Neural network analysis of sleep stages enables efficient diagnosis of narcolepsy.

Analysis of sleep for the diagnosis of sleep disorders such as Type-1 Narcolepsy (T1N) currently requires visual inspection of polysomnography records by trained scoring technicians. Here, we used neural networks in approximately 3,000 normal and abnormal sleep recordings to automate sleep stage scoring, producing a hypnodensity graph-a probability distribution conveying more information than classical hypnograms. Accuracy of sleep stage scoring was validated in 70 subjects assessed by six scorers. The best model performed better than any individual scorer (87% versus consensus). It also reliably scores sleep down to 5 s instead of 30 s scoring epochs. A T1N marker based on unusual sleep stage overlaps achieved a specificity of 96% and a sensitivity of 91%, validated in independent datasets. Addition of HLA-DQB1*06:02 typing increased specificity to 99%. Our method can reduce time spent in sleep clinics and automates T1N diagnosis. It also opens the possibility of diagnosing T1N using home sleep studies.

Reciprocal Relationship Between Sleep Macrostructure and Evening and Morning Cellular Inflammation in Rheumatoid Arthritis.

OBJECTIVE: This study examined the reciprocal associations between sleep macrostructure and levels of cellular inflammation in rheumatoid arthritis (RA) patients and controls. METHODS: RA patients (n = 24) and matched controls (n = 48) underwent all-night polysomnography, along with assessment of spontaneous- and Toll-like receptor-4-stimulated monocytic production of tumor necrosis factor α (TNF) and interleukin (IL)-6 at 11:00 PM and 8:00 AM. RESULTS: As compared with controls, RA patients showed lower levels of sleep efficiency (mean [standard deviation], 88.1 [6.1] versus 83.8 [7.0]), a higher percentage stage 3 sleep (9.3 [6.4] versus 13.1 [6.9]), and higher levels of percentage of monocytes either spontaneously expressing TNF at 11:00 PM (log transformed, 1.07 [0.28] versus 1.22 [0.17]), and higher Toll-like receptor-4-stimulated production of IL6 at 8:00 AM (log transformed, 3.45 [0.80] versus 3.83 [0.39]). Higher levels of stimulated production of TNF at 11:00 PM were associated with higher sleep efficiency (0.74). In turn, sleep efficiency had a countervailing relationship on TNF production at 8:00 AM (-0.64). Higher levels of spontaneous and stimulated production of IL6 at 11:00 PM were associated with more stage 3 (0.39), stage 4 (0.43), and slow-wave sleep (0.49), with evidence that stage 4 had a countervailing relationship on IL6 production at 8:00 AM (-0.60). CONCLUSIONS: RA patients show evidence of sleep fragmentation, greater sleep depth, and higher levels of cellular inflammation. Sleep maintenance and sleep depth show countervailing relationships with evening and morning levels of monocytic production of TNF and IL-6, respectively, which support the hypothesis of a feedback loop between sleep maintenance, slow-wave sleep, and cellular inflammation that is cytokine specific.

The reciprocal link between sleep and immune responses.

Good sleep is necessary for both physical and mental health; sleep and immune responses are reciprocally and closely linked. Sleep loss impairs the immune response, while, on the other hand, the immune response, activated for instance by an infection, alters sleep. Sleep alterations induced by immune activation are mediated by cytokines such as interleukin-1. In the past, it was thought that cytokines were produced only by the immune system, and active only there as signaling molecules. Today it is clear that IL-1 and other cytokines are present and active in the healthy brain, where they physiologically interact with the brain circuits and the neurotransmitter systems (for instance the serotonergic, GABAergic, and cholinergic systems) that control sleep. These interactions are altered by immune response, and, as a result, non-rapid eye movement (NREM) sleep is increased and fragmented, whereas rapid eye movements (REM) sleep is inhibited.

Can sleep deprivation studies explain why human adults sleep?

PURPOSE OF REVIEW: This review will concentrate on the consequences of sleep deprivation in adult humans. These findings form a paradigm that serves to demonstrate many of the critical functions of the sleep states. RECENT FINDINGS: The drive to obtain food, water, and sleep constitutes important vegetative appetites throughout the animal kingdom. Unlike nutrition and hydration, the reasons for sleep have largely remained speculative. When adult humans are nonspecifically sleep-deprived, systemic effects may include defects in cognition, vigilance, emotional stability, risk-taking, and, possibly, moral reasoning. Appetite (for foodstuffs) increases and glucose intolerance may ensue. Procedural, declarative, and emotional memory are affected. Widespread alterations of immune function and inflammatory regulators can be observed, and functional MRI reveals profound changes in regional cerebral activity related to attention and memory. Selective deprivation of rapid eye movement (REM) sleep, on the contrary, appears to be more activating and to have lesser effects on immunity and inflammation. SUMMARY: The findings support a critical need for sleep due to the widespread effects on the adult human that result from nonselective sleep deprivation. The effects of selective REM deprivation appear to be different and possibly less profound, and the functions of this sleep state remain enigmatic.

Overnight changes of immune parameters and catecholamines are associated with mood and stress.

OBJECTIVES: To test the hypothesis that a nocturnal decrease of secretion of inflammation markers and catecholamines would be associated with mood and stress variables even after controlling for objective sleep variables. METHODS: A total of 130 healthy volunteers participated in this study, spending 2 nights in the Gillin Laboratory of Sleep and Chronobiology at the University of California, San Diego, General Clinical Research Center. Blood samples were obtained before sleep (10:30 PM) and after awakening (6:30 AM) on the first day, and these samples were assayed for inflammatory biomarkers and catecholamines. On the second night, polysomnographic records were scored for objective sleep variables, e.g., total sleep time and wake after sleep onset. Self-rating scales for mood, stress, depression, and daily hassles were administered the second day. RESULTS: The nocturnal decrease in interleukin-6 was smaller in people who reported more negative mood or fatigue and greater in those who reported more uplift events (e.g., with Profile of Mood States fatigue r(p) = -.25 to -.30). People with high stress or high depression levels had smaller nocturnal decreases of epinephrine. That relationship was even stronger when partial correlations were used to control for morning level and sleep variables. The associations between nocturnal changes of C-reactive protein, soluble tumor necrosis factor-receptor I, and norepinephrine with psychological states were nonremarkable. CONCLUSIONS: The analyses of nocturnal change scores (difference scores) add substantial information compared with the traditional analyses of morning levels of immune variables and catecholamines alone. Subjective well-being is significantly associated with a greater nocturnal decrease of interleukin-6 and epinephrine. More research on nocturnal adaptation processes is warranted.

Neural-immune interactions in disorders of sleep-wakefulness organization.

Novel findings on the effects of inflammatory molecules on neuronal circuits, and on molecular interactions between immunity and sleep, in health and disease, shed light on the pathogenesis of disorders of past (encephalitis lethargica) and present concern (human African trypanosomiasis and narcolepsy), which share alterations in sleep-wakefulness transitions. Although these three disorders differ in etiology, synaptic interactions with immune-response-derived molecules could play a pathogenetic role. Knowledge obtained on neural-immune interplay during senescence also has implications for age-related sleep dysregulation, which is common in the elderly population. Altogether, the data indicate that cell groups implicated in the regulation of sleep and wakefulness, circadian timing, and their interactions could be sensitive to synaptic effects of immune molecules.

Effect of environmental temperature on sleep, locomotor activity, core body temperature and immune responses of C57BL/6J mice.

Ambient temperature exerts a prominent influence on sleep. In rats and humans, low ambient temperatures generally impair sleep, whereas higher temperatures tend to promote sleep. The purpose of the current study was to evaluate sleep patterns and core body temperatures of C57BL/6J mice at ambient temperatures of 22, 26 and 30 degrees C under baseline conditions, after sleep deprivation (SD), and after infection with influenza virus. C57BL/6J mice were surgically implanted with electrodes for recording electroencephalogram (EEG) and electromyogram (EMG) and with intraperitoneal transmitters for recording core body temperature (T(c)) and locomotor activity. The data indicate that higher ambient temperatures (26 and 30 degrees C) promote spontaneous slow wave sleep (SWS) in association with reduced delta wave amplitude during SWS in C57BL/6J mice. Furthermore, higher ambient temperatures also promote recuperative sleep after SD. Thus, in mice, higher ambient temperatures reduced sleep depth under normal conditions, but augmented the recuperative response to sleep loss. Mice infected with influenza virus while maintained at 22 or 26 degrees C developed more SWS, less rapid eye movement sleep, lower locomotor activity and greater hypothermia than did mice maintained at 30 degrees C during infection. In addition, despite equivalent viral titers, mice infected with influenza virus at 30 degrees C showed less leucopenia and lower cytokine induction as compared with 22 and 26 degrees C, respectively, suggesting that less inflammation develops at the higher ambient temperature.

Interferon type I receptor-deficient mice have altered disease symptoms in response to influenza virus.

The role of type I interferons (IFNs) in mediation of acute viral symptoms (fever, somnolence, anorexia, etc.) is unknown. To determine the role of type I IFN in selected symptom development, body temperature and sleep responses to a marginally lethal dose of X-31 influenza virus were examined in mice with a targeted mutation of the IFN receptor type I (IFN-RI knockouts) and compared to wild-type 129 SvEv control mice. Mice were monitored for 48 h to determine baseline temperature and sleep profiles prior to infection, and then for 9 days following infection. Hypothermic responses to virus were perceptible beginning at 64 h post-infection (PI) and were more marked in KO mice until 108 h, when hypothermia became more exaggerated in wild-type controls. Temperatures of wild-type mice continued to decline through day 9 while temperatures in IFN-RI KO mice stabilized. Time spent in non-rapid eye movement sleep (NREMS) increased in KO mice when hypothermia was marked and then returned to baseline levels, while NREMS continued to increase in wild-type mice through day 9. Other sleep parameters [time spent in rapid eye movement sleep (REMS), relative NREMS EEG slow wave activity, NREMS EEG power density] were all reduced in wild-type mice compared to KOs from days 3 to 8 while REMS low frequency EEG power density increased in wild-type relative to KOs. In conclusion, our results indicate that the presence of functional type I IFN slightly ameliorates disease symptoms early in the X-31 infection while exacerbating disease symptoms later in the infection.

Sleep and psychoneuroimmunology.

Personal experience indicates we sleep differently when sick. Data reviewed demonstrate the extent to which sleep is altered during the course of infection of host organisms by several classes of pathogens. One important unanswered question is whether or not the alterations in sleep during infection are of functional relevance. That is, does the way we sleep when sick facilitate or impede recovery? One retrospective, preclinical study suggests that sleep changes during infection are of functional relevance. Toth and colleagues [102] analyzed sleep responses of rabbits to three different microbial infections. Those rabbits that exhibited robust increases in NREM sleep were more likely to survive than those that exhibited long periods of NREM sleep suppression. These tantalizing data suggest that the precise alterations in sleep through the course of infection are important determinants of morbidity and mortality. Data from healthy subjects demonstrate a role for at least two cytokines in the regulation of spontaneous, physiologic NREM sleep. A second critical yet unanswered question is whether or not cytokines mediate infection-induced alterations in sleep. The hypothesis that cytokines mediate infection-induced alterations in sleep is logical based on observations of the impact of infection on levels of cytokines in the peripheral immune system and in the brain. No attempts have been made to intervene with cytokine systems in brain during the course of infection to determine if there is an impact on infection-induced alterations in sleep. Although substantial progress has been made in elucidating the myriad mechanisms by which cytokines regulate and modulate sleep, much remains to be determined with respect to mechanistic and functional aspects of infection-induced alterations in sleep.

Increased nocturnal interleukin-6 excretion in patients with primary insomnia: a pilot study.

The aim of the present study was to investigate whether there is a difference in evening/nocturnal interleukin-6 (IL-6) serum excretion in patients with primary insomnia compared to controls. We hypothesized that in insomniac patients, the excretion of evening/nocturnal IL-6 is enhanced, like observed in aged adults and after sleep deprivation in healthy subjects. We studied IL-6 serum concentrations in 11 patients (two males and nine females) with primary insomnia and 11 age and gender-matched healthy controls. Sleep was monitored polysomnographically for three consecutive nights. The measurement of IL-6 (from 19:00 h to 09:00 h) in 2-h intervals were performed prior to and during the last laboratory night. Polysomnographically determined sleep parameters and subjective ratings of sleep demonstrated clear-cut impairments of sleep in the insomniac group. Nocturnal IL-6 secretion was significantly increased (p<.05) in insomniac patients for the whole measurement period (mean area under the curve+/-SD: 27.94+/-14.15 pg/ml x 2h) compared to controls (16.70+/-7.64 pg/ml x 2h). Total IL-6 secretion correlated inversely with subjectively perceived sleep quality and amount of slow wave sleep in the insomniac patients. Amount of Wake Time correlated positively with IL-6 excretion in insomniacs. The results of the present study demonstrate significantly increased nocturnal IL-6 secretion in insomniacs. It might be speculated that chronic primary insomnia with polysomnographically documented sleep impairments activates the production of IL-6 analogous to sleep deprivation studies in healthy subjects. This might also implicate a higher risk for inflammatory and cardiovascular diseases in patients with chronic insomnia.

Sleep and body temperature responses in an acute viral infection model are altered in interferon type I receptor-deficient mice.

Type I interferons (IFNs) include IFNalpha and IFNbeta, both of which are elevated in acute viral infections and both of which have been shown to induce symptoms such as fever and somnolence when administered in pharmacological doses. To investigate the role of type I IFNs in mediation of acute respiratory viral symptoms we examined sleep and body temperature responses in mice with a targeted mutation of the IFN receptor type I (IFN-RI knockouts). IFN-RI knockouts (KOs) or wild-type 129 SvEv controls were challenged intratracheally (IT) with combined poly[rI.rC] (synthetic double-stranded RNA) and IFNgamma, a model that simulates an acute viral infection with respect to body temperature and locomotor activity responses. Control mice of both strains were treated with IT IFNgamma alone. Hypothermic responses to IT poly[rI.rC]/IFNgamma were more exaggerated in the IFN-RI KO mice than in wild-type. The non-rapid eye movement sleep (NREMS) response to IT poly[rI.rC]/IFNgamma was increased earlier in the IFN-RI KO mice than in wild-type, though the total time spent in NREMS was reduced in the KOs compared to wild-type and the return to baseline NREMS was faster in the KOs. The quality of NREMS also was altered more extensively in the wild-type than in the KO mice. Spontaneous rapid eye movement sleep (REMS) was suppressed in IFN-RI KOs as previously reported, but was not substantially altered in either mouse strain by IT poly[rI.rC]/IFNgamma challenge. Our results implicate type I IFNs as inhibitors of the hypothermic response and enhancers of the NREMS response to IT poly[rI.rC]/IFNgamma, a model of acute viral infection.

The association between interleukin-6, sleep, and demographic characteristics.

We examined the relationship between the pro-inflammatory cytokine IL-6 and sleep architecture in 70 healthy men and women. Blood was drawn in the early morning for assessment of IL-6 followed by nocturnal sleep monitoring with polysomnography. Sleep records were scored for sleep stages using standard criteria. Morning IL-6 levels were positively correlated with REM latency after sleep onset [rho = .31, p = .01], percent (%) stage 1 sleep [rho = .23, p = .053], % wake after sleep onset (WASO) [rho = .29, p<.05]. IL-6 levels were negatively correlated with sleep efficiency [rho = -.36, p<.01] and slow wave sleep (SWS) [rho = -.26, p<.05]. After controlling for demographic variables including race, gender, age, and BMI, multiple hierarchical regression analyses revealed that morning IL-6 levels accounted for a significant portion of the variance of REM latency (p<.01), sleep efficiency (p<.01), and % WASO (p = .01). IL-6 was no longer associated with % stage 1 sleep, SWS, and total sleep time after controlling for the demographic characteristics. These findings suggest that the inflammatory marker IL-6 is associated with sleep quality and that certain individual characteristics such as race, gender, and age modify that relationship. Higher IL-6 levels were associated with lower quality of sleep among healthy asymptomatic men and women.

Evaluation of immunogenicity and side effects of triple viral vaccine (MMR) in adults, given by two routes: subcutaneous and respiratory (aerosol).

Adult volunteers from two neighboring health centers were immunized with measles, mumps, rubella vaccine (MMR, Serum Institute of India Ltd.), either given by traditional injections or by an aerosol delivered to the respiratory tract. Baseline and one month post vaccination samples were taken and simultaneously assayed for all three antigens. Subjects were followed-up for temporally associated events after vaccination. The aerosol route was superior for measles, mumps and rubella when baseline titers were controlled for in multivariate analysis. Frequencies of post-vaccination events did not differ with statistical significance between the groups. Further evaluation of the aerosol route for MMR immunization appears warranted.

Diurnal variation of lipopolysaccharide-induced alterations in sleep and body temperature of interleukin-6-deficient mice.

Infectious challenge triggers a broad array of coordinated changes within the host organism, including alterations in sleep-wake behavior and body temperature. Pro-inflammatory cytokines orchestrate many of the behavioral, metabolic, and endocrine responses to immune challenge. Although interleukin (IL)-6 mediates several aspects of sickness behavior, a role for this cytokine as a mediator of alterations in sleep in response to immune challenge has not been established. We evaluated sleep-wake behavior and core body temperature of IL-6-deficient (IL-6 KO; B6.129S6-Il6tm1Kopf) mice and C57BL/6J control mice after intraperitoneal (IP) administration of 10 microg lipopolysaccharide (LPS). Because feedback mechanisms that regulate responses to immune challenge exhibit circadian rhythms, we evaluated responses to LPS administered at the beginning of both the light and dark portions of the light:dark cycle. LPS-induced increases in non-rapid eye movements sleep (NREMS) of both mouse strains, but this increase was less pronounced in IL-6 KO mice than in C57BL/6J mice. Strain differences in LPS-induced increases in NREMS were greatest after light-onset administration. During the 12 h light period, NREMS of C57BL/6J mice increased from 53.0+/-1.7% of recording time after vehicle to 65.4+/-1.4% of recording time after LPS. During this same time period, NREMS of IL-6 KO mice increased from 50.5+/-1.8% after vehicle to only 52.4+/-1.8% of recording time after LPS. REMS of both mouse strains was suppressed to the same extent after LPS, irrespective of timing of administration. LPS-induced fever in C57BL/6J mice, with peak magnitude of 1.4+/-0.3 degrees C and 1.8+/-0.2 degrees C after dark onset and light onset administration, respectively. In contrast, this dose of LPS-induced profound hypothermia in IL-6 KO mice, with nadirs of hypothermia reaching 4.9+/-1.0 degrees C after injection at dark onset and 2.2+/-0.5 degrees C after administration at light onset. These results indicate that IL-6 mediates some of the effects of LPS on NREMS and body temperature of mice, and that the magnitude and duration of these effects differ as a function of the time at which the challenge is given.

Cellular adhesion molecule expression, nocturnal sleep, and partial night sleep deprivation.

Sleep is hypothesized to have a role in the regulation of the immune system. This study evaluated the nocturnal expression of cellular adhesion molecules, Mac-1 and L-selectin on monocytes and lymphocytes during a full nights sleep and following a partial night of sleep deprivation (PSD). Healthy male subjects (n=16) had an increase in the percentage of Mac-1 positive lymphocytes across the baseline night. Whereas, the percentage of Mac-1 positive lymphocytes was reduced and L-selectin positive lymphocytes and monocytes were greater during the PSD night as compared to the baseline night. These data indicate that acute sleep disruption is associated with alterations in cellular adhesion molecule expression, with implications for the regulation of immune cell trafficking.

Nocturnal proinflammatory cytokine-associated sleep disturbances in abstinent African American alcoholics.

Animal studies reveal that cytokines play a key role in the regulation of sleep. Alcoholic patients show profound alterations of sleep and a defect in the homeostatic recovery of sleep following sleep loss. In this study, we investigated whether nocturnal plasma levels of interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF) were associated with disordered sleep in alcohol dependence by testing the temporal relationships between these inflammatory cytokines and sleep, before and after sleep deprivation. All-night polysomnography and serial blood sampling at 23:00, 03:00, and 06:30 h were conducted across baseline, partial sleep deprivation, and recovery nights in abstinent African American alcoholics (n=16) and matched controls (n=15). Coupled with prolonged sleep latency and increased rapid eye movement sleep, alcoholics showed nocturnal elevations of IL-6 and TNF as compared to controls after adjustment for alcohol consumption and body mass index. Following sleep deprivation, alcoholics showed greater nocturnal levels of IL-6 and greater nocturnal increases of TNF as compared to controls. Pre-sleep IL-6 levels at 23:00 h correlated with prolonged sleep latency after adjustment for potential confounders whereas IL-6 levels at 03:00 h correlated with rapid eye movement sleep in the second half of the night. Taken together, these findings indicate that circulating levels of proinflammatory cytokines may have a negative influence on sleep initiation. These findings have implications for determining why sleep is disordered in alcoholics and may aid in the development of novel treatments to optimize sleep in this population.

Macrophage participation in influenza-induced sleep enhancement in C57BL/6J mice.

Mice develop changes in sleep during the nonspecific immune response that occurs during the initial few days after inoculation with influenza virus. T lymphocytes, neutrophils, macrophages, and natural killer (NK) cells all participate in the early host response to influenza infection. All of these cell types are potential sources of endogenous substances that modulate sleep, but the contributory role of each cell type to the alteration of somnolence during infection has not been determined. To investigate which cell types contribute to the sleep enhancement that develops during influenza infection in mice, the sleep patterns of C57BL/6J mice with perturbations of particular facets of host immune response capabilities were assessed before and after influenza infection. Targeted mutation of the gene Ccl3 (macrophage inflammatory protein 1 alpha) prevented development of the dark phase sleep enhancement that is characteristic of C57BL/6J mice after influenza infection. Other experimental treatments that impair macrophage or monocyte function also produced significant (administration of pentoxifylline or CNI-1493) or marginally significant (deletion of the interferon-gamma gene or intranasal administration of carrageenan) changes in influenza-induced sleep enhancement in C57BL/6J mice. In contrast, functional impairments of NK cells, neutrophils, and T lymphocytes did not significantly influence sleep responses. These data therefore support a contributory role for macrophages, but not for NK cells, neutrophils, and T lymphocytes, in eliciting the sleep response typical of influenza-infected C57BL/6J mice.

Acute disseminated encephalomyelitis associated with Pasteurella multocida meningitis.

OBJECTIVE: To describe a case of Pasteurella multocida meningitis associated with acute disseminated encephalomyelitis (ADEM). CASE REPORT: A 33-year-old woman employed in a dog pound presented herself to hospital with fever and meningismus and was found to have culture positive Pasteurella multocida meningitis. Despite appropriate antibiotic treatment her clinical course was characterized by a persistent fever and worsening encephalopathy, which prompted further neurological investigation. Spinal fluid exam and serial MRI scans as well as her one-year clinical course were found to be compatible with ADEM. CONCLUSION: Persistent fever and worsening encephalopathy in meningitis may indicate a para-infectious immune process such as ADEM, and may serve as indications for further neurological investigation.

Interleukin-6 alters sleep of rats.

Although it is well established that the cytokines tumor necrosis factor (TNF) and interleukin (IL)-1 regulate sleep, there is no direct evidence implicating IL-6 in the regulation/modulation of sleep. We tested the hypotheses that central administration of rat recombinant IL-6 increases non-rapid eye movements (NREM) sleep of rats, and that central administration of anti-IL-6 antibodies reduces NREM sleep. Effective doses of IL-6 (100 and 500 ng) initially enhance NREM sleep, after which NREM sleep may be suppressed. IL-6 induces febrile responses at doses lower (50 ng) than those required to alter sleep. Rapid eye movements (REM) sleep is not altered by the doses of IL-6 tested. Central administration of monoclonal or polyclonal anti-rat IL-6 antibodies does not alter any of the parameters determined in this study. Collectively, these results support the hypothesis that IL-6 possesses sleep modulatory properties. However, this cytokine may not be involved in the regulation of spontaneous sleep in healthy animals because antagonizing the IL-6 system using antibodies does not alter sleep. The interpretation of these data is consistent with those of previous studies demonstrating correlations between increased IL-6 and excessive daytime sleepiness during some pathophysiological conditions.