Sleep loss and cytokines levels in an experimental model of psoriasis

Overview of Common Sleep Disorders and Intersection with Dermatologic Conditions

Sleep disorders are very common, often under-recognized and therefore undertreated, are associated with a myriad of medical conditions and could lead to significant impairment of quality of life. This review provides an up-to-date synopsis of common sleep disorders encompassing insufficient sleep syndrome, insomnia, circadian rhythm disorders and obstructive sleep apnea with a brief overview of epidemiology, screening, diagnostic testing and treatment. We also emphasize the emerging area of the intersection of sleep disorders and dermatologic conditions and present compelling data regarding underlying mechanisms including sleep dysfunction in relation to disorders of skin inflammation, aging and skin cancer.

Concomitant Sleep Disorders Significantly Increase the Risk of Cardiovascular Disease in Patients with Psoriasis

Background

The increased rates of cardiovascular morbidity and mortality in patients with psoriasis are not adequately explained by traditional risk factors. Whether concomitant sleep disorders (SDs) modify the risk of cardiovascular disease (CVD) in patients with psoriasis remains unknown.

Methods

Using the Taiwan National Health Insurance Research Database (NHIRD), we conducted a cohort study to investigate the association between concomitant SDs and CVD risk in patients with psoriasis. Data from 99,628 adults who received a psoriasis diagnosis during the period from 2004 to 2010 were analyzed. Cox proportional hazards regression analysis models were used to compare the risks of ischemic heart disease (IHD) and stroke between patients with and without SDs.

Results

Psoriasis patients with a concomitant SD had significantly higher risks of IHD (adjusted hazard ratio [aHR], 1.25; 95% confidence interval [CI], 1.22–1.28) and stroke (aHR, 1.24; 95% CI, 1.16–1.33) as compared with psoriasis patients without SDs. All psoriasis patient subgroups, including those with mild and severe psoriasis and those with and without arthritis, had increased HRs for IHD and stroke. The increases in IHD and stroke risks conferred by SDs were proportional to the dose of hypnotics used. The effect of SDs on the risks of IHD and stroke was greater in young adults than in middle-aged and older adults.

Conclusions

The risks of IHD and stroke were higher for psoriasis patients with SDs than for those without SDs. Clinicians should carefully evaluate CVD risk, particularly in young patients with psoriasis.

The bidirectional interactions between psoriasis and obstructive sleep apnea

Psoriasis is a chronic inflammatory skin disorder which can impair general routine activities and has been closely related to poor quality of life. Pruritus and scratching are frequently observed, occurring mainly during sleep and precipitating nighttime arousals. Indeed, sleep quality has been shown to be negatively affected in psoriatic patients, in a close relationship with stress exposure and immune response. Although psoriasis is known to impair sleep, leading to insomnia, its association with obstructive sleep apnea (OSA) is controversial. Similarly, OSA is considered a multifactorial inflammatory disease, characterized by intermittent hypoxia, sleep fragmentation and autonomic dysfunction, with important outcomes on the cardiovascular and metabolic systems. Importantly, immunological activities and pro-inflammatory cytokines play a prominent role in both OSA and psoriasis. Currently it is not clear whether OSA is a risk factor for psoriasis development or if psoriasis is a possible predictor of OSA. Thus, our main purpose is to provide an overview of this intriguing relationship and show the current link between psoriasis and OSA in a bidirectional relationship.

Sleep-deprivation reduces NK cell number and function mediated by β-adrenergic signalling

Reduction of sleep time triggers a stress response, leading to augmented levels of glucocorticoids and adrenaline. These hormones regulate components of the innate immune system such as natural killer (NK) and NKT cells. In the present study, we sought to investigate whether and how stress hormones could alter the population and function of NK and NKT cells of mice submitted to different lengths of paradoxical sleep deprivation (PSD, from 24 to 72 h). Results showed that 72h of PSD decreased not only NK and NKT cell counts, but also their cytotoxic activity against B16F10 melanoma cells in vitro. Propranolol treatment during PSD reversed these effects, indicating a major inhibitory role of beta-adrenergic receptors (β-AR) on NK cells function. Moreover, both corticosterone plasma levels and expression of beta 2-adrenergic receptors (β2-AR) in NK cells increased by 48 h of PSD. In vitro incubation of NK cells with dexamethasone augmented the level of β2-AR in the cell surface, suggesting that glucocorticoids could induce β2-AR expression. In summary, we propose that reduction of NK and NKT cell number and cytotoxic activity appears to be mediated by glucocorticoids-induced increased expression of β2-AR in these cells.

Influence of psoriasis on circulatory system function assessed in echocardiography

Psoriasis vulgaris is a chronic disease with a multifactorial pathogenesis. It affects about 2–4 % of the population all over the world. In course of psoriatic arthritis, joints’ damages are observed. In patients with psoriasis vulgaris and psoriatic arthritis, there is increased morbidity and mortality caused by cardiovascular diseases observed. The aim of the study is to analyze the echocardiography of patients with psoriasis vulgaris and psoriatic arthritis on the basis of the literature available in PubMed database. Abnormalities found in echocardiography of patients with psoriasis include valvular defects (40.7 % of the patients), left ventricle diastolic dysfunction (27.8 %), and left ventricle hypertrophy (11.1 %). Left ventricle’s systolic disorders, increased aorta stiffness index and increased pulmonary artery blood pressure were also observed in this group of patients.

Paradoxical sleep deprivation impairs mouse survival after infection with malaria parasites

Background

Parasitic diseases like malaria are a major public health problem in many countries and disrupted sleep patterns are an increasingly common part of modern life. The aim of this study was to assess the effects of paradoxical sleep deprivation (PSD) and sleep rebound (RB) on malarial parasite infection in mice.

Methods

After PSD, one group was immediately infected with parasites (PSD). The two other PSD rebound groups were allowed to sleep normally for either 24 h (24 h RB) or 48 h (48 h RB). After the recovery periods, mice were inoculated with parasites.

Results

The PSD group was the most affected by parasites presenting the higher death rate (0.02), higher number of infected cells (p < 0.01), and decrease in body weight (p < 0.04) compared to control and 48 h RB groups. The 24 h RB group was also different from control group in survival (p < 0.03), number of infected cells (p < 0.05) and body weight (p < 0.04). After 48 hours of sleep rebound animals were allowed to restore their response to parasitic infection similar to normal sleep animals.

Conclusions

These results suggest that PSD is damaging to the immune system and leads to an increased infection severity of malaria parasites; only 48 hours of recovery sleep was sufficient to return the mice infection response to baseline values.

Electronic supplementary material

The online version of this article (doi:10.1186/s12936-015-0690-7) contains supplementary material, which is available to authorized users.

Acute sleep fragmentation induces tissue-specific changes in cytokine gene expression and increases serum corticosterone concentration

Sleep deprivation induces acute inflammation and increased glucocorticosteroids in vertebrates, but effects from fragmented, or intermittent, sleep are poorly understood. Considering the latter is more representative of sleep apnea in humans, we investigated changes in proinflammatory (IL-1β, TNF-α) and anti-inflammatory (TGF-β1) cytokine gene expression in the periphery (liver, spleen, fat, and heart) and brain (hypothalamus, prefrontal cortex, and hippocampus) of a murine model exposed to varying intensities of sleep fragmentation (SF). Additionally, serum corticosterone was assessed. Sleep was disrupted in male C57BL/6J mice using an automated sleep fragmentation chamber that moves a sweeping bar at specified intervals (Lafayette Industries). Mice were exposed to bar sweeps every 20 s (high sleep fragmentation, HSF), 120 s (low sleep fragmentation, LSF), or the bar remained stationary (control). Trunk blood and tissue samples were collected after 24 h of SF. We predicted that HSF mice would exhibit increased proinflammatory expression, decreased anti-inflammatory expression, and elevated stress hormones in relation to LSF and controls. SF significantly elevated IL-1β gene expression in adipose tissue, heart (HSF only), and hypothalamus (LSF only) relative to controls. SF did not increase TNF-α expression in any of the tissues measured. HSF increased TGF-β1 expression in the hypothalamus and hippocampus relative to other groups. Serum corticosterone concentration was significantly different among groups, with HSF mice exhibiting the highest, LSF intermediate, and controls with the lowest concentration. This indicates that 24 h of SF is a potent inducer of inflammation and stress hormones in the periphery, but leads to upregulation of anti-inflammatory cytokines in the brain.

The circadian clock in skin: implications for adult stem cells, tissue regeneration, cancer, aging, and immunity

Historically, work on peripheral circadian clocks has been focused on organs and tissues that have prominent metabolic functions, such as the liver, fat, and muscle. In recent years, skin has emerged as a model for studying circadian clock regulation of cell proliferation, stem cell functions, tissue regeneration, aging, and carcinogenesis. Morphologically, skin is complex, containing multiple cell types and structures, and there is evidence for a functional circadian clock in most, if not all, of its cell types. Despite the complexity, skin stem cell populations are well defined, experimentally tractable, and exhibit prominent daily cell proliferation cycles. Hair follicle stem cells also participate in recurrent, long-lasting cycles of regeneration: the hair growth cycles. Among other advantages of skin is a broad repertoire of available genetic tools enabling the creation of cell type-specific circadian mutants. Also, due to the accessibility of skin, in vivo imaging techniques can be readily applied to study the circadian clock and its outputs in real time, even at the single-cell level. Skin provides the first line of defense against many environmental and stress factors that exhibit dramatic diurnal variations such as solar ultraviolet (UV) radiation and temperature. Studies have already linked the circadian clock to the control of UVB-induced DNA damage and skin cancers. Due to the important role that skin plays in the defense against microorganisms, it also represents a promising model system to further explore the role of the clock in the regulation of the body's immune functions. To that end, recent studies have already linked the circadian clock to psoriasis, one of the most common immune-mediated skin disorders. Skin also provides opportunities to interrogate the clock regulation of tissue metabolism in the context of stem cells and regeneration. Furthermore, many animal species feature prominent seasonal hair molt cycles, offering an attractive model for investigating the role of the clock in seasonal organismal behaviors.

FOS-like antigen 1 is highly expressed in human psoriasis tissues and promotes the growth of HaCaT cells in vitro

Psoriasis is a multifactorial disease and the mechanisms involved in its pathogenesis remain to be elucidated. FOS‑like antigen 1 (Fra‑1) is a proto‑oncogene. It is a negative inhibitor of activator protein‑1 activity and possesses transforming activity. The effect of and possible mechanisms underlying Fra‑1 in psoriasis remain to be elucidated. In the present study, western blot analysis and reverse transcription‑quantitative polymerase chain reaction (RT‑qPCR) techniques were used to identify differentially expressed Fra‑1 in psoriatic and in normal control tissues. Compared with the control samples, the expression of normalized Fra‑1 genes in psoriasis was 12.6 times higher. Western blot analysis was used to assess the protein levels of Fra‑1. The results demonstrated that the protein expression of Fra-1 was high in tissues affected by psoriasis. This also corresponded with the results of RT‑qPCR. Fra‑1‑stable expressing HaCaT/Fra‑1 or control HaCaT/vector cell lines were then generated to elucidate the function of Fra‑1 in the growth of HaCaT cells. The results demonstrated that Fra‑1 promoted the growth of HaCaT cells in vitro by arresting the cell cycle and inhibiting cell apoptosis. These results suggested that Fra‑1 may be important in psoriasis.

The effects of sleep deprivation on microRNA expression in rats submitted to pilocarpine-induced status epilepticus

Epilepsy is a neurological disorder with significant prevalence and the individuals affected by this disease have a great probability of occurrence of a lethal phenomenon known as Sudden Unexpected Death in Epilepsy (SUDEP). SUDEP occurs mainly during the night and probably during sleep. The pathophysiological mechanisms involved in this lethal phenomenon are still obscure and new evidences that could corroborate in this area are warranted. Thus, the aim of the present study was to evaluate the effect of sleep deprivation in the expression of microRNA (miRNA) in the frontal cortex and heart tissues of adult male rats after 50days of saline (SAL) or pilocarpine-induced status epilepticus (PILO). Initially 389 miRNA expressions were evaluated between SAL and PILO groups by microarray. Subsequently, 3 differentially expressed miRNAs of each tissue were investigated after total sleep deprivation (TSD 6h) and paradoxical sleep deprivation (PSD 24h). Still, it was analyzed that the effects of sleep rebound with equivalent duration of PSD and TSD. There was a significant increase of miR-146a expression, an important inflammatory modulator in the frontal cortex of PILO rats when compared to SAL animals. Animals treated with pilocarpine were affected by TSD (through overexpression of miRNAs related to inflammatory process) and these changes were maintained even after a sleep window of 6h. In contrast, miRNAs associated with heart diseases were down-regulated in PSD rebound, suggesting a possible restoration of homeostasis in cardiovascular system of SAL and PILO groups.

Current concepts in psychodermatology

Several diagnoses in the new DSM-5 chapter on 'Obsessive-Compulsive and Related Disorders' directly relate to psychodermatology. The new excoriation (skin-picking) disorder (SPD) and trichotillomania (TTM) both manifest as recurrent body-focused repetitive behaviors that have compulsive and dissociative features, the latter being more prevalent in TTM than SPD. The DSM-5 refers to SPD and TTM occurring without full awareness or preceding tension, however does not specifically mention the possible role of dissociation. This has important treatment implications, as patients with high dissociative symptoms are not likely to respond to the standard treatments for obsessive-compulsive disorder. Body dysmorphic disorder (BDD), which is frequently associated with cutaneous body image (CBI) dissatisfaction, is present in 9%-15% of dermatology patients. Treatment guidelines in dermatology are increasingly considering the psychosocial morbidity related to CBI in their treatment outcome measures. The presence of BDD, if unrecognized, may therefore directly affect the dermatologic treatment regimens offered to the patient.

Immunological and histological evaluation of clinical samples from psoriasis patients treated with anti-CD6 itolizumab

Psoriasis is a chronic inflammatory disease with a prevalence of approximately 2-3% in the general population. The majority of diagnosed patients have plaque psoriasis, and about 20% have moderate-to-severe disease. Itolizumab, a new monoclonal antibody specific for the CD6 molecule mainly expressed on T lymphocytes, has demonstrated to inhibit in vitro ligand-induced proliferation and pro-inflammatory cytokine production. We assessed the immunological and histopathological effect of the antibody using clinical samples taken from 26 patients with moderate-to-severe psoriasis included in a clinical trial. The precursor frequency of lymphocytes activated with anti-CD2/CD3/CD28 beads, as well as the number of interferon (IFN)-γ-secreting T cells after stimulation, were measured at different time points of the study. Serum cytokine levels and anti-idiotypic antibody response to itolizumab were also evaluated. Additionally, lymphocyte infiltration and epidermis hyperplasia were studied in five patients. A significant reduction in T cell proliferation capacity and number of IFN-γ-producing T cells was found in treated patients. Serum levels of interleukin-6, tumor necrosis factor and IFN-γ showed an overall trend toward reduction. No anti-idiotypic antibody response was detected. A significant reduction in the epidermis hyperplasia was observed in analyzed patients. These results support the relevance of the CD6 molecule as a therapeutic target for the treatment of this disease.

Urinary interleukin-8 is a biomarker of stress in emergency physicians, especially with advancing age--the JOBSTRESS* randomized trial

Background

Emergency physicians are exposed to greater stress during a 24-hour shift (24 hS) than a 14-hour night shift (14 hS), with an impact lasting several days. Interleukin-8 (IL-8) is postulated to be a chronic stress biomarker. However, no studies have tracked IL-8 over several shifts or used it for monitoring short-term residual stress. The IL-8 response to the shifts may also increase with age. Conveniently, IL-8 can be measured non-intrusively from urine.

Methods

We conducted a shifts-randomized trial comparing 17 emergency physicians’ urinary IL-8 levels during a 24 hS, a 14 hS, and a control day (clerical work on return from leave). Mean levels of IL-8 were compared using a Wilcoxon matched-pairs test. Independent associations of key factors including shifts, stress, and age with IL-8 levels were further assessed in a multivariable generalized estimating equations model.

Results

Mean urinary IL-8 levels almost doubled during and after a 24 hS compared with a 14 hS or a control day. Furthermore, IL-8 levels failed to return to control values at the end of the third day after the shift despite a rest day following the 24 hS. In the multivariable model, engaging in a 24 hS, self-reported stress, and age were independently associated with higher IL-8 levels. A 24 hS significantly increased IL-8 levels by 1.9 ng (p = .007). Similarly, for every unit increase in self-reported stress, there was a 0.11 ng increase in IL-8 levels (p = .003); and for every one year advance in age of physicians, IL-8 levels also increased by 0.11 ng (p = .018).

Conclusion

The 24 hS generated a prolonged response of the immune system. Urinary IL-8 was a strong biomarker of stress under intensive and prolonged demands, both acutely and over time. Because elevated IL-8 levels are associated with cardiovascular disease and negative psychological consequences, we suggest that emergency physicians limit their exposure to 24 hS, especially with advancing age.