The clinical applications of a systems approach

Proposing an integrative, dynamic and transdiagnostic model for addictions: dysregulation phenomena of the three main modes of the predostatic mind

Several theories have been proposed to explain the complex diagnostic aspects related to addiction disorders and their development. Recent frameworks tend to focus on dimensional perspectives of symptoms rather than categorical systems, since substance use disorders are frequently comorbid with other psychiatric and especially personality disorders. However, useful transdiagnostic models that could integrate clinical evaluation derived from neuroscientific theories are lacking. In the present manuscript, the authors propose a model based on a new paradigm, in an attempt to better explain this complex, multifaceted phenomenon. The new paradigm presupposes that emotions and behavior are a response to risk prediction. Individuals make choices and engage in actions to manage potential risks/rewards in order to seek or maintain homeostasis in their internal and external environments - a mechanism that the authors call predostatic (predictive mechanism with homeostatic purpose). The model considers three main modes of the predostatic mind: (1) Alarm Mode, activated by high and/or imminent risk prediction; (2) Seek Mode, activated by long-term risk or reward prediction; and (3) Balance Mode, a self-regulating state of mind related to low risk prediction, a soothing system and a calm state. Addiction is seen as a chronic dysregulation of organism systems leading to internalizing or externalizing phenomena mainly related to the Seek and Alarm Modes, which are persistently activated by reward and risk prediction, respectively, thus hindering Balance. Addiction neuroscience research has shown that chronic drug use or engagement in addictive behaviors can lead to neuroadaptations in the brain reward circuitry, disrupting normal balance and the regulation of reward processes. This dysregulation can contribute to persistent drug-seeking/addictive behaviors despite negative consequences. This newly proposed dynamic and integrative model, named dysregulation based on externalizing and internalizing phenomena of the three main modes of the predostatic mind (DREXI3), proposes six dysregulation dimensions with basic emotional and behavioral symptoms, such as neurophysiological alterations, impulsivity, compulsion, cognitive impairment/psychosis, mood, and anxiety/anger. In this paper, the authors explain the rationale behind DREXI3 and present some hypothetical clinical examples to better illustrate the use of the model in clinical practice. The development of this innovative model could possibly guide tailored treatment interventions in the addiction field.

A cultural-ecosocial systems view for psychiatry

While contemporary psychiatry seeks the mechanisms of mental disorders in neurobiology, mental health problems clearly depend on developmental processes of learning and adaptation through ongoing interactions with the social environment. Symptoms or disorders emerge in specific social contexts and involve predicaments that cannot be fully characterized in terms of brain function but require a larger social-ecological view. Causal processes that result in mental health problems can begin anywhere within the extended system of body-person-environment. In particular, individuals' narrative self-construal, culturally mediated interpretations of symptoms and coping strategies as well as the responses of others in the social world contribute to the mechanisms of mental disorders, illness experience, and recovery. In this paper, we outline the conceptual basis and practical implications of a hierarchical ecosocial systems view for an integrative approach to psychiatric theory and practice. The cultural-ecosocial systems view we propose understands mind, brain and person as situated in the social world and as constituted by cultural and self-reflexive processes. This view can be incorporated into a pragmatic approach to clinical assessment and case formulation that characterizes mechanisms of pathology and identifies targets for intervention.

Diagnostic Stability and Phenotypic Differences Among School-Age Children Diagnosed With ASD Before Age 2

Given the importance of early detection, it is critical to understand the non-linearity in manifestation of ASD before age 24 months, when ASD symptoms are beginning to consolidate, through the age of 36 months when stability of ASD diagnosis is reportedly high into school-age when increased demands may challenge previously successful compensatory processes and permit first ASD detection. We employed a prospective, longitudinal design focused on children with an older sibling with ASD (n = 210) who received diagnostic evaluations at mean ages of 15.4 months (Time 1), 36.6 months (Time 2), and 5.7 years (Time 3) to examine: (1) diagnostic stability, (2) developmental trajectories associated with different patterns of ASD vs. non-ASD classifications, and (3) predictors of classification group over time. Clinical best estimate (CBE) diagnosis of ASD or non-ASD was made at each time point. Linear mixed-effects models were implemented to examine differences in developmental trajectories of stable and dynamic diagnostic groups. Multinomial logistic regression analyses were used to examine predictors of the likelihood of belonging to each CBE diagnostic classification group. Results revealed that sensitivity and stability of an ASD diagnosis significantly increased from Time 1 (sensitivity: 52%; stability: 63%) to Time 2 (sensitivity: 86%; stability: 68%). Different developmental trajectories of autism symptom severity and non-verbal and verbal IQ were observed across groups, with differences first observed at Time 1 and becoming more pronounced through Time 3. Presence of restricted and repetitive behaviors as well as limitations in initiation of joint attention and expressive language skills differentially predicted the likelihood of belonging to the different CBE diagnostic classification groups. Results suggest that ASD symptoms may emerge or attenuate over time, with some children meeting diagnosis at follow-up, and other children no longer meeting diagnostic criteria. From a systems perspective, diagnostic non-linearity may be viewed as a dynamic developmental process, where emergent properties arising from various biological, genetic, and experiential factors interact, culminating in phenotypic phenomena that change over time. Clinical implications include extending universal ASD and social communication screening into school-age, supporting families' understanding of diagnostic shifts, and ensuring unbiased diagnostic decision-making when following children with ASD.

Interaction between Autonomic Regulation, Adiposity Indexes and Metabolic Profile in Children and Adolescents with Overweight and Obesity

Early obesity predicts initial modifications in cardiac and vascular autonomic regulation. The aim of this study was to assess the possible interaction between non-invasive measures of autonomic cardiovascular control and peripheral endothelium regulation in children with overweight and obesity. We involved 114 young subjects (77M/37F, 12.7 ± 2.2 years) with normal weight (NW, n = 46) to overweight or obesity (OB, n = 68). Multivariate statistical techniques utilizing a collection of modern indices of autonomic regulation, adiposity indexes and metabolic profile were employed. Resting values show substantial equivalence of data. Conversely, blood pressure variance is greater in NW/OB groups. The correlation matrix between major autonomic and metabolic/hemodynamic variables shows a clustered significant correlation between homogeneous indices. A significant correlation between metabolic indices and endothelial and autonomic control, mostly in its vascular end, was recorded. Particularly, the alpha index is significantly correlated with triglycerides (r = −0.261) and endothelial indices (RHI, r = 0.276). Children with obesity show a link between indices of autonomic and endothelial function, fat distribution and metabolic profile. The optimization of autonomic control, for instance by exercise/nutrition interventions, could potentially prevent/delay the occurrence of structural vascular damage leading to reduced cardiovascular health.

In search of scientific objectivity: Is there such a property for paediatric concussion?

Concussions are a significant public health problem worldwide. This brain injury is problematic in the paediatric population for a variety of reasons; however, the enquiry into these problems has been mainly through the biomedical perspective. This approach has impacted nursing knowledge and practice of children and youth with a concussion, primarily since other perspectives are viewed as not being objective. In this manuscript, I draw on Thomas Kuhn's view of objectivity to evaluate the biomedical perspective of concussion. I utilize current research and clinical examples to illustrate the advantages and drawbacks of this perspective for nursing. From this discussion, I propose an alternative perspective to capture the complexity of paediatric concussions for nursing, a systems perspective. Although I argue for an alternative perspective to approach paediatric concussions for nursing, I maintain that the biomedical perspective can be incorporated as one part of nursing knowledge and practice for paediatric concussion.

Revisiting the lumbosacral orthosis from the perspective of dynamical systems theory: a preliminary randomized clinical trial on patients with chronic low back pain

BACKGROUND

The prevalent method for investigating the effect of therapeutic interventions on walking in the individuals with chronic low back pain (CLBP) is component-level approach in which all measurements focus on the spine component alone. However, this approach cannot disclose information about the overall function of the movement system such as complex walking patterns, which, in turn, reveal the underlying movement control.

OBJECTIVES

To compare the effect of 3-week wearing of lumbosacral orthosis (LSO) along with routine physical therapy with routine physical therapy alone on walking complexity in the individuals with nonspecific CLBP on the basis of the systems approach.

STUDY DESIGN

Preliminary randomized clinical trial.

METHODS

Twenty-four subjects were randomly allocated to two groups. The control group received the routine physical therapy for 3 weeks. The intervention group received the same program plus an LSO. Nonlinear analysis was used to quantify walking complexity, as behavior of the entire movement system, before and after the intervention and at 1-month follow-up.

RESULTS

An average of 496 strides during ten minutes of walking was used for analysis. There was no significant difference (p > 0.05) in degree of walking complexity between two groups during all evaluation periods.

CONCLUSIONS

The administered orthotic intervention did not alter walking complexity. This suggests that therapeutic goal of current LSOs, which is not based on the systems approach, cannot recover the emergent behavior of the movement system. This may be a potential source of controversies.

CLINICAL RELEVANCE

To achieve an effective treatment, orthotists should focus on the individuals themselves, not only on their CLBP symptoms. Although the component-level approach aims to decrease the symptoms, the systems approach focuses on the whole context that fosters LBP symptoms.

Dismantling Anti-Ageing Medicine: Why Age-Relatedness of Cardiovascular Disease is Proof of Robustness Rather Than of Ageing-Associated Vulnerability

Ageing is perceived to be the common culprit behind the most prevalent noncommunicable chronic diseases (NCD) such as cardiovascular disease (CVD). Treating ageing as a means to prevent its downstream pathologies has become the logical extension of this idea, and the defining criterion of anti-ageing medicine (evidence-based early detection, prevention, and treatment of age-related diseases). Challenging the underlying rationale, we here argue that the disease's late-in-life occurrence is proof of a genetically conserved robustness that helps us resist disease long enough for it to masquerade as a consequence of living long rather than of living wrong. Robustness is an acknowledged hallmark phenomenon of all complex systems (while there exists no universally adopted definition, a hallmark of complex systems is that they consist of many networked components whose interactions may give rise to system behaviors which cannot be derived or predicted from a reductionist knowledge of the interacting parts, even if this knowledge is complete) and a key concept in the complexity sciences (a relatively new branch of science that attempts to find and understand the common mechanisms and patterns shared by all complex systems). To reconceptualise the age-relatedness of chronic diseases in this sense has important implications for medical research and practice. The goal of our essay is to open a discussion that may enhance the overall understanding of robustness and prevent a misguided redirection of funding away from established disease specific research and towards anti-ageing medicine. This essay is timely, as the forthcoming 11^th version of the International Classification of Diseases (ICD) will be the first to recognise ageing as a condition, thereby legitimising anti-ageing medical research. On a more pragmatic note, and for the benefit of people alive today, we propose a practical strategy to remedy the mismatch between heritable robustness and the lifestyle challenges that gradually overwhelm it.

Future Treatment of Sleep Disorders: Syndromic Approach Versus Management of Treatable Traits?

Sleep disorders are categorized in line with traditional taxonomy. This conventional approach allows adequate management of many patients. Failure of treatment, however, may be due to nonspecificity of symptoms, coincidental association between symptoms and pathophysiological endotype, as well as co-occurrence of different pathologic mechanisms affecting sleep. Complex phenotypes often do not respond well to standard therapeutic interventions. In these cases, the clinical workup should aim at identifying treatable traits that will likely improve under targeted therapy. The challenge for sleep medicine is to further develop this innovative approach that is driven by the principles of systems medicine.

Systems Biology and Biomarkers in Necrotizing Soft Tissue Infections

In necrotizing soft tissue infection (NSTI) there is a need to identify biomarker sets that can be used for diagnosis and disease management. The INFECT study was designed to obtain such insights through the integration of patient data and results from different clinically relevant experimental models by use of systems biology approaches. This chapter describes the current state of biomarkers in NSTI and how biomarkers are categorized. We introduce the fundamentals of top-down systems biology approaches including analysis tools and we review the use of current methods and systems biology approaches to biomarker discover. Further, we discuss how different "omics" signatures (gene expression, protein, and metabolites) from NSTI patient samples can be used to identify key host and pathogen factors involved in the onset and development of infection, as well as exploring associations to disease outcomes.

Advancing Biomarker Development Through Convergent Engagement: Summary Report of the 2nd International Danube Symposium on Biomarker Development, Molecular Imaging and Applied Diagnostics; March 14-16, 2018; Vienna, Austria

Here, we report on the outcome of the 2nd International Danube Symposium on advanced biomarker development that was held in Vienna, Austria, in early 2018. During the meeting, cross-speciality participants assessed critical aspects of non-invasive, quantitative biomarker development in view of the need to expand our understanding of disease mechanisms and the definition of appropriate strategies both for molecular diagnostics and personalised therapies. More specifically, panelists addressed the main topics, including the current status of disease characterisation by means of non-invasive imaging, histopathology and liquid biopsies as well as strategies of gaining new understanding of disease formation, modulation and plasticity to large-scale molecular imaging as well as integrative multi-platform approaches. Highlights of the 2018 meeting included dedicated sessions on non-invasive disease characterisation, development of disease and therapeutic tailored biomarkers, standardisation and quality measures in biospecimens, new therapeutic approaches and socio-economic challenges of biomarker developments. The scientific programme was accompanied by a roundtable discussion on identification and implementation of sustainable strategies to address the educational needs in the rapidly evolving field of molecular diagnostics. The central theme that emanated from the 2nd Donau Symposium was the importance of the conceptualisation and implementation of a convergent approach towards a disease characterisation beyond lesion-counting "lumpology" for a cost-effective and patient-centric diagnosis, therapy planning, guidance and monitoring. This involves a judicious choice of diagnostic means, the adoption of clinical decision support systems and, above all, a new way of communication involving all stakeholders across modalities and specialities. Moreover, complex diseases require a comprehensive diagnosis by converging parameters from different disciplines, which will finally yield to a precise therapeutic guidance and outcome prediction. While it is attractive to focus on technical advances alone, it is important to develop a patient-centric approach, thus asking "What can we do with our expertise to help patients?"

Unleashing the literature: a scoping review of canine zoonotic and vectorborne disease research in Canis familiaris in North America

Domestic dogs (Canis familiaris) provide important benefits to human beings but can also transmit pathogens. Information on the breadth of canine zoonoses and vectorborne research in North America is scarce. A scoping review was conducted to examine (1) the number and type of canine zoonoses and vectorborne studies in domestic dogs conducted in North America since the start of the 21st century; (2) the main research methods reported; (3) the Inequality-adjusted Human Development Index (IHDI) countries in which research was conducted; and (4) whether collaborative integrated terminology was reported in objectives or methods sections. Title/abstract screening, full-text screening, and data-charting were completed by two reviewers. We identified 507 publications evaluating 43 zoonotic or vectorborne pathogens in domestic dogs. Most studies (n = 391 of 512 (76.37%)) were conducted in the USA. The five most frequently researched pathogens were Ehrlichia spp. (n = 81 of 507 (15.98%)), Borrelia burgdorferi (n = 64 of 507 (12.62%)), Leptospira spp. (n = 54 of 507 (10.65%)), Rabies virus (n = 42 of 507 (8.28%)), and Influenza viruses (n = 41 of 507 (8.09%)). These pathogens can cause moderate to severe health outcomes in human beings and in dogs irrespective of IHDI ranking; our review highlights important counts of research conduct among North American countries.

Redesigning COVID-19 Care With Network Medicine and Machine Learning

Emerging evidence regarding COVID-19 highlights the role of individual resistance and immune function in both susceptibility to infection and severity of disease. Multiple factors influence the response of the human host on exposure to viral pathogens. Influencing an individual’s susceptibility to infection are such factors as nutritional status, physical and psychosocial stressors, obesity, protein-calorie malnutrition, emotional resilience, single-nucleotide polymorphisms, environmental toxins including air pollution and firsthand and secondhand tobacco smoke, sleep habits, sedentary lifestyle, drug-induced nutritional deficiencies and drug-induced immunomodulatory effects, and availability of nutrient-dense food and empty calories. This review examines the network of interacting cofactors that influence the host-pathogen relationship, which in turn determines one’s susceptibility to viral infections like COVID-19. It then evaluates the role of machine learning, including predictive analytics and random forest modeling, to help clinicians assess patients’ risk for development of active infection and to devise a comprehensive approach to prevention and treatment.

The origins of allergy from a systems approach

OBJECTIVE

The origins of allergic diseases have traditionally been explained by immunoglobulin E-mediated immune responses to account for asthma, atopic dermatitis, atopic rhinitis, and food allergy. Research insights into disease origins support a broader array of factors that predispose, initiate, or exacerbate altered immunity in allergic diseases, such as (1) inherent epithelial barrier dysfunction; (2) loss of immune tolerance; (3) disturbances in the gut; and (4) organ-specific microbiomes, diet, and age. Here, we discuss these influences that together form a better understanding of allergy as a systems disease.

DATA SOURCES

We summarize recent advances in epithelial dysfunction, environmental influences, inflammation, infection, alterations in the specific microbiome, and inherent genetic predisposition.

STUDY SELECTIONS

We performed a literature search targeting primary and review articles.

RESULTS

We explored microbial-epithelial-immune interactions underlying the early-life origins of allergic disorders and evaluated immune mechanisms suggesting novel disease prevention or intervention strategies. Damage to epithelial surfaces lies at the origin of various manifestations of allergic disease. As a sensor of environmental stimuli, the epithelium of the lungs, gut, and skin is affected by an altered microbiome, air pollution, food allergens in a changed diet, and chemicals in modern detergents. This collectively leads to alterations of lung, skin, or gut epithelial surfaces, driving a type 2 immune response that underlies atopic diseases. Treatment and prevention of allergic diseases include biologics, oral desensitization, targeted gut microbiome alterations, and changes in behavior.

CONCLUSION

Understanding the spectrum of allergy as a systems disease will allow us to better define the mechanisms of allergic disorders and improve their treatment.

Medical knowledge integration and "systems medicine": Needs, ambitions, limitations and options

Medicine today is an extremely heterogeneous field of knowledge, based on clinical observations and action knowledge and on data from the biological, behavioral and social sciences. We hypothesize at first that medicine suffers from a disciplinary hyper-diversity compared to the level of conceptual interdisciplinary integration. With the claim to "understand" and cure diseases, currently with the label "Systems Medicine" new forms of molecular medicine promise a general new bottom-up directed precise, personalized, predictive, preventive, translational, participatory, etc. medicine. Our second hypothesis rejects this claim because of conceptual, methodological and theoretical weaknesses. In contrary, this is our third hypothesis; we suggest that top-down organismic systems medicine, related to general system theory, opens better options for an integrative scientific understanding of processes of health and disease.

Clinical Applications of System Regulation Medicine

Increasing incidence and poor outcome of chronic non-communicable diseases in western population would require a paradigm shift in the treatments. Guidelines-based medical approaches continue to be the standard rule in clinical practice, although only less than 15% of them are based on high-quality research. For each person who benefits from the 10 best-selling drugs in the USA, a number between 4 and 25 has no one beneficial effect.

The reductionist linear medicine method does not offer solutions in the non-manifest preclinical stage of the disease when it would still be possible to reverse the pathological progression and the axiom “a drug, a target, a symptom” are still inconclusive. Needs additional tools to address these challenges.

System Medicine considers the disease as a dysregulation of the biological networks that changes throughout the evolution of the pathological process and with the comorbidities development. The strength of the networks indicates their ability to withstand dysregulations during the perturbation phases, returning to the state of stability. The treatment of dysregulated networks before the symptomatological manifestation emerges offers the possibility of treating and preventing pathologies in the preclinical phase and potentially reversing the pathological process, stopping it or preventing comorbidities. Furthermore, treating shared networks instead of individual phenotypic symptoms can reduce drug use, offering a solution to the problem of ineffective drug use.

Emergence and Evidence: A Close Look at Bunge’s Philosophy of Medicine

In his book “Medical Philosophy: Conceptual issues in Medicine”, Mario Bunge provides a unique account of medical philosophy that is deeply rooted in a realist ontology he calls “systemism”. According to systemism, the world consists of systems and their parts, and systems possess emergent properties that their parts lack. Events within systems may form causes and effects that are constantly conjoined via particular mechanisms. Bunge supports the views of the evidence-based medicine movement that randomized controlled trials (RCTs) provide the best evidence to establish the truth of causal hypothesis; in fact, he argues that only RCTs have this ability. Here, we argue that Bunge neglects the important feature of patients being open systems which are in steady interaction with their environment. We show that accepting this feature leads to counter-intuitive consequences for his account of medical hypothesis testing. In particular, we point out that (i) the confirmation of hypotheses is inherently stochastic and affords a probabilistic account of both confirmation and evidence which we provide here; (ii) RCTs are neither necessary nor sufficient to establish the truth of a causal claim; (iii) testing of causal hypotheses requires taking into account background knowledge and the context within which an intervention is applied. We conclude that there is no “best” research methodology in medicine, but that different methodologies should coexist in a complementary fashion.

Effects of Acute Normobaric Hypoxia on Non-linear Dynamics of Cardiac Autonomic Activity During Constant Workload Cycling Exercise

Aim

Measurements of Non-linear dynamics of heart rate variability (HRV) provide new possibilities to monitor cardiac autonomic activity during exercise under different environmental conditions. Using detrended fluctuation analysis (DFA) technique to assess correlation properties of heart rate (HR) dynamics, the present study examines the influence of normobaric hypoxic conditions (HC) in comparison to normoxic conditions (NC) during a constant workload exercise.

Materials and Methods

Nine well trained cyclists performed a continuous workload exercise on a cycle ergometer with an intensity corresponding to the individual anaerobic threshold until voluntary exhaustion under both NC and HC (15% O₂). The individual exercise duration was normalized to 10% sections (10-100%). During exercise HR and RR-intervals were continuously-recorded. Besides HRV time-domain measurements (meanRR, SDNN), fractal correlation properties using short-term scaling exponent alpha1 of DFA were calculated. Additionally, blood lactate (La), oxygen saturation of the blood (SpO₂), and rating of perceived exertion (RPE) were recorded in regular time intervals.

Results

We observed significant changes under NC and HC for all parameters from the beginning to the end of the exercise (10% vs. 100%) except for SpO₂ and SDNN during NC: increases for HR, La, and RPE in both conditions; decreases for SpO₂ and SDNN during HC, meanRR and DFA-alpha1 during both conditions. Under HC HR (40-70%), La (10-90%), and RPE (50-90%) were significantly-higher, SpO₂ (10-100%), meanRR (40-70%), and DFA-alpha1 (20-60%) were significantly-lower than under NC.

Conclusion

Under both conditions, prolonged exercise until voluntary exhaustion provokes a lower total variability combined with a reduction in the amplitude and correlation properties of RR fluctuations which may be attributed to increased organismic demands. Additionally, HC provoked higher demands and loss of correlation properties at an earlier stage during the exercise regime, implying an accelerated alteration of cardiac autonomic regulation.

Systems approach in medical education: The thesis, antithesis, and synthesis

Systems approach is a time tested, method of trying to understand the reality holistically, and resolving the issues by problem-solving method. It has resulted in enormous applications in almost every field of knowledge, science, technology, industries, agriculture, and health or education. The main essence of systems thinking lies in minimizing the inputs, optimizing the process to maximize the outputs through continuous feedback, and monitoring. Medical education has been greatly benefitted as the systems approach has influenced all aspects, from delineating the competencies of doctors, designing curriculum that includes comprehensive assessment. However, of late, there has been a debate as to whether the systems approach can really contribute to resolve complex issues such as bringing curricular reforms, or promote policy changes in patient care, education, or research. This involves a paradigm shift from problem-solving approach to “pattern recognition” and adaptive action to correct the system. This review based on critical appreciation, begins with a thesis that systems approach is a great tool. It then exposes its inadequacy to address complex systems. This is antithesis. In the end, a synthesis of both the contradictory views has been proposed as a take home.

A novel principled method for the measurement of vascular robustness uncovers hidden risk for premature CVD death

The detection of high risk for premature death of cardiovascular disease (CVD) among individuals with low-to-moderate risk factor scores is a major challenge. Systems biology suggests that the vasculature's functional robustness against risk factor challenges may serve as a novel discriminator of mortality risk under similar risk factor loads. However, principled methods to measure vascular robustness are not available. To develop a score for the vasculature's functional robustness we used a recently presented method that applies computational physiological modeling to the quantitation of vascular function. We hypothesized that the expected inverse robustness-mortality association is verifiable as a significant robustness-calendar age trend in a cross-sectional investigation of a population cohort of risk factor-challenged individuals. Using only functional parameters of the cardiovascular system we applied multivariate linear regression to derive from our study population of 372 adults gender-specific multivariate robustness scoring algorithms. For any individual, the deviation of his/her robustness score from the value of the regression function characterizes the deviation of the individual’s fatal CVD event probability from its age-appropriate fatal CVD event probability. Robustness correlated linearly with calendar age in our risk factor-challenged but not in our unchallenged cohorts. This observation supports the hypothesis of preferential elimination of less robust individuals along the aging trajectory under risk factor challenges. We conclude that physiologically principled scoring for vascular robustness may serve as a biomarker of vulnerability to CVD risk factor challenges, prognosticating otherwise undetectable elevated risk for premature CVD mortality.

NEW & NOTEWORTHY We developed a principled method for the derivation of a vascular robustness score that we translated into a correction factor for calendar age. We demonstrated the score’s potential to uncover risk for premature cardiovascular death in apparently healthy young adults whose risk elevation remains hidden in conventional risk factor models.

Identification of a Novel Clinical Phenotype of Severe Malaria using a Network-Based Clustering Approach

The parasite Plasmodium falciparum is the main cause of severe malaria (SM). Despite treatment with antimalarial drugs, more than 400,000 deaths are reported every year, mainly in African children. The diversity of clinical presentations associated with SM highlights important differences in disease pathogenesis that often require specific therapeutic options. The clinical heterogeneity of SM is largely unresolved. Here we report a network-based analysis of clinical phenotypes associated with SM in 2,915 Gambian children admitted to hospital with Plasmodium falciparum malaria. We used a network-based clustering method which revealed a strong correlation between disease heterogeneity and mortality. The analysis identified four distinct clusters of SM and respiratory distress that departed from the WHO definition. Patients in these clusters characteristically presented with liver enlargement and high concentrations of brain natriuretic peptide (BNP), giving support to the potential role of circulatory overload and/or right-sided heart failure as a mechanism of disease. The role of heart failure is controversial in SM and our work suggests that standard clinical management may not be appropriate. We find that our clustering can be a powerful data exploration tool to identify novel disease phenotypes and therapeutic options to reduce malaria-associated mortality.

Information-theoretic decomposition of embodied and situated systems

The embodied and situated view of cognition stresses the importance of real-time and nonlinear bodily interaction with the environment for developing concepts and structuring knowledge. In this article, populations of robots controlled by an artificial neural network learn a wall-following task through artificial evolution. At the end of the evolutionary process, time series are recorded from perceptual and motor neurons of selected robots. Information-theoretic measures are estimated on pairings of variables to unveil nonlinear interactions that structure the agent-environment system. Specifically, the mutual information is utilized to quantify the degree of dependence and the transfer entropy to detect the direction of the information flow. Furthermore, the system is analyzed with the local form of such measures, thus capturing the underlying dynamics of information. Results show that different measures are interdependent and complementary in uncovering aspects of the robots' interaction with the environment, as well as characteristics of the functional neural structure. Therefore, the set of information-theoretic measures provides a decomposition of the system, capturing the intricacy of nonlinear relationships that characterize robots' behavior and neural dynamics.

The cardiovascular robustness hypothesis: Unmasking young adults' hidden risk for premature cardiovascular death

An undetected high risk for premature death of cardiovascular disease (CVD) among individuals with low-to-moderate risk factor levels is an acknowledged obstacle to CVD prevention. In this paper, we present the hypothesis that the vasculature's robustness against risk factor load will complement conventional risk factor models as a novel stratifier of risk. Figuratively speaking, mortality risk prediction without robustness scoring is akin to predicting the breaking risk of a lake's ice sheet considering load only while disregarding the sheet's bearing strength. Taking the cue from systems biology, which defines robustness as the ability to maintain function against internal and external challenges, we develop a robustness score from the physical parameters that comprehensively quantitate cardiovascular function. We derive the functional parameters using a recently introduced novel system, VascAssist 2 (iSYMED GmbH, Butzbach, Germany). VascAssist 2 (VA) applies the electronic-hydraulic analogy to a digital model of the arterial tree, replicating non-invasively acquired pule pressure waves by modulating the electronic equivalents of the physical parameters that describe in vivo arterial hemodynamics. As the latter is also subject to aging-associated degeneration which (a) progresses at inter-individually different rates, and which (b) affects the biomarker-mortality association, we express the robustness score as a correction factor to calendar age (CA), the dominant risk factor in all CVD risk factor models. We then propose a method for the validation of the score against known time-to-event data in reference populations. Our conceptualization of robustness implies that risk factor-challenged individuals with low robustness scores will face preferential elimination from the population resulting in a significant robustness-CA correlation in this strata absent in the unchallenged stratum. Hence, we also present an outline of a cross-sectional study design suitable to test this hypothesis. We finally discuss the objections that may validly be raised against our robustness hypothesis, and how available evidence encourages us to refute these objections.

Race Disparities in the Contribution of miRNA Isoforms and tRNA-Derived Fragments to Triple-Negative Breast Cancer

Triple-negative breast cancer (TNBC) is a breast cancer subtype characterized by marked differences between White and Black/African-American women. We performed a systems-level analysis on datasets from The Cancer Genome Atlas to elucidate how the expression patterns of mRNAs are shaped by regulatory noncoding RNAs (ncRNA). Specifically, we studied isomiRs, that is, isoforms of miRNAs, and tRNA-derived fragments (tRF). In normal breast tissue, we observed a marked cohesiveness in both the ncRNA and mRNA layers and the associations between them. This cohesiveness was widely disrupted in TNBC. Many mRNAs become either differentially expressed or differentially wired between normal breast and TNBC in tandem with isomiR or tRF dysregulation. The affected pathways included energy metabolism, cell signaling, and immune responses. Within TNBC, the wiring of the affected pathways with isomiRs and tRFs differed in each race. Multiple isomiRs and tRFs arising from specific miRNA loci (e.g., miR-200c, miR-21, the miR-17/92 cluster, the miR-183/96/182 cluster) and from specific tRNA loci (e.g., the nuclear tRNA^Gly and tRNA^Leu, the mitochondrial tRNA^Val and tRNA^Pro) were strongly associated with the observed race disparities in TNBC. We highlight the race-specific aspects of transcriptome wiring by discussing in detail the metastasis-related MAPK and the Wnt/β-catenin signaling pathways, two of the many key pathways that were found differentially wired. In conclusion, by employing a data- and knowledge-driven approach, we comprehensively analyzed the normal and cancer transcriptomes to uncover novel key contributors to the race-based disparities of TNBC.Significance: This big data-driven study comparing normal and cancer transcriptomes uncovers RNA expression differences between Caucasian and African-American patients with triple-negative breast cancer that might help explain disparities in incidence and aggressive character. Cancer Res; 78(5); 1140-54. ©2017 AACR.

Is systems pharmacology ready to impact upon therapy development? A study on the cholesterol biosynthesis pathway

Background and Purpose

An ever‐growing wealth of information on current drugs and their pharmacological effects is available from online databases. As our understanding of systems biology increases, we have the opportunity to predict, model and quantify how drug combinations can be introduced that outperform conventional single‐drug therapies. Here, we explore the feasibility of such systems pharmacology approaches with an analysis of the mevalonate branch of the cholesterol biosynthesis pathway.

Experimental Approach

Using open online resources, we assembled a computational model of the mevalonate pathway and compiled a set of inhibitors directed against targets in this pathway. We used computational optimization to identify combination and dose options that show not only maximal efficacy of inhibition on the cholesterol producing branch but also minimal impact on the geranylation branch, known to mediate the side effects of pharmaceutical treatment.

Key Results

We describe serious impediments to systems pharmacology studies arising from limitations in the data, incomplete coverage and inconsistent reporting. By curating a more complete dataset, we demonstrate the utility of computational optimization for identifying multi‐drug treatments with high efficacy and minimal off‐target effects.

Conclusion and Implications

We suggest solutions that facilitate systems pharmacology studies, based on the introduction of standards for data capture that increase the power of experimental data. We propose a systems pharmacology workflow for the refinement of data and the generation of future therapeutic hypotheses.

Concussion As a Multi-Scale Complex System: An Interdisciplinary Synthesis of Current Knowledge

Traumatic brain injury (TBI) has been called "the most complicated disease of the most complex organ of the body" and is an increasingly high-profile public health issue. Many patients report long-term impairments following even "mild" injuries, but reliable criteria for diagnosis and prognosis are lacking. Every clinical trial for TBI treatment to date has failed to demonstrate reliable and safe improvement in outcomes, and the existing body of literature is insufficient to support the creation of a new classification system. Concussion, or mild TBI, is a highly heterogeneous phenomenon, and numerous factors interact dynamically to influence an individual's recovery trajectory. Many of the obstacles faced in research and clinical practice related to TBI and concussion, including observed heterogeneity, arguably stem from the complexity of the condition itself. To improve understanding of this complexity, we review the current state of research through the lens provided by the interdisciplinary field of systems science, which has been increasingly applied to biomedical issues. The review was conducted iteratively, through multiple phases of literature review, expert interviews, and systems diagramming and represents the first phase in an effort to develop systems models of concussion. The primary focus of this work was to examine concepts and ways of thinking about concussion that currently impede research design and block advancements in care of TBI. Results are presented in the form of a multi-scale conceptual framework intended to synthesize knowledge across disciplines, improve research design, and provide a broader, multi-scale model for understanding concussion pathophysiology, classification, and treatment.

Multiple reaction monitoring (MRM)-profiling for biomarker discovery applied to human polycystic ovarian syndrome

RATIONALE

We describe multiple reaction monitoring (MRM)-profiling, which provides accelerated discovery of discriminating molecular features, and its application to human polycystic ovary syndrome (PCOS) diagnosis. The discovery phase of the MRM-profiling seeks molecular features based on some prior knowledge of the chemical functional groups likely to be present in the sample. It does this through use of a limited number of pre-chosen and chemically specific neutral loss and/or precursor ion MS/MS scans. The output of the discovery phase is a set of precursor/product transitions. In the screening phase these MRM transitions are used to interrogate multiple samples (hence the name MRM-profiling).

METHODS

MRM-profiling was applied to follicular fluid samples of 22 controls and 29 clinically diagnosed PCOS patients. Representative samples were delivered by flow injection to a triple quadrupole mass spectrometer set to perform a number of pre-chosen and chemically specific neutral loss and/or precursor ion MS/MS scans. The output of this discovery phase was a set of 1012 precursor/product transitions. In the screening phase each individual sample was interrogated for these MRM transitions. Principal component analysis (PCA) and receiver operating characteristic (ROC) curves were used for statistical analysis.

RESULTS

To evaluate the method's performance, half the samples were used to build a classification model (testing set) and half were blinded (validation set). Twenty transitions were used for the classification of the blind samples, most of them (N = 19) showed lower abundances in the PCOS group and corresponded to phosphatidylethanolamine (PE) and phosphatidylserine (PS) lipids. Agreement of 73% with clinical diagnosis was found when classifying the 26 blind samples.

CONCLUSIONS

MRM-profiling is a supervised method characterized by its simplicity, speed and the absence of chromatographic separation. It can be used to rapidly isolate discriminating molecules in healthy/disease conditions by tailored screening of signals associated with hundreds of molecules in complex samples.

Applying a systems approach to thyroid physiology: Looking at the whole with a mitochondrial perspective instead of judging single TSH values or why we should know more about mitochondria to understand metabolism

Classical thinking in endocrine physiology squeezes our diagnostic handling into a simple negative feedback mechanism with a controller and a controlled variable. In the case of the thyroid this is reduced to TSH and fT3 and fT4, respectively. The setting of this tight notion has no free space for any additions. In this paper we want to challenge this model of limited application by proposing a construct based on a systems approach departing from two basic considerations. In first place since the majority of cases of thyroid disease develop and appear during life it has to be considered as an acquired condition. In the second place, our experience with the reversibility of morphological changes makes the autoimmune theory inconsistent.

While medical complexity can expand into the era of OMICS as well as into one where manipulations with the use of knock-outs and -ins are common in science, we have preferred to maintain a simple and practical approach. We will describe the interactions of iron, magnesium, zinc, selenium and coenzyme Q10 with the thyroid axis. The discourse will be then brought into the context of ovarian function, i.e. steroid hormone production. Finally the same elemental players will be presented in relation to the basic mitochondrial machinery that supports the endocrine.

We propose that an intact mitochondrial function can guard the normal endocrine function of both the thyroid as well as of the ovarian axis. The basic elements required for this function appear to be magnesium and iron. In the case of the thyroid, magnesium-ATP acts in iodine uptake and the heme protein peroxidase in thyroid hormone synthesis. A similar biochemical process is found in steroid synthesis with cholesterol uptake being the initial energy-dependent step and later the heme protein ferredoxin 1 which is required for steroid synthesis. Magnesium plays a central role in determining the clinical picture associated with thyroid disease and is also involved in maintaining fertility. With the aid of 3D sonography patients needing selenium and/or coenzyme Q10 can be easily identified. By this we firmly believe that physicians should know more about basic biochemistry and the way it fits into mitochondrial function in order to understand metabolism. Contemplating only TSH is highly reductionistic.

Outline

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Author's profiles and motivation for this analysis

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The philosophical alternatives in science and medicine

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Reductionism vs. systems approach in clinical thyroid disease guidelines

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The entry into complexity: the involvement of the musculoskeletal system

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Integrating East and West: teachings from Chinese Medicine and from evidence based medicine (EBM)

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Can a mathematical model represent complexity in the daily thyroid practice?

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How effective is thyroxine treatment?

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Resolving the situation of residual symptoms in treated patients with thyroid disease

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Importance of iron, zinc and magnesium in relation to thyroid function

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Putting together new concepts related to thyroid function for a systems approach

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Expanding our model into general aspects of medicine

A 3D self-organizing multicellular epidermis model of barrier formation and hydration with realistic cell morphology based on EPISIM

The epidermis and the stratum corneum (SC) as its outermost layer have evolved to protect the body from evaporative water loss to the environment. To morphologically represent the extremely flattened cells of the SC - and thereby the epidermal barrier - in a multicellular computational model, we developed a 3D biomechanical model (BM) based on ellipsoid cell shapes. We integrated the BM in the multicellular modelling and simulation platform EPISIM. We created a cell behavioural model (CBM) with EPISIM encompassing regulatory feedback loops between the epidermal barrier, water loss to the environment, and water and calcium flow within the tissue. This CBM allows a small number of stem cells to initiate self-organizing epidermal stratification, yielding the spontaneous emergence of water and calcium gradients comparable to experimental data. We find that the 3D in silico epidermis attains homeostasis most quickly at high ambient humidity, and once in homeostasis the epidermal barrier robustly buffers changes in humidity. Our model yields an in silico epidermis with a previously unattained realistic morphology, whose cell neighbour topology is validated with experimental data obtained from in vivo images. This work paves the way to computationally investigate how an impaired SC barrier precipitates disease.

Conceptual Foundations of Systems Biology Explaining Complex Cardiac Diseases

Systems biology is an important concept that connects molecular biology and genomics with computing science, mathematics and engineering. An endeavor is made in this paper to associate basic conceptual ideas of systems biology with clinical medicine. Complex cardiac diseases are clinical phenotypes generated by integration of genetic, molecular and environmental factors. Basic concepts of systems biology like network construction, modular thinking, biological constraints (downward biological direction) and emergence (upward biological direction) could be applied to clinical medicine. Especially, in the field of cardiology, these concepts can be used to explain complex clinical cardiac phenotypes like chronic heart failure and coronary artery disease. Cardiac diseases are biological complex entities which like other biological phenomena can be explained by a systems biology approach. The above powerful biological tools of systems biology can explain robustness growth and stability during disease process from modulation to phenotype. The purpose of the present review paper is to implement systems biology strategy and incorporate some conceptual issues raised by this approach into the clinical field of complex cardiac diseases. Cardiac disease process and progression can be addressed by the holistic realistic approach of systems biology in order to define in better terms earlier diagnosis and more effective therapy.

Social-Biological Interactions in Oral Disease: A 'Cells to Society' View

Oral diseases constitute a major worldwide public health problem, with their burden concentrating in socially disadvantaged and less affluent groups of the population, resulting in significant oral health inequalities. Biomedical and behavioural approaches have proven relatively ineffective in reducing these inequalities, and have potentially increased the health gap between social groups. Some suggest this stems from a lack of understanding of how the social and psychosocial contexts in which behavioural and biological changes occur influence oral disease. To unravel the pathways through which social factors affect oral health outcomes, a better understanding is thus needed of how the social 'gets under the skin,' or becomes embodied, to alter the biological. In this paper, we present the current knowledge on the interplay between social and biological factors in oral disease. We first provide an overview of the process of embodiment in chronic disease and then evaluate the evidence on embodiment in oral disease by reviewing published studies in this area. Results show that, in periodontal disease, income, education and perceived stress are correlated with elevated levels of stress hormones, disrupted immune biomarkers and increased allostatic load. Similarly, socioeconomic position and increased financial stress are related to increased stress hormones and cariogenic bacterial counts in dental caries. Based on these results, we propose a dynamic model depicting social-biological interactions that illustrates potential interdependencies between social and biological factors that lead to poor oral health. This work and the proposed model may aid in developing a better understanding of the causes of oral health inequalities and implicate the importance of addressing the social determinants of oral health in innovating public health interventions.

Systems Medicine: Sketching the Landscape

To understand the meaning of the term Systems Medicine and to distinguish it from seemingly related other expressions currently in use, such as precision, personalized, -omics, or big data medicine, its underlying history and development into present time needs to be highlighted. Having this development in mind, it becomes evident that Systems Medicine is a genuine concept as well as a novel way of tackling the manifold complexity that occurs in nowadays clinical medicine-and not just a rebranding of what has previously been done in the past. So looking back it seems clear to many in the field that Systems Medicine has its origin in an integrative method to unravel biocomplexity, namely, Systems Biology. Here scientist by now gained useful experience that is on the verge toward implementation in clinical research and practice.Systems Medicine and Systems Biology have the same underlying theoretical principle in systems-based thinking-a methodology to understand complexity that can be traced back to ancient Greece. During the last decade, however, and due to a rapid methodological development in the life sciences and computing/IT technologies, Systems Biology has evolved from a scientific concept into an independent discipline most competent to tackle key questions of biocomplexity-with the potential to transform medicine and how it will be practiced in the future. To understand this process in more detail, the following section will thus give a short summary of the foundation of systems-based thinking and the different developmental stages including systems theory, the development of modern Systems Biology, and its transition into clinical practice. These are the components to pave the way toward Systems Medicine.

Implementation of the systems approach to improve a pharmacist-managed vancomycin dosing service

PURPOSE

Quality improvements achieved by applying the systems approach to assess the clinical effectiveness, operational efficiency, and financial feasibility of a pharmacist-managed vancomycin dosing service are described.

SUMMARY

Faced with increased patient volumes and resource demands, the pharmacy department at Tufts Medical Center conducted an evaluation of its adult inpatient vancomycin dosing service using the systems approach, which emphasizes multidisciplinary assessment of system inputs, processes, and outcomes and consensus-building methods to identify needed changes and recommended action steps. A multidisciplinary committee composed of representatives of the medical center's pharmacy, internal medicine, infectious diseases, nursing, phlebotomy, and clinical laboratory services was assembled; in a series of three moderated monthly sessions, committee members deliberated and ultimately reached consensus on a list of action items. Relative to a concurrent intradepartmental assessment of the vancomycin dosing service based solely on pharmacist feedback, the systems approach identified a greater number and wider array of needed improvements in key program areas. Quality improvements implemented as a direct result of the systems-based analysis included a policy change authorizing pharmacists to order serum vancomycin determinations without physician cosignature and inclusion of a vancomycin dosing algorithm in the institutional antibiotic dosing guide. Future changes based on deliverable action items will result in a structured process to help direct program resources toward the patients most in need of pharmacist-managed vancomycin dosing services.

CONCLUSION

The systems approach allowed for a comprehensive multidisciplinary evaluation of the service, as indicated by the identification of process improvements not identified by the department of pharmacy alone.

Systems medicine: evolution of systems biology from bench to bedside

High-throughput experimental techniques for generating genomes, transcriptomes, proteomes, metabolomes, and interactomes have provided unprecedented opportunities to interrogate biological systems and human diseases on a global level. Systems biology integrates the mass of heterogeneous high-throughput data and predictive computational modeling to understand biological functions as system-level properties. Most human diseases are biological states caused by multiple components of perturbed pathways and regulatory networks rather than individual failing components. Systems biology not only facilitates basic biological research but also provides new avenues through which to understand human diseases, identify diagnostic biomarkers, and develop disease treatments. At the same time, systems biology seeks to assist in drug discovery, drug optimization, drug combinations, and drug repositioning by investigating the molecular mechanisms of action of drugs at a system's level. Indeed, systems biology is evolving to systems medicine as a new discipline that aims to offer new approaches for addressing the diagnosis and treatment of major human diseases uniquely, effectively, and with personalized precision.

[Advances in asthma: review of publications in Archivos de Bronconeumología in the last year]

Interest in asthma research among Spanish pneumologists is increasing. In the last year, 22 articles on asthma have been published in Archivos de Bronconeumología, six more than in the previous year. Furthermore, 56 communications were presented at the National Congress of the Spanish Society of Pneumology and Thoracic Surgery and were published in a supplement of the journal, representing 60% more than in the previous year's congress. A critical review of all these articles is provided. The original articles contribute further knowledge on epidemiological and clinical aspects of the disease and basic research. A notable contribution is the publication of two clinical practice guidelines, the Spanish Guideline for the Management of Asthma 2009 and the ALERTA-2 Guideline for the Management of Asthma Exacerbations. These two guidelines represent not only an update but also a change in the methodology used in their drafting, thus improving their scientific quality.

Traditional East Asian medicine: how to understand and approach diagnostic findings and patterns in a modern scientific framework?

Research into the diagnostic methods and patterns of traditional East Asian medical (TEAM) systems of practice such as acupuncture and herbal medicine face certain challenges due to the nature of thinking in TEAM and the subjective basis of judgments made in practice. The TEAM-based diagnosis can take into account various findings and signs such as the appearance of the tongue, palpable qualities of the radial pulses, palpable qualities and findings on the abdomen, the complexion of the patient and so on. Both diagnostic findings and the patterns of diagnosis cannot be assumed to have objective bases or to be causally related to the complaints of the patient. However, the diagnoses of TEAM based acupuncture and herbal medicine have tended to look at pictures of the whole patient and rather than focus on a particular symptom, they have looked across a myriad of signs and symptoms to decide or identify the 'pattern' of diagnosis according to the theory in question. Although open for selective and subjective biases each diagnosis pattern always comes with a prescribed treatment tailored to the pattern. Further, the same research requirements needed for the validation of the diagnoses are needed also for these clinical observations and judgments. Hence, it is necessary, albeit challenging for research on TEAM diagnoses to first address these issues before proceeding to more complex investigations such as the development of instruments for making diagnostic observations, instruments for forming diagnostic conclusions or studies investigating the physiological bases of the diagnostic patterns. Preliminary work has started and instruments have been made, but we suggest that any instrumentation must necessarily be first validated by matching of the calibrated or scaled observations or judgments to observations made and agreed upon by relevant experts. Reliability of all observations and judgments are needed before any other tool, technology or more advanced approach can proceed and also whenever the natural system of diagnosis-treatment is applied in clinical trials. In this paper the authors highlight the core problems and describe a step wise process for addressing them.

A novel oral nutraceutical formula of omega-3 and omega-6 fatty acids with vitamins (PLP10) in relapsing remitting multiple sclerosis: a randomised, double-blind, placebo-controlled proof-of-concept clinical trial

OBJECTIVE

To assess whether three novel interventions, formulated based on a systems medicine therapeutic concept, reduced disease activity in patients with relapsing-remitting multiple sclerosis (MS) who were either treated or not with disease-modifying treatment.

DESIGN

A 30-month randomised, double-blind, placebo-controlled, parallel design, phase II proof-of-concept clinical study.

SETTINGS

Cyprus Institute of Neurology and Genetics.

PARTICIPANTS

80 participants were randomised into four groups of 20 each. A total of 41 (51%) patients completed the 30-month trial. The eligibility criteria were an age of 18-65; a diagnosis of relapsing-remitting MS according to the McDonald criteria; a score of 0.0-5.5 on the Expanded Disability Status Scale (EDSS); MRI showing lesions consistent with MS; at least one documented clinical relapse and either receiving or not a disease-modifying treatment within the 24-month period before enrolment in the study. Patients were excluded because of a recent (<30 days) relapse, prior immunosuppressant or monoclonal antibody therapy, pregnancy or nursing, other severe disease compromising organ function, progressive MS, history of recent drug or alcohol abuse, use of any additional food supplements, vitamins or any form of polyunsaturated fatty acids, and a history of severe allergic or anaphylactic reactions or known specific nutritional hypersensitivity.

INTERVENTIONS

The first intervention (A) was composed of Ω-3 and Ω-6 polyunsaturated fatty acids at 1:1 wt/wt. Specifically, the Ω-3 fatty acids were docosahexaenoic acid and eicosapentaenoic acid at 3:1 wt/wt, and the Ω-6 fatty acids were linoleic acid and γ-linolenic acid at 2:1 wt/wt. This intervention also included minor quantities of other specific polyunsaturated, monounsaturated and saturated fatty acids as well as vitamin A and vitamin E (α-tocopherol). The second intervention (B, PLP10) was a combination of A and γ-tocopherol. The third intervention (C) was γ-tocopherol alone. The fourth group of 20 participants received placebo. The interventions were administered per os (by mouth) once daily, 30 min before dinner for 30 months.

MAIN OUTCOME MEASURES

The primary end point was the annualised relapse rate (ARR) of the three interventions versus the placebo at 2 years. The secondary end point was the time to confirmed disability progression at 2 years.

RESULTS

A total of 41 (51%) patients completed the 30-month trial. Overall, for the per-protocol analysis of the 2-year primary end point, eight relapses were recorded in the PLP10 group (n=10; 0.40 ARR) versus 25 relapses in the placebo group (n=12; 1.04 ARR), representing a 64% adjusted relative rate reduction for the PLP10 group (RRR 0.36, 95% CI 0.15 to 0.87, p=0.024). In a subgroup analysis that excluded patients on monoclonal antibody (natalizumab) treatment, the observed adjusted RRR became stronger (72%) over the 2 years (RRR 0.28, 95% CI 0.10 to 0.79, p=0.016). The per-protocol analysis for the secondary outcome at 2 years, the time to disability progression, was significantly longer only for PLP10. The cumulative probability of disability progression at 2 years was 10% in the PLP10 group and 58% in the placebo group (unadjusted log-rank p=0.019). In a subgroup analysis that excluded patients on natalizumab, the cumulative probability of progression was 10% for the 10 patients in the PLP10 group and 70% for the 12 patients in the placebo group, representing a relative 86% decrease in the risk of the sustained progression of disability in the PLP10 group (unadjusted log-rank p=0.006; adjusted HR, 0.11; 95% CI 0.01 to 0.97, p=0.047). No adverse events were reported. Interventions A (10 patients) and C (9 patients) showed no significant efficacy.

CONCLUSIONS

In this small proof-of-concept, randomised, double-blind clinical trial; the PLP10 treatment significantly reduced the ARR and the risk of sustained disability progression without any reported serious adverse events. Larger studies are needed to further assess the safety and efficacy of PLP10.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial, number ISRCTN87818535.

Complexity-based measures inform Tai Chi's impact on standing postural control in older adults with peripheral neuropathy

BACKGROUND

Tai Chi training enhances physical function and may reduce falls in older adults with and without balance disorders, yet its effect on postural control as quantified by the magnitude or speed of center-of-pressure (COP) excursions beneath the feet is less clear. We hypothesized that COP metrics derived from complex systems theory may better capture the multi-component stimulus that Tai Chi has on the postural control system, as compared with traditional COP measures.

METHODS

We performed a secondary analysis of a pilot, non-controlled intervention study that examined the effects of Tai Chi on standing COP dynamics, plantar sensation, and physical function in 25 older adults with peripheral neuropathy. Tai Chi training was based on the Yang style and consisted of three, one-hour group sessions per week for 24 weeks. Standing postural control was assessed with a force platform at baseline, 6, 12, 18, and 24 weeks. The degree of COP complexity, as defined by the presence of fluctuations existing over multiple timescales, was calculated using multiscale entropy analysis. Traditional measures of COP speed and area were also calculated. Foot sole sensation, six-minute walk (6MW) and timed up-and-go (TUG) were also measured at each assessment.

RESULTS

Traditional measures of postural control did not change from baseline. The COP complexity index (mean ± SD) increased from baseline (4.1 ± 0.5) to week 6 (4.5 ± 0.4), and from week 6 to week 24 (4.7 ± 0.4) (p=0.02). Increases in COP complexity-from baseline to week 24-correlated with improvements in foot sole sensation (p=0.01), the 6MW (p=0.001) and TUG (p=0.01).

CONCLUSIONS

Subjects of the Tai Chi program exhibited increased complexity of standing COP dynamics. These increases were associated with improved plantar sensation and physical function. Although more research is needed, results of this non-controlled pilot study suggest that complexity-based COP measures may inform the study of complex mind-body interventions, like Tai Chi, on postural control in those with peripheral neuropathy or other age-related balance disorders.

Multilevel omic data integration in cancer cell lines: advanced annotation and emergent properties

Background

High-throughput (omic) data have become more widespread in both quantity and frequency of use, thanks to technological advances, lower costs and higher precision. Consequently, computational scientists are confronted by two parallel challenges: on one side, the design of efficient methods to interpret each of these data in their own right (gene expression signatures, protein markers, etc.) and, on the other side, realization of a novel, pressing request from the biological field to design methodologies that allow for these data to be interpreted as a whole, i.e. not only as the union of relevant molecules in each of these layers, but as a complex molecular signature containing proteins, mRNAs and miRNAs, all of which must be directly associated in the results of analyses that are able to capture inter-layers connections and complexity.

Results

We address the latter of these two challenges by testing an integrated approach on a known cancer benchmark: the NCI-60 cell panel. Here, high-throughput screens for mRNA, miRNA and proteins are jointly analyzed using factor analysis, combined with linear discriminant analysis, to identify the molecular characteristics of cancer. Comparisons with separate (non-joint) analyses show that the proposed integrated approach can uncover deeper and more precise biological information. In particular, the integrated approach gives a more complete picture of the set of miRNAs identified and the Wnt pathway, which represents an important surrogate marker of melanoma progression. We further test the approach on a more challenging patient-dataset, for which we are able to identify clinically relevant markers.

Conclusions

The integration of multiple layers of omics can bring more information than analysis of single layers alone. Using and expanding the proposed integrated framework to integrate omic data from other molecular levels will allow researchers to uncover further systemic information. The application of this approach to a clinically challenging dataset shows its promising potential.

Phenotyping the heterogeneity of chronic obstructive pulmonary disease

COPD (chronic obstructive pulmonary disease) is a heterogeneous disease associated with significant morbidity and mortality. Current diagnostic criteria based on the presence of fixed airflow obstruction and symptoms do not integrate the complex pathological changes occurring within lung, do not define different airway inflammatory patterns, nor do they define different physiological changes or differences in structure as can be defined by imaging. Over recent years, there has been interest in describing this heterogeneity and using this information to subgroup patients into COPD phenotypes. Most approaches to phenotyping have considered disease at a single scale and have not integrated information from different scales (e.g. organ-whole person, tissue-organ, cell-tissue and gene-cell) of disease to provide multi-dimensional phenotypes. Integration of disease biology with clinical expression is critical to improve understanding of this disease. When combined with biostatistical modelling, this information may lead to identification of new drug targets, new end points for clinical trials and targeted treatment for subgroups of COPD patients. It is hoped this will ultimately improve COPD outcomes and represent a move towards personalised medicine. In the present review, we will consider these aspects of multi-dimensional phenotyping in more detail.

A complex, nonlinear dynamic systems perspective on Ayurveda and Ayurvedic research

The fields of complexity theory and nonlinear dynamic systems (NDS) are relevant for analyzing the theory and practice of Ayurvedic medicine from a Western scientific perspective. Ayurvedic definitions of health map clearly onto the tenets of both systems and complexity theory and focus primarily on the preservation of organismic equanimity. Health care research informed by NDS and complexity theory would prioritize (1) ascertaining patterns reflected in whole systems as opposed to isolating components; (2) relationships and dynamic interaction rather than static end-points; (3) transitions, change and cumulative effects, consistent with delivery of therapeutic packages in the reality of the clinical setting; and (4) simultaneously exploring both local and global levels of healing phenomena. NDS and complexity theory are useful in examining nonlinear transitions between states of health and illness; the qualitative nature of shifts in health status; and looking at emergent properties and behaviors stemming from interactions between organismic and environmental systems. Complexity and NDS theory also demonstrate promise for enhancing the suitability of research strategies applied to Ayurvedic medicine through utilizing core concepts such as initial conditions, emergent properties, fractal patterns, and critical fluctuations. In the Ayurvedic paradigm, multiple scales and their interactions are addressed simultaneously, necessitating data collection on change patterns that occur on continuums of both time and space, and are viewed as complementary rather than isolated and discrete. Serious consideration of Ayurvedic clinical understandings will necessitate new measurement options that can account for the relevance of both context and environmental factors, in terms of local biology and the processual features of the clinical encounter. Relevant research design issues will need to address clinical tailoring strategies and provide mechanisms for mapping patterns of change that account for the contiguous, self-replicating, cumulative, and synergistic theories associated with successful Ayurvedic treatment approaches.

Genetic deficiency in neprilysin or its pharmacological inhibition initiate excessive stress-induced alcohol consumption in mice

Both acquired and inherited genetic factors contribute to excessive alcohol consumption and the corresponding development of addiction. Here we show that the genetic deficiency in neprilysin [NEP] did not change the kinetics of alcohol degradation but led to an increase in alcohol intake in mice in a 2-bottle-free-choice paradigm after one single stress stimulus (intruder). A repetition of such stress led to an irreversible elevated alcohol consumption. This phenomenon could be also observed in wild-type mice receiving an orally active NEP inhibitor. We therefore elucidated the stress behavior in NEP-deficient mice. In an Elevated Plus Maze, NEP knockouts crossed more often the area between the arms, implicating a significant stronger stress response. Furthermore, such animals showed a decreased locomotor activity under intense light in a locomotor activity test, identifying such mice to be more responsive in aversive situations than their wild-type controls. Since the reduction in NEP activity itself does not lead to significant signs of an altered alcohol preference in mice but requires an environmental stimulus, our findings build a bridge between stress components and genetic factors in the development of alcoholism. Therefore, targeting NEP activity might be a very attractive approach for the treatment of alcohol abuse in a society with increasing social and financial stress.