We monitor our streets to prevent assault and
rodents to develop drugs, but not those for whom the drugs are intended. It
took over half a century to begin to monitor blood sugar values in patients
with insulin-dependent diabetes. Monitoring blood pressure is equally timely
and technically feasible for individual home- and website-based personalised
care. It also serves basic science and someday perhaps the management of
societal illnesses.
Around-the-clock monitoring of blood pressure
(BP) and heart rate (HR) can detect Vascular Variability Disorders. VVDs
include high BP and/or pulse pressure, that is MESOR (midline-estimating
statistic of rhythm) hypertension (MH) and excessive pulse pressure (EPP). For
all newly diagnosed hypertensives, at least two 24-hour/7-day records are
recommended for the prevention of stroke and other life-threatening diseases.
Lifetime-long self-surveillance may be advocated, once the diagnosis of MH or
other VVD is confirmed, to validate dosage and timing of treatment.
Decades-long records of BP and HR reveal potential signatures of cycles found
in solar wind speed, e.g. far-transyears and cis-halfyears (shorter than a
standard half-year), of about 16 and 5 months length, respectively. Transyears
(more than – ‘trans’ – a calendar year) replace the calendar year in
categorising some events, in the incidence patterns of cardiac arrhythmia,
sudden death and suicide.
Data from satellites and other modern
technologies allow us to apply the advice of Sir Norman Lockyer, the
co-discoverer of helium and the founder of the journal Nature: “Surely in meteorology, as in astronomy [and
we would add, “and as in personal and societal health care”], the thing to
hunt down is a cycle [emphasis ours], and if that is not to be found in the temperate
zone, then go to the frigid zones or to the torrid zone to look for it; and if
found, then above all things, and in whatever manner, lay hold of it, study it,
record it and see what it means” (Lockyer, 1874).
Miroslav Mikulecky, emeritus professor of internal medicine and statistics at
Comenius University, Bratislava, Slovakia, indeed found what he dubbed
‘Halberg’s transyear’ in Mindanao (Philippines) and Brazil as well as in
Slovakia for variables ranging from birth rate to the incidence of epilepsy and
stroke (see e.g. Kovac and Mikulecky, 2005).
Sir Norman knew the importance of the cycles
generated by our cosmos and like Professor Mikulecky, we followed his advice (Halberg et al, 2006). We argue that through nucleic acid, these
cycles eventually become self-sustaining and self-reproducing organisms,
including humans, with impacts at the level of society. For all longstanding
environmental cycles in the electromagnetic spectrum, whether in the visible
range (photics, such as the day and the seasons) or beyond (nonphotics), biospheric reciprocals in terms of similar
period lengths, τ, have been found. Nonphotics relate to particle radiation
from space weather, broadly galacto-helio-ionosphero-geomagnetics, gravity, UV
flux and whatever else can be measured in time in our cosmos.
There are more τs than those of about a
fraction of a second encountered in the electroencephalogram or about 1 second
in the electrocardiogram. There are cycles with τs of ~1 day, those of ~1, ~2
and ~4 weeks, and ~5 months, as well as ~6, ~12 and ~13 month (near-transyear),
and ~16 to ~21 month (far-transyear) cycles. There are also ~11, ~22, ~33, ~50
and ~500 year and myriadennian (Rohde and Muller, 2005) recurring patterns.
Reciprocity of cycles in and around us
Some cycles have a periodicity measured in
millions of years, e.g. the diversity ofgenera on the ocean floor. Equally, for each built-in
cycle in living matter an environmental counterpart may be sought (Halberg et al, 2000) and has been
found, for the visible day and year (photics) first, and now also for the week
and a near-transyear, longer than 12 months by a few weeks (one of the
nonphotics).
The τ of 24 hours has served to classify three
domains within a broad array of frequencies (f = 1/τ). These are circadian (τ =
20–28 hours), ultradian (τ < 20 hours) and infradian (τ > 28 hours).
Many, notably nonphotic cycles around us and their signatures in us, are
nonstationary; they wax and wane in amplitude to the point of disappearing,
reappearing and drifting in frequency, bifurcating and rejoining. The built-in
nature of the cycles, with periods of their own, amenable to synchronisation by
the environment but persisting when the environmental cycle is no longer
detected, can be documented. A combination of methods is used to assess
uncertainties across entire time series, as well as some concerning variation
with time. If, and only if, these procedures have been completed, then these
quasi-periodicities can be inferentially statistically described as Aeolian, so called because they mimic and may be
related to solar wind speed (SWS) – from the Greek god Aeolus who ruled the
winds. These periodicities in the biosphere are the realm of chronobiology,
while aligned with weather on earth and in space, they form the basis of
chronomics.
A microscopy-in-time revealed cycles in broad
time structures with their mechanisms embedded in living matter, and this was
resolved as chronobiology. The alignment of time series in biology with series
from physics led to chronomics, a telescopy-in-time. The ~20-year population
cycles found in religiosity, crime and war can be mapped and examined for
associations in underlying putative neuroendocrine and cellular mechanisms in
some motivated persons’ blood pressure. These may serve as a starting point for
a focus on diseases of nations through the study of individuals. Starting with
a focus upon the psychophysiological mechanisms of underlying cycles of
diseases of nations, complex relations will have to be resolved – perhaps the
major task of applied biomedicine if humanity is to meet the extremist
challenges of our time – via chronobioethics.
Rules of chronobiology
Whether biospheric and environmental cycles
have corresponding periods can be tested – and has been documented – once the
zero-amplitude (A) assumption of each cycle is rejected (i.e. by ascertaining
that the lower limit of the CI or 95% confidence interval of A is positive).
CIs of τs can then be compared and may overlap. They can be characterised by
intradisciplinary congruence when we deal with time series of the same
variables, or from the same discipline such as physics or biology. Congruence
is interdisciplinary when the variables are from two different disciplines such
as biology and physics. There can also be ‘transdisciplinary congruence’ when
other disciplines beyond biology and physics are also involved. Moreover, these
environmental-biospheric associations can reveal a ‘selective assortment’ of
congruences of a given physiological variable with different environmental
cycles at various frequencies.
Happenstance can never be ruled out, but must
be estimated and rendered unlikely by further steps. ‘Consistent subtractive
and/or additive behaviour’ is examined by the subtraction, up to removal, of an
environmental component from the transdisciplinary spectrum or, alternatively,
by both the addition and the removal of a component to this spectrum. When
changes in the biosphere correspond to those in the environment yet persist in
the absence of the latter, we can actually validate the long-term occurrence of
the very environmental cycle which is (transiently) lost.
In summary, there are four main rules:
- Rule 1 is congruence in τ (not necessarily in phase), documented by overlapping CIs of infradian τs, in various regions of the spectra from multiples and submultiples of 7 days (multiseptans) over transyears, up to τs of ~11 or ~22 years (decadals and didecadals) (Halberg et al, 2003) and longer than 30 years (transtridecadals) (Halberg et al, 2009).
- Rule 2, a selective assortment of biospheric-cosmic pairing, can be illustrated for an individual’s heart rate with a trans-tridecadal environmental cycle and for blood pressure of the same subject with a didecadal one. A consistent selective pull of the HR, but not of the BP circa-septan phase, also constitutes selective assortment (Halberg et al, 2006), and so does at the cis-half-year frequency the parallelism of phases in 17-ketosteroid excretion and of the geomagnetic planetary index Kp (Halberg et al, 2008). The application of these first two rules is reminiscent of Mendel’s laws of segregation and independent assortment of what became genes.
- Rule 3, a consistent subtractive and/or additive behaviour, is opportunistically examined by subtraction (up to removal) from the transdisciplinary spectrum of an environmental ~7-day component or of an ~1.3-year component or by the addition of a 7-day or of a transyear component (Halberg et al., 2006). Each entails corresponding changes in the biosphere (damping but not loss, or amplification).
- Rule 4 is concerned with the genetic coding of the biospheric cycle, quantified by cosinor and thus more completely revealed at the molecular level for circadians (Sothern et al., 2009) and perhaps at the atomic level for some circaseptans and for other infradians by a damping effect due to the removal of an environmental component. This rule validates the long-term occurrence of an environmental cycle to the point that it became genetically coded. Damped persistence of the biospheric cycle is hence a transdisciplinary tool pertinent to physics, biology and beyond for an eventual transdisciplinary unified science.
The implications for societal issues can be investigated by
mapping photic circadian and circannual cycles in variables as different as
nucleic acid synthesis, BP and HR. A multitude of infradian nonphotic cycles
then can also be found in a multitude of variables occurring in individuals and
in the broader biosphere, such as the incidence patterns of sudden cardiac
death and suicide . Future research into the potential role of
the sun has much to gain from physiological monitoring taking place in
preventive and curative self-surveillance strategies taught and implemented at
primary and secondary education levels
Self-help
Chronobiologic steps toward personalised
healthcare at home could replace the current, mostly office- or
hospital-delivered spot check. This is often only pseudo-evidence-based care as
much that relates to everyday physiological variability is lost, being
described (and ignored) as “within normal limits”. These limits often serve
only to identify a value that may be ‘too high’ or ‘too low’, while a ‘too
early’ or ‘too late’ event, or an unacceptable swing around an acceptable mean,
remain unassessed. Yet the identification of these VVDs is of critical
importance as they may be indicators of a reversible risk. Self-surveillance is
in this context useful for everyone and a sine qua non for all treated hypertensives.
Without chronobiology, differences in
amplitude, phase or frequency in two groups being compared can yield opposite
results at different times. In the individual as well, opposite results can be
obtained at different rhythm stages, approximated by clock-hours, as documented
in. Currently, a vast number of uninformed care
providers, blind to large everyday BP and HR variability, treat equally
uninformed patients, also blind to variability. Unintentionally because
unknowingly, the treatment may induce a circadian overswing (which could be
diagnosed with chronobiology) even while all the data lie within so-called
normal limits (i.e. no one value is neither too high nor too low). A VVD can
represent a greater risk than that of a high BP and can be treated. Two or more
VVDs can coexist as vascular variability syndromes, VVSs, with a very high risk
of stroke and other life-threatening events . Some VVDs can be eliminated if detected,
but otherwise they could be unknowingly iatrogenically induced.
The incidence of VVDs
was assessed in a clinic population of 297 patients. Blood pressure (BP) and
heart rate (HR) of each subject were monitored around the clock for two days at
15-minute intervals at the start of study. Each record was analysed
chronobiologically and results interpreted in the light of time-specified
reference limits qualified by gender and age. On this basis, MESOR-hypertension
(MH, diagnosed in 176 patients), excessive pulse pressure (EPP), CHAT (a
circadian overswing), and a deficient heart rate variability (DHRV) were
identified and their incidence related to outcomes (cerebral ischemic attack,
coronary artery disease, nephropathy, and/or retinopathy). Outcomes, absent at
the start of study in these non-diabetic patients, were checked every six
months for six years, to estimate the relative risk associated with each VVD
alone (primary diagnosis, PD) or in combination with 1, 2, or 3 additional
VVDs. Earlier work showed that CHAT was associated with a risk of cerebral
ischemic event and of nephropathy higher than MH, and that the risks of CHAT,
EPP, and DHRV were mostly independent and additive. It thus seemed important to
determine the incidence of each VVD, present alone or in combination with one
or more additional VVDs. The 176 patients with MH were broken down into 103
(34.7% of the population of 297 patients) with uncomplicated MH, 55 (18.5%)
with MH complicated by one additional VVD, 15 (5.1%) and 3 (1.0%) with MH
complicated by two or three additional VVDs. In the last group, all three
patients had a morbid outcome within six years of the BP monitoring. Ambulatory
BP monitoring over only 48 hours, used for diagnosis, is much better than a
diagnosis based on casual clinic measurements, yet its results apply only to
groups. With this qualification, of the 176 patients with MH, 73 (42.2%) had
additional VVDs that further increase their vascular disease risk, and that are
not considered in the treatment plan of these patients since current practice
does not assess these VVDs. This proportion may be smaller when VVDs are
diagnosed on the basis of a 7-day record (available for CHAT). Results related
to EPP (bottom left), CHAT (upper right), and DHRV (bottom right) illustrate
that these conditions can be present in the absence of MH in as many as 12
(4.0%) of the 297 subjects. Since they do not have MH, it is unlikely that these
subjects would be treated from a conventional viewpoint, even though their
vascular disease risk can be as high as or even higher than MH. Evidence
suggests that treating these conditions may translate into reducing morbidity
and/or mortality from vascular disease. Another lesson is that around-the-clock
monitoring of BP and HR interpreted chronobiologically is needed, even in the
absence of MH, to detect vascular disease risk associated with VVDs such as
CHAT and DHRV, that cannot be assessed on the basis of casual clinic
measurements, so that non-pharmacologic and/or pharmacologic intervention can
be instituted in a timely fashion before the occurrence of adverse outcomes.
Once implemented across the board rather than in selected patient populations,
vascular disease could be curbed to a much larger extent at relatively low cost
if the monitoring is offered directly to the public and care providers become
involved only after detection of a VVD. A website has to be built to interest
many people and to provide cost-free analyses in exchange for the data, as is
now provided worldwide by the BIOCOS project on a small scale (corne001@umn.edu). This is an alternative to a polypill that
as yet neither detects nor treats VVDs and VVSs.
The detection of VVDs can lead to more
extensive preventive treatment and better care (since inferential statistics
can be applied to the individual) for previously ignored as well as known
conditions – and this can be achieved at much less cost by computer-based
self-surveillance within a home-based health programme. Chronobiologic
surveillance by apparently complex personalised inferential statistical
procedures can actually be implemented automatically for the individual via a
website providing inferential statistical analyses. These would prompt
treatment or modification of existing measures and so prevent strokes,
myocardial infarctions, kidney disease and blindness.
The same monitoring for personal healthcare on
a large scale also provides research data on societies’ health and on any
underlying cosmic roots of population disease like crime. One may then try to
develop rational countermeasures to roots of society’s ills in space weather,
just as we already cope with extremes of heat and cold in terrestrial weather
with the aid of air conditioning or heating.
The mapping of cycles shared by living matter
and the environment, seen and unseen, constitutes the essential control in a
transdisciplinary unified science. These cycles can be resolved by a temporal
microscopy (chronobiology) and telescopy (chronomics), which are already
available today cost-free worldwide through BIOCOS (corne001@umn.edu) and sooner or later, we trust, through the
Phoenix project website (www.phoenix.tc-ieee.org). The Phoenix Group of electrical and
electronic engineers from the Twin Cities chapter of the Institute of
Electrical and Electronics Engineers is planning to develop an inexpensive,
cuffless automatic monitor for blood pressure
Concluding discussion
With respect to critics and fierce opposition
to antisepsis (and we would argue also applicable with respect to ignorance of
chronobiology and chronomics), Oliver Wendell Holmes elegantly remarked that
“medical logic … does not seem to have been either taught or practised in our
schools”. Well over a century later, his statement can also be cited in the
context of a new practicable chronobiology and chronomics – the concepts
involved are not new though.
Janeway, an opinion leader at Johns Hopkins
University, wrote at the turn of the last century : “… it is
essential that
a record of the pressure be made at frequent intervals at some time
previous [presumably
to an examination], to establish the normal level and the extent of the
periodic variations. When this is done, it may be possible to demonstrate
changes of small extent which, lacking this standard for comparison, would be
considered within the limits of normal variation.”
In 1974, Frederic C Bartter, then head of the
Hypertension-Endocrine Branch at the (US) National Institutes of Health (NIH)
and subsequently of the NIH Clinical Center, wrote of a patient whose blood
pressure was diagnosed differently by two physicians who saw him at different
times of day : “By conventional standards, this patient is
clearly normotensive every morning. But the blood pressure determined each day
at six in the afternoon provides especially convincing evidence that this
patient is a hypertensive. … My plea today is that information contained in
[data curves compiled under differing circumstances, such as 24-h/7-day a week]
become a routine minimal amount of information accepted for the description of
a patient’s b by cosinor should become a routine. It is essential that enough information be
collected to allow objective characterisation of a periodic phenomenon, to wit,
an estimate of M [the time structure or chronome-adjusted mean, or MESOR] … an
estimate of [the amplitude] A itself, and finally an estimate of acrophase,
[a measure of timing]. In this way, a patient can be compared
with himself at another time, or under another treatment, and the patient can
be compared with a normal or with another patient.”
Today it is documented that some circadian
VVDs – notably in combination, as VVSs – entail a risk far exceeding the risk
of high blood pressure in itself. These VVDs have raised the risk of having a
stroke within six years in MESOR-hypertensives from perhaps 5% to near 100%.
For many millions worldwide, the high risk, greater than that of high blood
pressure, can be eliminated if the detection of VVDs enters the business plan
of every care provider who realises the cost-effectiveness of their detection.
Alternatively, or preferably concomitantly, the educable and educated public,
notably the community of biologists, may be the agent against apathy and lack
of action.
Reference:
Chronobiology and chronomics: detecting and applying the cycles
of nature
Franz Halberg, Germaine Cornélissen, Douglas Wilson, R B Singh,Fabien De Meester, Yoshihiko Watanabe, Kuniaki Otsuka, and Elchin Khalilov
