Complexity is one of the most addressed features of life and a possible major hindrance to the advancement of knowledge in life science. This inevitably makes life science a non-exact scientific field largely operating through qualitative, verbose descriptions, as opposed to the quantitative, mathematical models of physics. Consequently, the predictivity of theoretical models in life science is generally low, posing serious limits to their application to the real world. This is mirrored by serious difficulties in biomedical investigations, with several diseases remaining etiologically puzzling and recalcitrant to treatments, including tumor malignancies, neurodegenerative diseases, immune disorders, metabolic syndromes, and different infectious diseases. However, rather than being due to the excessive complexity of life, these drawbacks could derive from an unsuitable approach to the study of life processes, including transitions from physiological to pathological conditions.

The human body is believed to consist of about 10 ¹³ cells ( Bianconi et al., 2013), while about 10 ¹⁰ s ^-1 chemical reactions can be roughly calculated to occur inside each cell, considering basal metabolism and the energy released per mole by ATP hydrolysis ( Wackerhage et al., 1998), thus making up a total of about 10 ²³ s ^-1 chemical reactions in the whole body. The ability of maintaining a metabolic steady state, despite such a huge complex of events, seems statistically paradoxical. However, this would be true if metabolic processes were uncorrelated from each other, whereas they are supposed to be strictly regulated and cross-adjusted ( Burlando, 2017; El-Samad, 2021). Hence, if reciprocal control is the prerequisite of life processes, their study cannot be exempted from an appropriate analysis of control mechanisms.

Seminal theoretical work by Ludwig Von Bertalanffy has led to the development of systems theory ( von Bertalanffy, 1968), which in the beginning was inspired by living systems, and thereafter was widely applied to engineering. Thereafter, systems and control theory has developed the study of dynamic systems consisting of negative or positive feedback loops, i.e. sequences of interactions among functional agents arranged as closed chains ( Blanchini et al., 2014). Negative loops have an uneven number of inhibitory steps, in addition to possible activation steps, and one stable equilibrium point or a limit cycle with oscillatory behavior. By contrast, positive loops have an even number of inhibitory steps, or none, and admit multiple stable equilibrium points.

Physiological mechanisms based on negative feedback loops are known to maintain homeostasis, or induce oscillations within fixed boundaries, thus ensuring the body’s steady state ( Blanchini et al., 2014; Burlando et al., 2019). Conversely, positive feedback loops have been classically underestimated and assumed to occur sparingly, due to their supposed destabilizing effect in need of compensation by negative loops. However, the advent of systems biology has favored a new analysis of life complexity, by focusing not so much on the biodiversity of life constituents, but rather on the interactions that are established between them ( Wolkenhauer and Mesarovic, 2005; Wolkenhauer et al., 2005). Such a new trend has proved that several life processes, especially those that produce irreversible changes, can be modeled by positive loops. A noncomprehensive list includes bistable gene expression ( Olivenza et al., 2019), cell cycle ( Mochida et al., 2016; Vigneron et al., 2018; Stallaert et al., 2019), mitosis ( Hutter et al., 2017), cell migration ( Nguyen et al., 2018), cell differentiation ( Wang et al., 2009), and axon growth ( Padmanabhan and Goodhill, 2018).

The accumulating evidence that loops play an essential role in several functions accomplished by living beings ( El-Samad, 2021) has inspired the loopomics paradigm, i.e. the assumption that any functional element of a biological system is somehow involved in a loop mechanism, while the whole system can be conceptualized as an intertwined array of loops ( Burlando, 2017). Hence, the dynamics of the whole system obey to a restricted number of rules, but nevertheless, they give rise to a highly complex biodiversity, expressed in terms of epiphenomena occurring at different dimensional scales, e.g. subcellular organelles, cells, tissues, human beings, etc. Hence, given the above dynamical behavior of functional loops, any change or transition that can be observed within the human body would be the result of a multistable positive loop system switching among different equilibrium points ( Laurent and Kellershohn, 1999).

This is a completely new redefinition of life, shifting from complexity to uniformity through a comprehensive and unifying modeling in terms of loops. Such a new paradigm has deep repercussions in the field of medicine because any disease that affects a healthy organism must have at its origin an early event in the form of a change that drives the system from a physiological to an altered functional regimen.

A rapidly increasing number of pathogenic processes are being modeled as bistable switches, a few representative examples of which include cancer ( Kim et al., 2007; Huang et al., 2014), prion infections ( Kellershohn and Laurent, 2001), immunological disorders ( Beutler, 2009), dermatitis ( Dominguez-Huttinger et al., 2017), neurological problems ( Mucci et al., 2020), and neurodegenerative diseases ( De Caluwe and Dupont, 2013; Burlando et al., 2020). In other cases, a bistable model has not been explicitly used to describe pathogenesis, but a positive loop has been nevertheless invoked ( Beutler, 2009; Norwitz et al., 2019). However, this kind of approach is generally conducted on a case-by-case basis, without making any attempt at proving generalizability, despite long established evidence that could be used to move towards this direction, as explained below. First, it is obvious that diseases affecting a healthy human must involve at their origin pathophysiological changes leading to transitions from a physiological to pathological condition. Second, diseases are classifiable (e.g. https://www.who.int/standards/classifications/classification-of-diseases), i.e. they make up an ordered set, showing that the above changes are predictable. Third, diseases are recurrent through human generations, showing that pathophysiological changes depend on the activity of clonable physiological pathways that have been selected for by natural selection. Therefore, these changes must admit stability as a starting point, otherwise their selection would not have been possible. However, stability must also characterize their ending point, otherwise disease classification would not be possible. In summary, diseases depend on predictable changes carried out by multistable systems, and therefore a generalization of these processes can be achieved by using dynamic models able to develop transitions between different stable equilibrium points.

Such a view is to some extent counterintuitive because diseases are generally thought as complex processes involving many factors, progressing as gradual processes rather than by abrupt switch-like transitions, like for example diabetes, cardiovascular disorders, and obesity. However, the clinical presentation of a disease, independently from its severity, generally consists of several altered metabolic and physiological conditions deriving from widespread cascade effects. This can be inferred e.g. from the SOD1-G93A mouse model of amyotrophic lateral sclerosis, in which metabolic alterations are detectable well before symptom onset ( Ravera et al. 2019). In contrast, the present analysis is aimed at understanding the very early events located at the boundary between the physiological and the pathogenic condition, i.e. the seminal etiological processes.

Given the above considerations, a new hypothesis can be proposed, stating that any disease that affects a healthy human involves at its primary causal event a change that can be conceptually reduced to a multistable system (typically a bistable one) depending on a positive functional loop consisting of cellular, molecular, or biochemical elements interplaying with each other. Also, the mathematical study of loop dynamics can allow the identification of bifurcation parameters that drive the transition from monostability to multistability ( Freyer et al., 2012), thus realizing the condition for the switching of the system from a “physiological” to a “pathological” stable equilibrium point, or steady state. Hence, the physical correspondents of these parameters, which could be single factors or pathways, are to be recognized as best therapeutic targets, potentially allowing the achievement of disease manageability via pharmacological or non-pharmacological treatments. Moreover, this kind of system is characterized by hysteresis, i.e. the transitions from physiological to pathological steady states occur at different threshold values of the bifurcation parameter, according to the direction of movement along the steady state trajectory, and therefore, irreversibility is also possible for a strengthening of the interactions among the functional agents of the loop ( Figure 1).

A huge set of data from systems biology suggests that changes occurring within living systems are the result of the activity of multistable switches depending on positive functional loops. The theory of systems and control provides a description of loop system dynamics in terms of a restricted set of mathematical rules, providing a basis for bypassing the drawbacks caused by the biodiversity of life constituents, spanning from molecules to individuals. Such a new conceptualization, focused on interactions rather than on objects, results in a recodification of life in terms of biouniformity, instead of biodiversity, allowing the application of unifying formal analyses on a ground where this approach seemed almost impossible. Accordingly, provided that pathogenic processes affecting healthy individuals must themselves be the result of functional changes, a general hypothesis of pathogenesis can be formulated. Based on this theory, the enormous diversity of pathologies that have been described in the human body can be essentially reduced to a single, unifying pathogenic model, of which any disease would represent a variant. Consequently, each disease can be approached by a standard procedure of analysis aimed at identifying positive loops and their bifurcation parameters, thus addressing critical pharmacological targets. Such a theoretical framework could have a huge impact on pharmacology, medicinal chemistry, and clinical practice. Therefore, given the impasse of many approaches to the study of pathogenesis, this hypothesis would deserve to be validated on specific cases by preclinical and clinical studies, in order to explore the extent to which it can be generalized and represent a turning point in biomedical and pathophysiological research.

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