did of course get complaints and lots of hate mail about it not about me shopping but of course about the use of animals this is Deirdre by the way who ended up being a pet rat but nevertheless we continue with that research and then a few years later I decided I was going to move from Manchester to Manchester where you may have gathered I'm from the north of England and then went on to a chair in physiology and decided that I had to carve out something of my own research career that rather than just working on obesity I had to work on something slightly different so as a metabolic physiologist which is what I knew all about metabolism I didn't change completely I decided instead of working on why do people get fat I worked on cichexia which is why is it that in disease there is such extreme weight loss and to cut a long story short we did studies on animals and on patients that demonstrated as had been shown by others that there is a very high metabolic rate in many diseases particularly when you think that patients are often eating less than they would do normally and of course we know this from the key hallmark of disease in particular infection which is fever and that fever has achieved a rising body weight partly through reducing heat loss but also through increasing energy expenditure and this is where the chance experiment came along we had an animal model of stroke that a colleague was using and I had a hypothesis that the high metabolism in these animals was due to inflammation in the brain and so we used a blocker of inflammation and indeed the metabolism was reduced and the animals lost less weight and I wrote this up later in a series in nature called changing and it was called the one last control experiment because the last control experiment we had to do was to check that the intervention was simply blocking the high metabolism who wasn't reducing the damage caused by the stroke and of course we found out that it dramatically reduced the damage caused by the stroke so within a period of six weeks I decided to change feels completely to move away from metabolism and into neuroscience and stroke and from being a platform invited speaker at conferences I ended up having to pay and go and learn and reread my undergraduate neuroscience textbooks but for anybody considering changing feels it's hugely invigorating to change because you have no baggage with you whatsoever so I started working on stroke and as you've just heard this is a massive clinical condition across the world it's the second leading cause of death and it is the leading cause of neurological disability and we have got a little better at treating stroke but we're still not particularly good so down here this is stroke here is death and here are all the other neurological conditions so very briefly and I recognize you're a mixed audience of eminent and very knowledgeable scientists and those with less background so I'll dip in and out of things in case you're not familiar stroke is simply defined as a reduced blood flow to part or parts of the brain and critically therefore reduced oxygen in the UK it is actually the third greatest killer and it can be caused by a number of different factors there can be blockage of an artery supplying a part of the brain that's the most common as depicted here and the territory supplied by the artery then has reduced oxygen it can result from a brain hemorrhage or an artery bleeding it can result from poor general circulation from heart failure from respiratory failure and of course in babies from birth asphyxia quite commonly and this is a condition where during birth normally there's restricted oxygen supply to the fetus often resulting in severe impairments so what are the current treatments sorry what are the current treatments we have well actually very few the key one is this one thrombolysis using an enzyme a tissue plus minogen activator is the clot and the result of you can see here's an occluded artery in the brain of a patient and here after tpa a reperfusion when tpa works it is unbelievable it is amazing and indeed when it was first licensed there was a consideration of how the story of tpa would be promoted in the usa because many patients who came into hospital with a stroke they didn't rush in and so you may have heard that it was the story of a patient given tpa was shown on the medical drama tv drama er and there's a patient who came in with paralysis down one side couldn't speak gave him tpa and walked out an hour later but the trouble is that episode of er was shown in the UK before tpa was licensed so lots of people who stepped on their right arm or something were coming into hospital but nevertheless tpa has transformed the acute treatment of stroke more recently mechanical movement of the clot endovascular thrombectomy is also showing very positive signs but we have to bear in mind these treatments are available to less than 20% of patients and there were two reasons for that if there's any uncertainty about whether it may have been a bleed rather than a clot then you don't obviously give something that's going to unblock a clot and secondly because there is a time frame during which tpa is effective and it's really only up to about six possibly eight hours and many stroke patients don't even know when they have the stroke they may have woken up in the morning or they may have been on their own so we're still left with a problem with stroke as a massive burden what we have had advances in is stroke specialised stroke units managing stroke reducing infections giving treatments that limit the cause of that stroke such as aspirin treatment for high blood pressure and so on but honestly where we are it's not in a particularly good place it is as I mentioned a massive clinical social and economic burden with limited treatments major failure of clinical trials as I'll come on to in a moment little interest now from major pharmaceutical industry and very very low government funding if you look at the funding per person who's had a stroke relative to some other diseases he's one of the lowest so why were they the wrong targets that were being attempted wrong animal studies the wrong patients the wrong trials on the answer that's probably yes to all of them there has in recent years been a really systematic approach to animal research on stroke and I didn't want to acknowledge the work of Mark McLeod from Edinburgh who's done a great deal of work on preclinical studies and he published this quite some time ago now tests in vitro and in vivo of potential treatments over a thousand tested in animals over 600 the numbers are even bigger than this now effective in vivo nearly 400 that's nearly 400 different treatments were effective in animal studies one came through positively in a trial and that's tpa so that does start to beg the question which I've thought about many many times are we doing the wrong animal studies and I think I can say in this audience that it's something we should question all the time are we doing the right animal studies have we got the right animal models so what went wrong I think there are a number of things that went wrong there was a focus on the brain why not stroke as a neurological disease but actually it's a cardiovascular disease almost always it originates outside the brain the fact the organs affected is the brain is secondary secondly and I'll come back to this there was a tendency to focus on disruption of normal processes rather than on specific disease processes what I mean by that is much of the research was looking at the massive disruption to the release of neurotransmitters like glutamate to changes in iron concentration inside cells like calcium and sodium these are all critical for normal brain function but they're incredibly well controlled and in a stroke there is a massive disruption thousands of fold change when you step back and think about it the task of blocking that thousands of fold change while leaving that little bit that's critical for normal function intact is a huge undertaking and in fact all of those approaches failed there is no doubt that the animal studies have been lacking failure to account for comorbodities failure to properly mimic nearly all studies on stroke were done in young male spragory rats or mice so that in itself is a limitation there is undoubtedly limitations on clinical design because stroke not until recently was treated like one disease in the way we used to treat cancer now it's categorised much more and trials are much more sophisticated but coming back to the normal versus the disease processes we thought about well what is a disease process that is unimportant in normal function and of course the classical one is inflammation this is from the front of time magazine the secret killer because of course inflammation is well recognised to contribute to arthritis inflammatory bowel disease and so on but we now realise that inflammation is a key feature if not a key cause of a hugely diverse range of diseases including interestingly obesity and that's changed since the time I worked on obesity because we now know that fat cells are not dormant storages of lipid they're very active sites of inflammation and that is probably one of the factors that contributes to the high rates of stroke and heart disease in obesity it's not just carrying that weight around or not even just foring up arteries it is because there are there are a site of major inflammation and of course atherosclerosis key cause of stroke and cardiovascular disease is also very much associated with inflammation now we've known about inflammation for thousands of years we've known about the pain the loss of function the redness the swelling and the heat and but it's only recently that we've started to recognise that this is important in just about every disease that we are aware of now of course inflammation is a host defense response it's something really important it diverts blood to tissues that have either an infection or an injury it diverts white cells it activates the immune system but when inflammation is inappropriate i it's too severe it's prolonged or it's in the wrong place it's massively damaging and indeed it is the cause of many of those diseases and we know that many of the risk factors for stroke are inflammatory whether it's chronic inflammatory disease recent infection or surgery and this builds up an inflammatory response key to inflammation is a whole range of inflammatory molecules and this is where I had to learn go back and learn undergraduate immunology again which is a task in itself and of course there are many many inflammatory molecules that's complement chemokines there are prostanoids and so on but particularly important are the cytokines and these are interesting the cytokines because they're normally produced by immune cells not always and they are released in the brain during injury but a key feature of most cytokines is they have little or no role in normal physiology there have been some suggestions of minor roles but really not particularly significant the first cytokine that was ever discovered was known as the endogenous pyrogen remember my reference to fever because it was recognised that since a bacterial infection didn't have to get into the brain to cause that increase in set point of course the fever there must be some signal from the infected site to the brain and so there was a long search for that endogenous pyrogen in the end actually it was isolated from many litres of urine of nuns in a convent who will got an infection at the same time and they're isolated the cytokine that was then known as interleukin 1 and it is still considered the first cytokine and by some particularly those who work on it the master cytokine but actually even interleukin 1 is itself a huge family now of many molecules and I'm just going to simplify it by presenting the major ones there are two agonists that activate cells interleukin 1 alpha and interleukin 1 beta there are others but these are the main ones and rather fortunately for us there is a naturally occurring interleukin 1 et cetera antagonist as far as I'm aware it is the only example of a molecule that does absolutely nothing as far as we can tell apart from antagonised the actions of another endogenous molecule interestingly these are all formed of precursors which for interleukin 1 beta it's inactive the others are active but this is very important because it has to be cleaved by an enzyme cuspase 1 cuspase 1 is involved in cell death and when the cialiguns genes for cell death were identified one of the first things that people doing when they found the cialiguns death genes was to say are there any similar mammalian genes and they found cuspase 1 and it does have a role in cell death and they act on a receptor there are a number of different receptors there must be more than one functional receptor but it's not known the nature of those as yet with a very complex intercellular cascade and there are loads of regulations on interleukin 1 things that regulate the synthesis regulate the cleavage block the receptor release the receptor block the downstream which you would expect of a molecule that is potentially damaging so when you activate cial 1 key is that it's deactivated it tends to produce very very locally indeed in fact you almost never find interleukin 1 in circulation it's just in the tissue that is damaged unlike other cytokines so i'll give you a few examples of this but it's got a long story short after that first serendipitous experiment when the brain damage was reduced by giving actually this interleukin 1 receptor antagonist after stroke we did a whole series of studies and what we found was that there's rapid production of interleukin 1 in the brain of animals after a stroke that administering interleukin 1 increases the damage caused by a stroke and that blocking my l1 markedly inhibits injury and i'll just give you a few examples of those in some data to illustrate so in rats this was we've used a number of different species and in rats we looked at the expression of interleukin 1 and found it occurred very early indeed and and it's shown here with interesting it was mainly our one alpha unexpectedly the red staining here and it actually all co localises with microglia and one of the forms of glia in the brain and it is actually on the contralateral side as well as the side of the stroke we administered interleukin 1 to animals to determine if that had any impact on the stroke and this is assessed either histologically or through mr imaging to determine the size of the stroke in the brain in just the same way as you might use mr imaging in patients and on the left is animals given vehicle on the right given a very low dose of interleukin 1 giving an exogenous agent and seeing an effect in itself proves nothing of course but this could be very important because one of the things that makes a stroke a lot worse is an infection in fact pretty much all neurological disorders are worse during infection now we can't say for sure but that might be because there is more interleukin 1 being produced patients with multiple sclerosis in particular have much worse symptoms and patients with dementia also do but obviously the more important experiment which i've mentioned before was blocking endogenous interleukin 1 and for this we used the endogenous interleukin 1 receptor antagonist and here is the total damage the vehicle treated and here markedly reduced and it reduced it in both the cortex and the striatum now of course it is possible that the antagonist is doing something else other than just blocking interleukin 1 so we used a whole range of other approaches with antibodies with inhibitors of the enzyme caspase 1 probably most definitively using knockout animals and these are now mice in which the genes for interleukin 1 alpha or interleukin 1 beta or both were deleted and what you see here is if you delete either our 1 alpha or our 1 beta there is no effect on the damage because they compensate for each other if they're both deleted there's a marked reduction in damage so this and many other studies bias and other people did suggest that endogenous interleukin 1 in rodents at least mediates a significant part of the damage caused by a stroke what an experiment we did which which had led to a result we hadn't expected was to see what happens when you delete the gene for naturally occurring interleukin 1 antagonist and what we found there was the damage is much worse so in other words that naturally occurring antagonist is serving to limit the effects of our 1 it is actually putting a break on it and when you look at look for mutations in the our 1 family genes and the relationship to stroke or worse outcome actually most of the mutations you find are in this antagonist and it's likely that the antagonist which is produced after the interleukin 1 serves to limit its effect both spatially and temporally so then of course a big question is how does it work and where does it work one of the problems in treating stroke is getting drugs into the brain although there is a disrupted blood brain barrier it may not be enough so is interleukin 1 just acting very locally so we'd have to get the antagonist in very locally because although it is effective when given peripherally large doses are needed so we did some studies to inject very low doses of interleukin 1 peripherally systemically in mice and found that even at doses this dose here of 10 units doesn't even cause fever but it does worse than brain damage and this is actually neurological deficit which is also worse so this suggests that even very small doses you cannot detect that interleukin 1 in circulation kind of have an effect on the brain how is it doing that well we think that one of the ways it's doing it is by mobilising neutrophils from the bone marrow and the reason we think that is if we do this experiment and then give an antibody to neutrophils the effect is lost so here's the brain with lots of neutrophils in it and in animals treated with interleukin 1 here with the antibody none here's the exacerbation by interleukin 1 and when neutrophils are blocked then the damage is not exacerbated so it looks as though tiny doses can exacerbate the stroke by mobilising neutrophils but that suggests it can work peripherally not it does so the big question is what about indod on a interleukin 1 is that mainly peripheral outside the brain or is it mainly in the brain and in some heroics experiments by Adam Dinesh when he was a postdoc he did adoptive transfer bone marrow transplantation so what he did is he took classical way of doing this mice that have interleukin 1 and mice that have none irradiated them and then did a bone marrow transplant you end up with mice that have got aisle 1 in the brain and outside the brain ones that have got it only in the brain ones that have only got it outside the brain and ones that haven't got any and the surprising result was that actually in all of them the damage was reduced so it suggests that both peripheral and brain interleukin 1 contributes to that damage and actually the reason for this might be because a major target for interleukin 1 is endothelial cells the lining of the blood vessels on this I'm not I apologize it's slightly complicated side the work done by Emmanuel Pinto he did targeted deletion of the receptor only on endothelial cells in animals and what he found was deleting it here just on the end of the old cells caused a reduction in damage and this is just immune staining as well on this neurological score so in other words a key target for interleukin 1 is actually the blood vessels we know there are other targets as well so from our studies it was shown by us and many more that inhibiting aisle 1 through a number of different means inhibits damage caused by focal very localized or global cerebral ischemia or stroke whether it was permanent or reversible experimental traumatic brain injury chemical damage caused by excited toxins animal models of multiple sclerosis seizures actually are not on here but animal models of birth asphyxia and in animal models of dementia in the triple transgenic Alzheimer model it reduces the mechanisms which I'm only going to say very very briefly appear complex and multiple so what we think is that in the brain at least most interleukin 1 is produced by microglia it does act on astrocytes to release toxins from astrocytes locally interesting the effects on neurons are probably beneficial but it also acts on the endothelium within the brain to cause activation production of adhesion molecules and release of chemokines but also there is a peripheral inflammatory response to a stroke which you can see an acute phase response to a stroke and that in turn activates bone marrow to release neutrophils which aisle 1 mediates and again appears to act to worsen damage and in terms of downstream mechanisms I'll say no more than this that's enough probably but that's all well and good but but you know are do these studies have any meaning for stroke patients particularly given what I've said about everything else has failed and again Markiplier did some interesting studies where if you can't read it he did a system a meta-analysis of all the experiments done within to look in one receptor antagonist and he said the animal data supporting our one receptor antagonist as a candidate drug for stroke are limited and further experiments are required before a trial is undertaken unfortunately we'd already undertaken a trial but nevertheless we went back efficacy at later time points and animals with comorbidities and it does say it's more effective when given into the brain than peripherally so that prompted a whole series of studies if you like going back and saying we need to stop just using young male rats and mice and we need to much more closely mimic the clinical condition that happens in a stroke and I'll just illustrate a few of the things that we did so this is actually showing that when given quite delayed it's still effective so this is when it was given six or eight hours later and it's still effective and actually you probably can't see it on here but these are lean animals and these are corpulent which I'll show you those in a minute so it was effective when given at a time after the stroke that could be clinically relevant we also then found that it provides long-term recovery because a concern is interleukin 1 might be causing the short-term damage but maybe it's good for a pair of recovery and you don't want to block it but actually what we found and this is giving interleukin 1 either at the time of the stroke or 12 hours later then looking 28 days later this is the key graph here so this is looking at success in a neurological score controls here animals given R1 receptor antagonist are still improved and almost back to normal 30 nearly 30 days later and actually it seems that not only does R1 receptor antagonist limit the damage and that's long term it actually may promote repair and recovery because it appears to drive neurogenesis the formation of new neurons which does occur although not in large amounts in the brain after an injury and obviously the younger the animal or the person the more likely it is that they're going to have neurogenesis so this shows a placebo an R1 receptor antagonist and signs here of new cells being formed and when they're counted the R1 receptor antagonist was causing a significant increase in neurogenesis so this is of course reassuring but still doesn't answer a number of significant questions that you might want to answer if you're going to take it into clinical trials and in terms of clinical relevance we looked at comorbidities beyond the obesity timing of administration which i've briefly told you pharmacokinetics is it going to get to the place which is going to be effective in the right concentrations does it is it effective with existing treatments does it work when given with gpa and how do we improve the design of clinical trials because otherwise this might be yet another failure in the long list in stroke so in terms of comorbidities when you think of many people who get a stroke they are often obese they may have diabetes they often have atherosclerosis, hypertension, infection and they are largely old not all and indeed we are actually looking at industryable hemorrhage and sobriquant hemorrhage which tends to occur in younger people so i won't show you all the data but we've modelled all of these in animals and looked at obese animals diabetic we've also looked at animals with severe infection and in each of these cases the interleukin one receptor antagonist is effective and just to give you one example here's the corpulent rat here very corpulent and the lean one here which caused a bit of problem looking after them this is the damage in the lean and this is in the corpulent and the lower one is animals given the R1 receptor antagonist and it was just as effective and actually we then had a big argument about what dose should be giving to a corpulent rat which is two and a half times the size of its lean litumate so we actually dropped it to the same absolute dose and it still was protective rather than adjusting for the greater body weight but then on i think importantly what we did was a large cross-slap study funded by the European Union i'll have to say go no further on that um it was a great we had a long series of european um funded research between a number of stroke labs and we decided what we had to do was each do the experiment in our setting in our animals completely blinded so all by should have said that now following all the guidelines every experiment is double blinded it's fully randomized everything is you need to do or should do and having got involved in clinical trials there's a lot that you could take back to animal studies that is routine in clinical trials so what we did was a study in budapest two separate studies in calm one in lubeck and three in manchester different investigator for each study there were different strains of rats but you'll see the meta analysis showed a significant benefit for treatment so i think that does suggest that it is robust and i think now um we have done multiple laboratories we've done male and female animals we've done old animals and we've done comorbidity so this does suggest at least that the data are robust and thankfully mark and mcleod was happy um did a systematic review of meta analysis of the efficacy um and uh he says the only major standard remaining evidence required is efficacy of hypertensive animals which has been done on the basis of our one of evidence currently available our one receptor antagonist is an attractive candidate for clinical trial yeah so how does this relate to clinical studies and which we've been doing for quite some time one of the questions that's been around for a long time is is inflammation a cause of stroke never mind what happens afterwards and actually there's there's good evidence that that is the case um but well we we also looked at biomarkers for inflammation and risk factors pharmacokinetics trial design and patient selection so uh there's good evidence that there are inflammatory episodes throughout life whether it's a bout of um flu or respiratory infection and that each contributes to a growing inflammatory load we all get more inflammation as we get older whether it's a slightly creaky joints or you know slightly more i don't recover quite so well but there was good evidence not from us some very good epidemiological studies that showed in older patients who suffered from an upper respiratory tract infection they had a three fold greater risk of getting a stroke or a heart attack in the three weeks after the infection now there could be all sorts of reasons for that but an inflammatory dive might well be one of them and in fact a lot of research has been done looking at inflammation in the brains of patients either with stroke or with other conditions or at risk so this has involved postmortem analysis looking at the expression of cytokines and other inflammatory factors in their brains it's involved micro dialysis or sampling of brain tissue but obviously some of the most powerful approaches are to use imaging and one example that i'll give you here is using pet and mr imaging so there's a stroke patient the stroke is here this is using a well known tracer that binds to activated microglia there are neural ones now that have been used this is pk triple 195 and microglia are the main source of interleukin 1 and you see the concentration here of activated microglia around the site of the stroke it's circumstantial but it does suggest at least and there've been a number of other studies down and indeed in dementia as well but it does at least suggest that there is inflammation in the brains of people who've had a stroke um we did some very small studies looking at patients at risk um and and we defined risk as having um significantly raised levels of a key inflammatory marker but without any neurological symptoms and any obvious ongoing infection and the marker we use will see reactive protein it's a good long-term marker of inflammation and this just illustrates it's not definitive by any means um again pet imaging in four patients with high crp and four with low to normal these were all older patients in their 70s now what we need to do really but it's unbelievably expensive is to get a larger cohort then ask to the ones with the high inflammation go on to get either dementia or stroke but the cost of doing that in pet in all of them and then a long-term follow-up is absolutely huge but in terms of taking what we had done in the lab in animals into patients we felt we had three key questions to answer these were the pharmacokinetics how much do we have to give does it get into the brain does it need to get into the brain is it safe and is it effective and i'm going to give you the answer to the first two and only the half answer to the third i'll warn you now we haven't got quite to the end of the story so pharmacokinetics um we first did some studies where we pet labeled our interleukinworm receptor antagonist and animal studies suggested that it did get into the brain when you do the imaging but we wanted to do it in patients and that's quite difficult to do so we decided that rather than look at stroke patients we look at patients with some arachnoid hemorrhage now um this is obviously um bleeding in the brain significant portion of those patients go on to get a secondary stroke about 20 get delayed cerebral ischemia in the two or three weeks afterwards um and this just illustrates um uh aneurysm here um which often bursts or starts to leak causing a hemorrhage uh with damage here or here and it's actually not that different one of the differences though between patients who've suffered subarachnoid hemorrhage and those who've had stroke is firstly they're very intensively managed normally on a neuro surgical intensive care unit whereas stroke patients until recently have been on general wards but also that many of them have an extra ventricular drain put in that means the csf is drawn off because the pressure in the brain goes up because of the swelling and therefore that has to be relieved so a drain is inserted into many of these patients sorry about the gore bits um drilled in through here and this is withdrawn so we thought this routine sampling could be a way of testing whether or not the interleukinworm receptor antagonist got into the brain now we had to do this after the initial bleed and we had to check that there wasn't still a bleed ongoing because that would just be coming straight in obviously what we found in these patients um was that um if we looked at plasma levels go very high very quickly this is the levels in the csf now the concentration required in animals to be effective is about here so enough was getting into the brain so that suggests that we could get enough into the brain in these patients and in others we have surprisingly seen almost no side effects of interleukinworm receptor antagonist given at least for two to three weeks the one we were worried about was opportunist infections particularly on these very sick patients on neuro surgical intensive care but really saw either minimal or no increase in infection um so we've done a number of clinical studies now in stroke and sub-rack narrowed hemorrhage and I'll just highlight a few of those um in taking it into patients we knew it was very safe because this drug is actually used to treat rheumatoid arthritis it's not particularly good compared to satia enough hunting bodies because it got quite a short half life but actually for stroke you want a short half life for chronic treatment you want a longer half life but there were really very few side effects reported on our trials now ongoing with inhibitors of aisle one in mycardial infarction in birth asphyxia in a number of other conditions we've done primary clinical studies so we had an idea of the feasibility of giving it and it was given intravenously in the first study and later it's been given subcutaneously and we've done pharmacokinetics on that as well so the first study we did was a phase two study really just to determine can it be given and is it safe and can we get any indication from biomarkers uh that it was actually blocking inflammation it was a fairly small study this was a number of years ago so we chose to study a range of biomarkers in the stroke patients and these are all markers of inflammation and all suggested that the aisle one receptor antagonist was indeed reducing the levels of inflammation which was positive so if we just look at these four graphs this one gives neutral count in blood this is total white blood cell count this is a C reactive protein and this is interleukin six interleukin six is interesting it's another inflammatory cytokine you find lots of it in circulation it's downstream of interleukin one and one of the reasons we know that interleukin one doesn't worsen damage just by increasing temperature is because interleukin six also increases temperature but it's actually protective it's the opposite but in each case the first thing you see is this acute phase response to the stroke the open triangles here are the stroke patients given placebo and in every case there's an acute phase response which is probably worsening the damage and in each case the patients given the R1 receptor antagonist the active component it was largely reversed it was far too small the study to be powered to get any definitive outcome but we did look at neurological scores and these are two different scores and in each case the white part is fully recovered the black is died this is lost and on both measures it did appear that there was more patients in the R1 RA treated group that did well we've then done a large study with biomarkers as primary outcome and we used interleukin six in CRP the area under the curve in patients treated with placebo or the interleukin one receptor antagonist and in both cases it met the primary endpoint we then did a larger study of R1 RA in acute stroke and it met the primary endpoint of reduced markers but there was no clinical benefit so we asked what's changed and from the first study when not a single patient got tpa all the patients in this trial got tpa so we are looking into whether that might be an interaction with tpa and the largest study we're doing now is in subarachnord hemorrhage and in fact i won't go through these but there are now either ongoing or completed quite a number of clinical studies um all led from Manchester but now multi centre and the two big ongoing ones at the present time are a phase two study in intersteroidal hemorrhage very serious condition more rare and a phase three definitive study in subarachnord hemorrhage we chose subarachnord hemorrhage because of the most recent stroke study i could have said also that interleukin one has been implicated in many different neurological disorders and indeed in some psychiatric disorders it's been implicated in schizophrenia in depression in many others in some cases there's good evidence and in others there are but just as i finish i do want to say a huge thank you to all the people i just want to say a couple of words about public engagement um so large group in Manchester very large group um too many to mention i'm extremely fortunate that since i became vice chancellor they let me meddle so i can still do some research because there are now eight members of staff at the university who trained with me at various different times four of them are professors and they do all the hard work and they're both clinical and scientists and i go to the lab meetings i read the grants i read the final papers and i sort of meddle when i when i want to public engagement talking about animal research has always been a focus of what i've done and what this group currently does largely led by stewart allen they do a huge amount of work with stroke survivors and with the stroke association and many descriptions and discussions we've had stroke survivors come into the animal facility see exactly what we're doing they see the surgery which is can be quite distressing um it's now instilled in all researchers they all take part in it very pleased that Manchester won the only goal more watermark from the national coordinating centre for public engagement and they talk to schools uh the public and so on and the animal facility in Manchester is very heavily involved in this and has always been extremely supportive but i'll leave you with a thought um which if you remember what i said when i was two um still aspiring to be a famous scientist and i was given this um present by somebody a little while ago and it's somebody who knew me quite well and i thought it was a i didn't quite know what to make of it um this is well behaved women rarely make history i'll still finish there thank you thank you Nancy for a wonderful lecture seems to me it was a stroke of good luck not bad but anyway you call it bad luck um i'm not quite so delighted to realise that since i've got a stinking cold i've got a three times higher risk of a stroke next week and i don't feel quite so happy but still anyway um we've got time for questions and i'm sure people would like to ask some so please raise your hand wave and there are microphones will come to you uh all shy come on somebody ask a question while you're thinking um it makes me think and i should know the answer but i don't since you can give aisle one receptor antagonist in a significant period after the stroke and reduce the symptomology and perhaps recovery enhances have people actually systematically tried this post mi yes i know it's a different process but yes they have and it's very interesting um that the studies um done in Sheffield um they went to a phase two trial and the outcome was negative and then it was found that there was a flaw in the independent analysis and it actually was positive it wasn't powered for um clinical efficacy although there was what you always look for that hint of efficacy but it certainly met all its primary endpoints after mi yeah and i would think you'd give it in conjunction with the other things you give in mi why not it's not harmful it doesn't be um so it could be very useful to be given post mi yes because i think my comparison with the idea that you chronically give an antagonist to try and reduce the incidence of mi this is well it might work but it's a very expensive and b doesn't do very much it's even been suggested that perhaps it should be given to patients at high risk um prior to you know crotted um under under our tractomy or crotted bypass or coronary bypass or transplant because the last thing you want is an inflammation during that period so why not just it will bring down to anything else question about thank you for that wonderful lecture um the work that you showed with the multi centers all repeating the same work was very inspiring and also that that was in different strains of mice and some rats i think um what's so that's very felt very definitive moving forward to patients did you feel you should also try in other species of animals yeah we haven't done but others have it's never been tested in primates but it has been tested in pigs rabbits i think at least one other yeah and of course clinical trials are always multi center so the worry with the small study small studies on patients are always done in a single center incredibly well controlled or under the same condition then you go to a multi center trial and it all goes to pot because it's all slightly different in every one what i should say and i didn't go into the detail is we narrow down the entry criteria are quite significant for entry into the trial because that's the other problem if you take all comers some of them might have a clot some of them might have to be hypertensive so we did narrow down the range of severity the range of age and the time of presentation but it's not been tested in primates there was one small study in in mama's that's which looked promising but wasn't very definitive can i can everybody shout i have this job that's his brain inflammation ever a good idea don't think so i don't think it is no um well no let me take that back if it was highly localised and defined it could be hugely beneficial in a response to a very localized injury or a very localized infection that's what inflammation is good for it's very very localized and it's terminated quickly but if you think one of the major problems in cerebral malaria in head injury and hemorrhage in all of those it's a really bad thing but like most things our immune system is phenomenal and inflammation is phenomenal as long as it's very tightly controlled and there are many controls on it it's when it seems to go out of control but i'm often asked a slightly different question is why have we evolved to have into looking one produced after a stroke when it's so damaged we could use the same argument why have we evolved to have all sorts of nasty things produced firstly you could argue that the many neurological disorders probably occur later in life so there would have been no evolutionary pressure either way and secondly there is evidence that very small amounts of interleukin 1 are protective to neurons so it could be that they're protective and the final thing and this is highly speculative um is you could imagine that actually if you've got damaged cells in the brain which you know well that are misfiring that's a really bad thing you're better off given dead probably than misfiring so it could actually be a let's kill these cells or it could have been something that emerged in response to um cells with DNA damage as in cancer hi i'm just wondering whether or not there were any differences ever seen between male and female animals or patients um yes um in our studies um not absolutely i in animals is protective in females you have all sorts of worries about um you know if you're using animals you've got to worry about Easter cycle and whether that affects certain and Easter gen is protective slightly um against stroke um but not fundamentally in terms of um whether or not um it works i protects in patients um stroke tends to be slightly more common in women um Sir Brock and I hemorrhage tends to be slightly more common in women reason isn't known just not enough studies done to know if the response to into looking one is any different of course women tend to be much more prone to autoimmune disease so might be generally more inflammatory much more prone to um uh Lucas to rheumatoid arthritis not you know men do get it but but there is tends to be a more inflammatory response and really interesting of course the time when when when women with autoimmune disease um see an alleviation of symptoms is due to pregnancy and they get immune suppression i miss a slightly more common as well in women hello thank you for such an excellent talk i actually wanted to ask about your gold award for public interest oh right um has it what kind of impact has holding that award had within the university so i think already i think i think we won it because they came and they interviewed stuff and students picked at random without any staff there so we couldn't pretend and the questions they ask was is this held as important is it part of your training is it encouraged and generally they said yes so i think that was there anyway i think the gold award has done two things one is the pride people are very proud of it but the second thing is when you do find these isolated pockets and they are isolated i hope of the phd student who says but my supervisor says i'm too busy doing my research and i haven't got time to go out on you know saturday morning and talk about what i do so we're just going to show them this gold award will you um you know and they say well it won't count for ref i see it will count for impact believe me we happen to know brown cox's lectures on television got a four star in ref so you know um well they double the sale of telescopes so um that was a good measure actually um but you know i think i think it did um on others will win it i'm sure but given you know i'm always been very passionate about it i say you're not doing this just because you know we say you should do it or the funders say you should do it you are funded by the general public but if you do public engagement you pretty much get better at doing most sorts of presentations one of the things in one of the faculties the phd students are asked to do is talk about their research and the audience is the cleaners and the secretaries and they judge and that has two benefits firstly it's a public audience with no knowledge and secondly it makes um the cleaners and the secretaries feel very proud and much more engaged in the research that's going on in their building which are similar things with animal research talk to them about what we do and then they feel a pride in it when you did the life scientific oh yes yes you mentioned your animal research i did quite a lot through it did you have any was that did you get feedback on that at all did you get any negative no i didn't i mean 30 years ago i would have done i mean i would have gone into it i would have done it but i would have thought oh goodness you know i've got to think about this and then you know the university would say oh what are you doing are you going to talk about it oh god do we need to get you more protection i didn't really think about it anymore i know this is a concord out of open nurses this is what UARs don't what NC3Rs and what everybody else has done i don't really think about it now i mean you occasionally get one or two people writing in or twitter comments you know how outrageous this is what you do um but nothing like it used to be where there was a sense of real hatred and and and you know organised unpleasantness you know i don't have special branch visiting me saying don't put your car there anymore and you need to change your phone number and stuff it just doesn't really happen um i think i even raised it on desert islandists actually but um yeah i didn't worry about it though i didn't think about it on the back oh mike and unsee my ancestor oh yeah he's a plant yeah he's going to ask me the most difficult question so i did this he didn't really unsee but how do you explain to the general public the fact that you've done thousands of animal studies over the years and we've still only got one target stroke that's a very fair question so stewart gets this question on i know i know yeah stewart allan is now leads the neuroscience group first of all stroke is very very complicated and very difficult you think how hard it's been with cancer to get treatments how long it's taken and actually you can get at cancers much more easily trying to get at something that happens inside the brain is unbelievably difficult and i think we've spent a long time learning and i think it's best to be honest and say we didn't get it right always um and i think we're doing better now so to pretend that actually i was all fantastic and we did everything brilliantly i don't think is the right way i think i've always found when i must that question is yeah we learned a lot as we went along and we realised we weren't doing it all as well as we could have done and then they said well do you know you are now and you say i can't be certain the trials might fail and it might still be wrong and you know what do you do then but i always find honesty's best you most pharmaceutical companies now would probably want some indication that there's good human genetic evidence that the ire one system is important in stroke and i guess there is some there is some yeah um i'll just very briefly skipped over the fact that we've done a lot looking at um polymorphisms in the ire one family and others have done as well and we looked particularly at patients at high risk who did get a stroke and the two groups we looked at were patients who'd had a TIA a transient ischemic attack or a mini stroke quite a number of which go on to get a major stroke um ones who'd had some right annoyed hemorrhage and did go on to have a secondary ischemia or didn't and ask what featured there so and we look for plasma biomarkers as well um we found polymorphisms associated with the promoter region of the ire one receptor antagonist gene suggesting maybe it's not too much ire one but it's too little antagonist and the single correlate from bioplasma biomarkers was the esr ishrus writes a wreath recite sedimentation rate which of course is an inflammatory marker to some extent that came out of both levels so yes but not great there are extreme mutations of course in the ire one family where you get massive inflammatory conditions and ire one array is used in those um in extreme hyperpyrexia and things like that any more questions yes one here you mentioned the liver and we need the mic as well just to expand on that you indicated there was the oh sorry that's all i can repeat the question um you mentioned the liver but didn't expand on that and but also mentioned that there's the impact of the periphery yes and it's become well more trendy but also relevant obviously in terms of understanding this gut brain access and the yep so um what you see after a stroke is the classical acute phase response and many of the acute phase proteins are produced by the liver um and we think and some of that happens very fast we think it must be neural some of it because you can actually see it in minutes um so it could be a neural um supply to the liver and then of course the liver activates a load of other things but bone marrow experiment adam did he um denivated um bone marrow um in the leg of animals and showed that there was a neural component to that as well so it's the whole acute phase you know stroke is no different to having you know breaking your leg you just get a massive acute phase response in the brain and in the periphery the surprising thing was that ire one seems to be important in the brain and outside the brain that was that was somewhat surprising I guess my question is a little bit broader than the specifics um Nancy that was a great presentation thank you very much um there seems to be we take a much greater focus nowadays on mental disease as being something that is actually physiologically difficult pathologically changing perhaps and association with inflammation for diseases such as or conditions such as depression so is what you're describing here part of that whole story around how we will understand the mechanical changes that take place in mental disease as opposed to just thinking it's people going crazy well the first thing to say in the spirit of honesty is I'm not a psychiatrist and so I should be careful here I think the evidence for inflammation in um psychiatric disease like depression is fascinating but not definitive would be my take on it at the moment um and you know you have to rule out the fact they've got some patients might have something else wrong with them that's causing inflammation they're depressed about it so um but but there's been some very interesting studies not done by us I mean Robert Robert Dancer did an awful lot of work on depression in animals and on behaviour and into looking one is a very key driver of what's often called sickness behaviour which is the fact that you'll feel depressed when you've got a some sort of infection you're sleepy you don't want to eat and that is all I want mediated uh or at least block it and you do block it what hasn't been done very much and of course my deciphering anti-inflammatory is in trials and quite a number of diseases um mental health diseases I've not seen any really big studies and that's not to say there haven't been any because I don't follow it that well the literature um to show that actually there is a very strong correlation between depression and bouts of depression and inflammation or the anti inflammatory agents and it's very hard doing these studies because the first research on dementia arose because of the lower incidence of dementia in patients with rheumatoid arthritis but only if they were on anti-inflammatory agents then they did the proactive trials and they couldn't prove it now they've done them better and for longer and it is looking like it's true so it's quite they're quite difficult studies to do I think no further questions then the first thing I have to do is make sure we all thank plants you get resplendent and don't worry I'm not doing more speeches I want to say something which isn't in my notes I want to make sure that we recognise the whole of UAR staff who've done a fantastic job A in running and keeping UAR going as the wonderful organisation it is over the last year but also in what they've contributed to putting tonight together so thank you everybody very much