The effect of light on the human circadian pacemaker

Relating Photoperiod and Outdoor Temperature With Sleep Architecture in Patients With Neuropsychiatric Sleep Disorders

While artificial light in urban environments was previously thought to override seasonality in humans, recent studies have challenged this assumption. We aimed to explore the relationship between seasonally varying environmental factors and changes in sleep architecture in patients with neuropsychiatric sleep disorders by comparing two consecutive years. In 770 patients, three-night polysomnography was performed at the Clinic for Sleep & Chronomedicine (St. Hedwig Hospital, Berlin, Germany) in 2018/2019. Sleep times were adjusted to patients' preferred schedules, patients slept in, and were unaware of day-night indicators. Digital devices and clocks were not allowed. Days were spent outside the lab with work or naps not allowed. After exclusions (mostly due to psychotropic medication), analysis was conducted on the second PSG-night in 377 patients (49.1 ± 16.8 year; 54% female). Sleep parameters were plotted as 90-day moving-averages (MvA) across date-of-record. Periodicity and seasonal windows in the MvA were identified by utilizing autocorrelations. Linear mixed-effect models were applied to seasonal windows. Sleep parameters were correlated with same-day photoperiod, temperature, and sunshine duration. The MvA of total sleep time (TST) and REM sleep began a 5-month-long decline shortly after the last occurrence of freezing 24-h mean temperatures (correlation of TST between 2018 and 2019 at 2-month lag: rs361 = 0.87, p < 0.001; maximum peak-to-nadir amplitude: ΔTST ~ 62 min, ΔREM ~ 24 min). The MvA nadirs of slow wave sleep (SWS) occurred approximately at the autumnal equinox (correlation between 2018 and 2019: rs361 = 0.83, p < 0.001). Post hoc testing following significant linear mixed-effect model indicate that TST and REM sleep were longer around November till February than May till August (ΔTST = 36 min; ΔREM = 14 min), while SWS was 23 min longer around February till May than August till November. Proportional seasonal variation of SWS and of REM sleep as percentages of TST differed profoundly (SWS = 31.6%; REM = 8.4%). In patients with neuropsychiatric sleep disorders living in an urban environment, data collected in 2018 show similar patterns and magnitudes in seasonal variation of sleep architecture as the 2019 data. Interestingly, whereas SWS patterns were consistent between years with possible links to photoperiod, annual variations of TST and REM sleep seem to be related to times of outside freezing temperature. For generalization, the data need to be confirmed in a healthy population. No clinical trial was registered.

SEMIPARAMETRIC BIVARIATE HIERARCHICAL STATE SPACE MODEL WITH APPLICATION TO HORMONE CIRCADIAN RELATIONSHIP

The adrenocorticotropic hormone and cortisol play critical roles in stress regulation and the sleep-wake cycle. Most research has been focused on how the two hormones regulate each other in terms of short-term pulses. Few studies have been conducted on the circadian relationship between the two hormones and how it differs between normal and abnormal groups. The circadian patterns are difficult to model as parametric functions. Directly extending univariate functional mixed effects models would result in a large dimensional problem and a challenging nonparametric inference. In this article, we propose a semi-parametric bivariate hierarchical state space model, in which each hormone profile is modeled by a hierarchical state space model, with nonparametric population-average and subject-specific components. The bivariate relationship is constructed by concatenating two latent independent subject-specific random functions specified by a design matrix, leading to a parametric inference on the correlation. We propose a computationally efficient state-space EM algorithm for estimation and inference. We apply the proposed method to a study of chronic fatigue syndrome and fibromyalgia and discover an erratic regulation pattern in the patient group in contrast to a circadian regulation pattern conforming to the day-night cycle in the control group.

Link between circadian rhythm and benign prostatic hyperplasia (BPH)/lower urinary tract symptoms (LUTS)

BACKGROUND

Benign prostatic hyperplasia (BPH) is the most common urologic disease in aging males, affecting 50% of men over 50 and up to 80% of men over 80 years old. Its negative impact on health-related quality of life implores further investigation into its risk factors and strategies for effective management. Although the exact molecular mechanisms underlying pathophysiological onset of BPH are poorly defined, the current hypothesized contributors to BPH and lower urinary tract symptoms (LUTS) include aging, inflammation, metabolic syndrome, and hormonal changes. These processes are indirectly influenced by circadian rhythm disruption. In this article, we review the recent evidence on the potential association of light changes/circadian rhythm disruption and the onset of BPH and impact on treatment.

METHODS

A narrative literature review was conducted using PubMed and Google Scholar to identify supporting evidence. The articles referenced ranged from 1975 to 2023.

RESULTS

A clear relationship between BPH/LUTS and circadian rhythm disruption is yet to be established. However, common mediators influence both diseases, including proinflammatory states, metabolic syndrome, and hormonal regulation that can be asserted to circadian disruption. Some studies have identified a possible relationship between general LUTS and sleep disturbance, but little research has been done on the medical management of these diseases and how circadian rhythm disruption further affects treatment outcomes.

CONCLUSIONS

There is evidence to implicate a relationship between BPH/LUTS and circadian rhythm disruptions. However, there is scarce literature on potential specific link in medical management of the disease and treatment outcomes with circadian rhythm disruption. Further study is warranted to provide BPH patients with insights into circadian rhythm directed appropriate interventions.

Effects of chronotype-tailored bright light intervention on post-treatment symptoms and quality of life in breast cancer survivors

PURPOSE

Bright light therapy holds promise for reducing common symptoms, e.g., fatigue, experienced by individuals with cancer. This study aimed to examine the effects of a chronotype-tailored bright light intervention on sleep disturbance, fatigue, depressive mood, cognitive dysfunction, and quality of life among post-treatment breast cancer survivors.

METHODS

In this two-group randomized controlled trial (NCT03304587), participants were randomized to receive 30-min daily bright blue-green light (12,000 lx) or dim red light (5 lx) either between 19:00 and 20:00 h or within 30 min of waking in the morning. Self-reported outcomes and in-lab overnight polysomnography sleep study were assessed before (pre-test) and after the 14-day light intervention (post-test).

RESULTS

The sample included 30 women 1-3 years post-completion of chemotherapy and/or radiation for stage I to III breast cancer (mean age = 52.5 ± 8.4 years). There were no significant between-group differences in any of the symptoms or quality of life (all p > 0.05). However, within each group, self-reported sleep disturbance, fatigue, depressive mood, cognitive dysfunction, and quality of life-related functioning showed significant improvements over time (all p < 0.05); the extent of improvement for fatigue and depressive mood was clinically relevant. Polysomnography sleep findings showed that a number of awakenings significantly decreased (p = 0.011) among participants who received bright light, while stage 2 sleep significantly increased (p = 0.015) among participants who received dim-red light.

CONCLUSION

The findings support using light therapy to manage post-treatment symptoms in breast cancer survivors. The unexpected symptom improvements among dim-red light controls remain unexplained and require further investigation.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03304587, October 19, 2017.

Diurnal changes in choroidal optical coherence tomography angiography indices over 24 hours in healthy young adults

This prospective study investigated the magnitude and pattern of variation in choroidal optical coherence tomography angiography (OCT-A) indices every 4 h over 24 h in healthy young myopic (n = 24) and non-myopic (n = 20) adults. Choriocapillaris and deep choroid en-face images from macular OCT-A scans were analysed from each session to extract magnification-corrected vascular indices including choriocapillaris flow deficit number, size and density and deep choroid perfusion density in the sub-foveal, sub-parafoveal, and sub-perifoveal regions. Choroidal thickness was also obtained from structural OCT scans. Significant variations over 24 h (P < 0.05) were observed in most of the choroidal OCT-A indices excluding sub-perifoveal flow deficit number, with peaks observed between 2 to 6 AM. For myopes, peaks occurred significantly earlier (3-5 h), and the diurnal amplitude was significantly greater for sub-foveal flow deficit density (P = 0.02) and deep choroidal perfusion density (P = 0.03) compared with non-myopes. Choroidal thickness also showed significant diurnal changes (P < 0.05) with peaks between 2 to 4 AM. Significant correlations were found between diurnal amplitudes or acrophases of choroidal OCT-A indices and choroidal thickness, intraocular pressure, and systemic blood pressure. This provides the first comprehensive diurnal assessment of choroidal OCT-A indices over 24 h.

Seasonality of human sleep: Polysomnographic data of a neuropsychiatric sleep clinic

While short-term effects of artificial light on human sleep are increasingly being studied, reports on long-term effects induced by season are scarce. Assessments of subjective sleep length over the year suggest a substantially longer sleep period during winter. Our retrospective study aimed to investigate seasonal variation in objective sleep measures in a cohort of patients living in an urban environment. In 2019, three-night polysomnography was performed on 292 patients with neuropsychiatric sleep disturbances. Measures of the diagnostic second nights were averaged per month and analyzed over the year. Patients were advised to sleep "as usual" including timing, except alarm clocks were not allowed. Exclusion criteria: administration of psychotropic agents known to influence sleep (N = 96), REM-sleep latency > 120 min (N = 5), technical failure (N = 3). Included were 188 patients: [46.6 ± 15.9 years (mean ± SD); range 17-81 years; 52% female]; most common sleep-related diagnoses: insomnia (N = 108), depression (N = 59) and sleep-related breathing disorders (N = 52). Analyses showed: 1. total sleep time (TST) longer during winter than summer (up to 60 min; not significant); 2. REM-sleep latency shorter during autumn than spring (about 25 min, p = 0.010); 3. REM-sleep longer during winter than spring (about 30 min, p = 0.009, 5% of TST, p = 0.011); 4. slow-wave-sleep stable winter to summer (about 60-70 min) with 30-50 min shorter during autumn (only significant as % of TST, 10% decrease, p = 0.017). Data suggest seasonal variation in sleep architecture even when living in an urban environment in patients with disturbed sleep. If replicated in a healthy population, this would provide first evidence for a need to adjust sleep habits to season.

Changes in Retinal Optical Coherence Tomography Angiography Indexes Over 24 Hours

Purpose

To evaluate changes in the retinal microvasculature of young adults over 24 hours using optical coherence tomography angiography (OCT-A).

Methods

Participants (n = 44, mean age 23.2 ± 4.1 years, 24 myopes and 20 nonmyopes) with normal ophthalmological findings were recruited. Two macular OCT-A and OCT scans, systemic blood pressure, intraocular pressure (IOP), and biometry measurements were taken every four hours over 24 hours. Superficial and deep retinal layer en face images were analyzed to extract magnification-corrected vascular indexes using image analysis including foveal avascular zone metrics, vessel density, and perfusion density for the foveal, parafoveal, and perifoveal zones.

Results

Significant diurnal variations (P < 0.001) were observed in the vessel and perfusion density in the three superficial retinal layer regions, with acrophase between 4:30 PM and 8:30 PM. Only foveal and parafoveal regions of the deep retinal layer exhibited significant diurnal variations with acrophase between 9 AM and 3 PM. Myopes and nonmyopes had different acrophases but not amplitudes in the parafoveal perfusion density of superficial retinal layer (P = 0.039). Significant correlations were observed between diurnal amplitudes or acrophases of superficial retinal layer indexes and systemic pulse pressure, IOP, axial length and retinal thickness.

Conclusions

This study shows, for the first time, that significant diurnal variation exists in OCT-A indexes of macular superficial and deep retinal layer over 24 hours and were related to variations in various ocular and systemic measurements. Myopes and nonmyopes showed differences in the timing but not in amplitude of the superficial retinal layer parafoveal perfusion density variations but not in deep retinal layer.

Multi-Level Processes and Retina-Brain Pathways of Photic Regulation of Mood

Light exerts powerful biological effects on mood regulation. Whereas the source of photic information affecting mood is well established at least via intrinsically photosensitive retinal ganglion cells (ipRGCs) secreting the melanopsin photopigment, the precise circuits that mediate the impact of light on depressive behaviors are not well understood. This review proposes two distinct retina–brain pathways of light effects on mood: (i) a suprachiasmatic nucleus (SCN)-dependent pathway with light effect on mood via the synchronization of biological rhythms, and (ii) a SCN-independent pathway with light effects on mood through modulation of the homeostatic process of sleep, alertness and emotion regulation: (1) light directly inhibits brain areas promoting sleep such as the ventrolateral preoptic nucleus (VLPO), and activates numerous brain areas involved in alertness such as, monoaminergic areas, thalamic regions and hypothalamic regions including orexin areas; (2) moreover, light seems to modulate mood through orexin-, serotonin- and dopamine-dependent pathways; (3) in addition, light activates brain emotional processing areas including the amygdala, the nucleus accumbens, the perihabenular nucleus, the left hippocampus and pathways such as the retina–ventral lateral geniculate nucleus and intergeniculate leaflet–lateral habenula pathway. This work synthetizes new insights into the neural basis required for light influence mood

Pilot Observational Study to Detect Diurnal Variation and Misalignment in Heart Rate Among Critically Ill Patients

Circadian disruption is common in critically ill patients admitted to the intensive care unit (ICU). Understanding and treating circadian disruption in critical illness has significant potential to improve critical illness outcomes through improved cognitive, immune, cardiovascular, and metabolic function. Measurement of circadian alignment (i.e., circadian phase) can be resource-intensive as it requires frequent blood or urine sampling over 24 or more hours. Less cumbersome methods of assessing circadian alignment would advance investigations in this field. Thus, the objective of this study is to examine the feasibility of using continuous telemetry to assess diurnal variation in heart rate (HR) among medical ICU patients as a proxy for circadian alignment. In exploratory analyses, we tested for associations between misalignment of diurnal variation in HR and death during hospital admission. This was a prospective observational cohort study embedded within a prospective medical ICU biorepository. HR data were continuously collected (every 5 s) via telemetry systems for the duration of the medical ICU admission; the first 24 h of this data was analyzed. Patients were extensively characterized via medical record chart abstraction and patient interviews. Of the 56 patients with complete HR data, 48 (86%) had a detectable diurnal variation. Of these patients with diurnal variation, 39 (81%) were characterized as having the nadir of their HR outside of the normal range of 02:00–06:00 (“misalignment”). Interestingly, no deaths occurred in the patients with normally aligned diurnal variation; in contrast, there were seven deaths (out of 39 patients) in patients who had misaligned diurnal variation in HR. In an exploratory analysis, we found that the odds ratio of death for misaligned vs. aligned patients was increased at 4.38; however, this difference was not statistically significant (95% confidence interval 0.20–97.63). We conclude that diurnal variation in HR can be detected via continuous telemetric monitoring of critically ill patients. A majority of these patients with diurnal variation exhibited misalignment in their first 24 h of medical ICU admission. Exploratory analyses suggest possible associations between misalignment and death.

Molecular Mechanisms Underlying the Circadian Rhythm of Blood Pressure in Normotensive Subjects

PURPOSE OF REVIEW

Blood pressure (BP) follows a circadian rhythm (CR) in normotensive subjects. BP increases in the morning and decreases at night. This review aims at providing an up-to-date overview regarding the molecular mechanisms underlying the circadian regulation of BP.

RECENT FINDINGS

The suprachiasmatic nucleus (SCN) is the regulatory center for CRs. In SCN astrocytes, the phosphorylated glycogen synthase kinase-3β (pGSK-3β) also follows a CR and its expression reaches a maximum in the morning and decreases at night. pGSK-3β induces the β-catenin migration to the nucleus. During the daytime, the nuclear β-catenin increases the expression of the glutamate excitatory amino acid transporter 2 (EAAT2) and glutamine synthetase (GS). In SCN, EAAT2 removes glutamate from the synaptic cleft of glutamatergic neurons and transfers it to the astrocyte cytoplasm where GS converts glutamate into glutamine. Thus, glutamate decreases in the synaptic cleft. This decreases the stimulation of the glutamate receptors AMPA-R and NMDA-R located on glutamatergic post-synaptic neurons. Consequently, activation of NTS is decreased and BP increases. The opposite occurs at night. Despite several studies resulting from animal studies, the circadian regulation of BP appears largely controlled in normotensive subjects by the canonical WNT/β-catenin pathway involving the SCN, astrocytes, and glutamatergic neurons.

Relevance of Electrical Light on Circadian, Neuroendocrine, and Neurobehavioral Regulation in Laboratory Animal Facilities

Light is a key extrinsic factor to be considered in operations and design of animal room facilities. Over the past four decades, many studies on typical laboratory animal populations have demonstrated impacts on neuroendocrine, neurobehavioral, and circadian physiology. These effects are regulated independently from the defined physiology for the visual system. The range of physiological responses that oscillate with the 24 hour rhythm of the day include sleep and wakefulness, body temperature, hormonal secretion, and a wide range of other physiological parameters. Melatonin has been the chief neuroendocrine hormone studied, but acute light-induced effects on corticosterone as well as other hormones have also been observed. Within the last two decades, a new photosensory system in the mammalian eye has been discovered. A small set of retinal ganglion cells, previously thought to function as a visual output neuron, have been shown to be directly photosensitive and act differently from the classic photoreceptors of the visual system. Understanding the effects of light on mammalian physiology and behavior must take into account how the classical visual photoreceptors and the newly discovered ipRGC photoreceptor systems interact. Scientists and facility managers need to appreciate lighting impacts on circadian, neuroendocrine, and neurobehavioral regulation in order to improve lighting of laboratory facilities to foster optimum health and well-being of animals.

Glycogen synthase kinase 3 regulates photic signaling in the suprachiasmatic nucleus

Glycogen synthase kinase 3 (GSK3) is a serine-threonine kinase that regulates mammalian circadian rhythms at the behavioral, molecular and neurophysiological levels. In the central circadian pacemaker, the suprachiasmatic nucleus (SCN), inhibitory phosphorylation of GSK3 exhibits a rhythm across the 24 h day. We have recently shown that GSK3 is capable of influencing both the molecular clock and SCN neuronal activity rhythms. However, it is not known whether GSK3 regulates the response to environmental cues such as light. The goal of this study was to test the hypothesis that GSK3 activation mediates light-induced SCN excitability and photic entrainment. Immunofluorescence staining in the SCN of mice showed that late-night light exposure significantly increased GSK3 activity (decreased pGSK3β levels) 30-60 min after the light-pulse. In addition, pharmacological inhibition of GSK3 blocked the expected light-induced excitability in SCN neurons; however, this effect was not associated with changes in resting membrane potential or input resistance. Behaviorally, mice with constitutively active GSK3 (GSK3-KI) re-entrained to a 6-h phase advance in the light-dark cycle in significantly fewer days than WT control animals. Furthermore, the behavioral and SCN neuronal activity of GSK3-KI mice was phase-advanced compared to WT, in both normal and light-exposed conditions. Finally, GSK3-KI mice exhibited normal negative-masking behavior and electroretinographic responses to light, suggesting that the enhanced photic entrainment is not due to an overall increased sensitivity to light in these animals. Taken together, these results provide strong evidence that GSK3 activation contributes to light-induced phase-resetting at both the neurophysiological and behavioral levels.

The Case for Addressing Operator Fatigue

Sleep deficiency, which can be caused by acute sleep deprivation, chronic insufficient sleep, untreated sleep disorders, disruption of circadian timing, and other factors, is endemic in the U.S., including among professional and non-professional drivers and operators. Vigilance and attention are critical for safe transportation operations, but fatigue and sleepiness compromise vigilance and attention by slowing reaction times and impairing judgment and decision-making abilities. Research studies, polls, and accident investigations indicate that many Americans drive a motor vehicle or operate an aircraft, train or marine vessel while drowsy, putting themselves and others at risk for error and accident. In this chapter, we will outline some of the factors that contribute to sleepiness, present evidence from laboratory and field studies demonstrating how sleepiness impacts transportation safety, review how sleepiness is measured in laboratory and field settings, describe what is known about interventions for sleepiness in transportation settings, and summarize what we believe are important gaps in our knowledge of sleepiness and transportation safety.

Pharmacokinetics of the dual melatonin receptor agonist tasimelteon in subjects with hepatic or renal impairment

Tasimelteon is a circadian regulator that resets the master clock in the suprachiasmatic nuclei of the hypothalamus by binding to both melatonin MT1 and MT2 receptors making it a dual melatonin receptor agonist. Tasimelteon has been approved by the United States Food and Drug Administration for the treatment of Non-24-Hour Sleep-Wake Disorder (Non-24). Two prospective, single-center, open-label studies evaluated the pharmacokinetics of tasimelteon and its main metabolites after a single 20 mg dose administered to subjects with mild or moderate hepatic impairment or severe renal impairment, including subjects on dialysis compared to healthy controls. In subjects with mild or moderate hepatic impairment, exposure to tasimelteon after a single 20 mg dose, as measured by area under the plasma concentration-time curve to infinity, was increased by approximately 2-fold. There was no apparent relationship between tasimelteon clearance and renal function. No safety concerns were apparent in either study. Based on these results, the changes in the pharmacokinetics of tasimelteon due to mild or moderate hepatic or severe renal impairment are not considered clinically relevant, and no dose adjustment is necessary in these patients.

The Timing of the Circadian Clock and Sleep Differ between Napping and Non-Napping Toddlers

The timing of the internal circadian clock shows large inter-individual variability across the lifespan. Although the sleep-wakefulness pattern of most toddlers includes an afternoon nap, the association between napping and circadian phase in early childhood remains unexplored. This study examined differences in circadian phase and sleep between napping and non-napping toddlers. Data were collected on 20 toddlers (34.2±2.0 months; 12 females; 15 nappers). Children followed their habitual napping and non-napping sleep schedules (monitored with actigraphy) for 5 days before an in-home salivary dim light melatonin onset (DLMO) assessment. On average, napping children fell asleep during their nap opportunities on 3.6±1.2 of the 5 days before the DLMO assessment. For these napping children, melatonin onset time was 38 min later (p = 0.044; d = 0.93), actigraphically-estimated bedtime was 43 min later (p = 0.014; d = 1.24), sleep onset time was 59 min later (p = 0.006; d = 1.46), and sleep onset latency was 16 min longer (p = 0.030; d = 1.03) than those not napping. Midsleep and wake time did not differ by napping status. No difference was observed in the bedtime, sleep onset, or midsleep phase relationships with DLMO; however, the wake time phase difference was 47 min smaller for napping toddlers (p = 0.029; d = 1.23). On average, nappers had 69 min shorter nighttime sleep durations (p = 0.006; d = 1.47) and spent 49 min less time in bed (p = 0.019; d = 1.16) than non-nappers. Number of days napping was correlated with melatonin onset time (r = 0.49; p = 0.014). Our findings indicate that napping influences individual variability in melatonin onset time in early childhood. The delayed bedtimes of napping toddlers likely permits light exposure later in the evening, thereby delaying the timing of the clock and sleep. Whether the early developmental trajectory of circadian phase involves an advance associated with the decline in napping is a question necessitating longitudinal data as children transition from a biphasic to monophasic sleep-wakefulness pattern.

Theory of Inpatient Circadian Care (TICC): A Proposal for a Middle-Range Theory

The circadian system controls the daily rhythms of a variety of physiological processes. Most organisms show physiological, metabolic and behavioral rhythms that are coupled to environmental signals. In humans, the main synchronizer is the light/dark cycle, although non-photic cues such as food availability, noise, and work schedules are also involved. In a continuously operating hospital, the lack of rhythmicity in these elements can alter the patient’s biological rhythms and resilience. This paper presents a Theory of Inpatient Circadian Care (TICC) grounded in circadian principles. We conducted a literature search on biological rhythms, chronobiology, nursing care, and middle-range theories in the databases PubMed, SciELO Public Health, and Google Scholar. The search was performed considering a period of 6 decades from 1950 to 2013. Information was analyzed to look for links between chronobiology concepts and characteristics of inpatient care. TICC aims to integrate multidisciplinary knowledge of biomedical sciences and apply it to clinical practice in a formal way. The conceptual points of this theory are supported by abundant literature related to disease and altered biological rhythms. Our theory will be able to enrich current and future professional practice.

Cumulative neurobehavioral and physiological effects of chronic caffeine intake: individual differences and implications for the use of caffeinated energy products

The use of caffeine-containing energy products has increased worldwide in recent years. All of the top-selling energy drinks contain caffeine, which is likely to be the primary psychoactive ingredient in these products. Research shows that caffeine-containing energy products can improve cognitive and physical performance. Presumably, individuals consume caffeine-containing energy products to counteract feelings of low energy in situations causing tiredness, fatigue, and/or reduced alertness. This review discusses the scientific evidence for sleep loss, circadian phase, sleep inertia, and the time-on-task effect as causes of low energy and summarizes research assessing the efficacy of caffeine to counteract decreased alertness and increased fatigue in such situations. The results of a placebo-controlled experiment in healthy adults who had 3 nights of total sleep deprivation (with or without 2-hour naps every 12 hours) are presented to illustrate the physiological and neurobehavioral effects of sustained low-dose caffeine. Individual differences, including genetic factors, in the response to caffeine and to sleep loss are discussed. The review concludes with future directions for research on this important and evolving topic.

Opposite influence of light and blindness on pituitary-gonadal function

Some environmental factors may influence the pituitary-gonadal function. Among these, light plays an important role in animals and in humans. The effect of light on the endocrine system is mediated by the pineal gland, through the modulation of melatonin secretion. In fact, melatonin secretion is stimulated by darkness and suppressed by light, thus its circadian rhythm peaks at night. Light plays a favorable action on the hypothalamic-pituitary axis likely inhibiting melatonin secretion, while the exogenous melatonin administration does not seem to impair the hormonal secretions of this axis. The basal and rhythmic pituitary-gonadal hormone secretions are regulated by a central clock gene and some independent clock genes in the peripheral tissues. Light is able to induce the expression of some of these genes, thus playing an important role in regulating the hormonal secretions of pituitary-gonadal axis and the sexual and reproductive function in animals and humans. The lack of light stimulus in blind subjects induces increase in plasma melatonin concentrations with a free-running rhythm of secretion, which impairs the hormonal secretions of pituitary-gonadal axis, causing disorders of reproductive processes in both sexes.

Blurring the boundaries of vision: novel functions of intrinsically photosensitive retinal ganglion cells

Mammalian vision consists of the classic image-forming pathway involving rod and cone photoreceptors interacting through a neural network within the retina before sending signals to the brain, and a non image-forming pathway that uses a photosensitive cell employing an alternative and evolutionary ancient phototransduction system and a direct connection to various centers in the brain. Intrinsically photosensitive retinal ganglion cells (ipRGCs) contain the photopigment melanopsin, which is independently capable of photon detection while also receiving synaptic input from rod and cone photoreceptors via bipolar cells. These cells are the retinal sentry for subconscious visual processing that controls circadian photoentrainment and the pupillary light reflex. Classified as irradiance detectors, recent investigations have led to expanding roles for this specific cell type and its own neural pathways, some of which are blurring the boundaries between image-forming and non image-forming visual processes.

Managing neurobehavioral capability when social expediency trumps biological imperatives

Sleep, which is evolutionarily conserved across species, is a biological imperative that cannot be ignored or replaced. However, the percentage of habitually sleep-restricted adults has increased in recent decades. Extended work hours and commutes, shift work schedules, and television viewing are particularly potent social factors that influence sleep duration. Chronic partial sleep restriction, a product of these social expediencies, leads to the accumulation of sleep debt over time and consequently increases sleep propensity, decreases alertness, and impairs critical aspects of cognitive functioning. Significant interindividual variability in the neurobehavioral responses to sleep restriction exists-this variability is stable and phenotypic-suggesting a genetic basis. Identifying vulnerability to sleep loss is essential as many adults cannot accurately judge their level of impairment in response to sleep restriction. Indeed, the consequences of impaired performance and the lack of insight due to sleep loss can be catastrophic. In order to cope with the effects of social expediencies on biological imperatives, identification of biological (including genetic) and behavioral markers of sleep loss vulnerability as well as development of technological approaches for fatigue management are critical.

Sex difference in the near-24-hour intrinsic period of the human circadian timing system

The circadian rhythms of melatonin and body temperature are set to an earlier hour in women than in men, even when the women and men maintain nearly identical and consistent bedtimes and wake times. Moreover, women tend to wake up earlier than men and exhibit a greater preference for morning activities than men. Although the neurobiological mechanism underlying this sex difference in circadian alignment is unknown, multiple studies in nonhuman animals have demonstrated a sex difference in circadian period that could account for such a difference in circadian alignment between women and men. Whether a sex difference in intrinsic circadian period in humans underlies the difference in circadian alignment between men and women is unknown. We analyzed precise estimates of intrinsic circadian period collected from 157 individuals (52 women, 105 men; aged 18-74 y) studied in a month-long inpatient protocol designed to minimize confounding influences on circadian period estimation. Overall, the average intrinsic period of the melatonin and temperature rhythms in this population was very close to 24 h [24.15 ± 0.2 h (24 h 9 min ± 12 min)]. We further found that the intrinsic circadian period was significantly shorter in women [24.09 ± 0.2 h (24 h 5 min ± 12 min)] than in men [24.19 ± 0.2 h (24 h 11 min ± 12 min); P < 0.01] and that a significantly greater proportion of women have intrinsic circadian periods shorter than 24.0 h (35% vs. 14%; P < 0.01). The shorter average intrinsic circadian period observed in women may have implications for understanding sex differences in habitual sleep duration and insomnia prevalence.

Sex differences in phase angle of entrainment and melatonin amplitude in humans

Studies of sex differences in the timing of human circadian rhythms have reported conflicting results. This may be because the studies conducted to date have not controlled for the masking effects of the rest activity cycle on the circadian rhythms being assessed. In the present analysis of data collected under controlled conditions, we examined sex differences in the timing of circadian rhythms while minimizing masking from behavioral and environmental factors using a constant routine (CR) protocol. All participants (28 women and 28 men paired by habitual wake time; age range, 18 30 years) maintained a regular self selected sleep wake schedule at home prior to the study. After 3 baseline days in the laboratory, participants began a CR. Women were found to have a significantly higher melatonin amplitude and lower temperature amplitude than men. While sleep timing was the same between the 2 groups, the timing of the circadian rhythms of core body temperature and pineal melatonin secretion was earlier relative to sleep time in women as compared to men. Sleep therefore occurred at a later biological time for women than men, despite being at the same clock time. Given that sleep propensity and structure vary with circadian phase and are impacted by circulating melatonin, these findings may have important implications for understanding sex differences in sleep timing and duration, diurnal preference, and the prevalence of sleep disorders such as insomnia.

Circadian photoreception: ageing and the eye's important role in systemic health

AIM

To analyse how age-related losses in crystalline lens transmittance and pupillary area affect circadian photoreception and compare the circadian performance of phakic and pseudophakic individuals of the same age.

METHODS

The spectral sensitivity of circadian photoreception peaks in the blue part of the spectrum at approximately 460 nm. Photosensitive retinal ganglion cells send unconscious information about environmental illumination to non-visual brain centres including the human body's master biological clock in the suprachiasmatic nuclei. This information permits human physiology to be optimised and aligned with geophysical day-night cycles using neural and hormonal messengers including melatonin. Age-related transmittance spectra of crystalline lenses and photopic pupil diameter are used with the spectral sensitivity of melatonin suppression and the transmittance spectra of intraocular lenses (IOLs) to analyse how ageing and IOL chromophores affect circadian photoreception.

RESULTS

Ageing increases crystalline lens light absorption and decreases pupil area resulting in progressive loss of circadian photoreception. A 10-year-old child has circadian photoreception 10-fold greater than a 95-year-old phakic adult. A 45-year-old adult retains only half the circadian photoreception of early youth. Pseudophakia improves circadian photoreception at all ages, particularly with UV-only blocking IOLs which transmit blue wavelengths optimal for non-visual photoreception.

CONCLUSIONS

Non-visual retinal ganglion photoreceptor responses to bright, properly timed light exposures help assure effective circadian photoentrainment and optimal diurnal physiological processes. Circadian photoreception can persist in visually blind individuals if retinal ganglion cell photoreceptors and their suprachiasmatic connections are intact. Retinal illumination decreases with ageing due to pupillary miosis and reduced crystalline lens light transmission especially of short wavelengths. Inadequate environmental light and/or ganglion photoreception can cause circadian disruption, increasing the risk of insomnia, depression, numerous systemic disorders and possibly early mortality. Artificial lighting is dimmer and less blue-weighted than natural daylight, contributing to age-related losses in unconscious circadian photoreception. Optimal intraocular lens design should consider the spectral requirements of both conscious and unconscious retinal photoreception.

Circadian rhythm dysfunction in glaucoma: A hypothesis

The absence of circadian zeitgebers in the social environment causes circadian misalignment, which is often associated with sleep disturbances. Circadian misalignment, defined as a mismatch between the sleep-wake cycle and the timing of the circadian system, can occur either because of inadequate exposure to the light-dark cycle, the most important synchronizer of the circadian system, or reduction in light transmission resulting from ophthalmic diseases (e.g., senile miosis, cataract, diabetic retinopathy, macular degeneration, retinitis pigmentosa, and glaucoma). We propose that glaucoma may be the primary ocular disease that directly compromises photic input to the circadian time-keeping system because of inherent ganglion cell death. Glaucomatous damage to the ganglion cell layer might be particularly harmful to melanopsin. According to histologic and circadian data, a subset of intrinsically photoresponsive retinal ganglion cells, expressing melanopsin and cryptochromes, entrain the endogenous circadian system via transduction of photic input to the thalamus, projecting either to the suprachiasmatic nucleus or the lateral geniculate nucleus. Glaucoma provides a unique opportunity to explore whether in fact light transmission to the circadian system is compromised as a result of ganglion cell loss.

Light exposure is related to social and emotional functioning and to quality of life in older women

While there are data supporting the use of light in clinical populations, there has been less investigation of relationships among light and psychological variables in non-clinical samples. Subjects were 459 ethnically diverse women (mean age 67.68) recruited as part of the Women's Health Initiative. Light exposure and sleep were measured with an Actillume wrist actigraph. Subjects completed questionnaires, investigating Social Support, Social Functioning, Social Strain, Quality of Life, Satisfaction with Life, Emotional Well-being, Optimism, Negative Emotional Expressiveness, and Role Limitation Due to Emotional Problems. Significant partial correlations (controlling for age, education and ethnicity) were found between mesor light exposure and Social Functioning, Quality of Life, Satisfaction with Life, and Emotional Well-Being. Quality of Life and Satisfaction with Life were also found to be significantly correlated with morning light. The most parsimonious model to account for the variance shared between mesor light and the predictors included only Quality of Life. The variance shared between mesor light exposure and social and emotional functioning could be subsumed under the variance shared between mesor light exposure and Quality of Life. Increased light exposure is related to improved quality of life and social and emotional functioning.

Daily illumination exposure and melatonin: influence of ophthalmic dysfunction and sleep duration

BACKGROUND

Ocular pathology lessens light's efficacy to maintain optimal circadian entrainment. We examined whether ophthalmic dysfunction explains unique variance in melatonin excretion of older adults over and above the variance explained by daily illumination, medical, and sociodemographic factors. We also examined whether ophthalmic dysfunction influences relationships between ambient illumination and melatonin.

METHODS

Thirty older adults (mean age = 69 years; Blacks = 42% and Whites = 58%) of both genders participated in the study. Demographic and health data were collected at baseline. Participants underwent eye exams at SUNY Downstate Medical Center, wore an actigraph to monitor illumination and sleep, and collected urine specimens to estimate aMT6s concentrations.

RESULTS

Hierarchical regression analysis showed that illumination factors explained 29% of the variance in aMT6s mesor. The proportion of variance explained by ophthalmic factors, sleep duration, and race was 10%, 2%, and 2%, respectively. Illumination factors explained 19% of the variance in aMT6s acrophase. The proportion of variance explained by ophthalmic factors, sleep duration, and race was 11%; 17%; and 2%, respectively. Controlling for sleep duration and race reduced the correlations between illumination and melatonin, whereas controlling for ophthalmic factors did not.

CONCLUSION

Ophthalmic exams showed that elevated intraocular pressure and large cup-to-disk ratios were independently associated with earlier melatonin timing. Lower illumination exposure also had independent associations with earlier melatonin timing. Conceivably, ophthalmic and illumination factors might have an additive effect on the timing of melatonin excretion, which in turn might predispose individuals to experience early morning awakenings.

Light treatment and circadian adaptation to shift work

Work at unconventional hours can have both long and short term consequences. Shift workers are often required to perform their duties at times that are not favoured by the body's endogenous clock, or circadian pacemaker. A typical night shift worker, for example, may report reductions in alertness and performance during shifts, or significant difficulty attaining sleep of recuperative value in the day, all the while being more likely to develop health complications. The study of circadian physiology has significantly contributed to our current ability to aid the shift worker deal with atypical schedules. We discuss the usefulness of light treatment as a countermeasure for maladaptation to atypical work schedules.

Efficacy of a single sequence of intermittent bright light pulses for delaying circadian phase in humans

It has been shown in animal studies that exposure to brief pulses of bright light can phase shift the circadian pacemaker and that the resetting action of light is most efficient during the first minutes of light exposure. In humans, multiple consecutive days of exposure to brief bright light pulses have been shown to phase shift the circadian pacemaker. The aim of the present study was to determine whether a single sequence of brief bright light pulses administered during the early biological night would phase delay the human circadian pacemaker. Twenty-one healthy young subjects underwent a 6.5-h light exposure session in one of three randomly assigned conditions: 1) continuous bright light of approximately 9,500 lux, 2) intermittent bright light (six 15-min bright light pulses of approximately 9,500 lux separated by 60 min of very dim light of <1 lux), and 3) continuous very dim light of <1 lux. Twenty subjects were included in the analysis. Core body temperature (CBT) and melatonin were used as phase markers of the circadian pacemaker. Phase delays of CBT and melatonin rhythms in response to intermittent bright light pulses were comparable to those measured after continuous bright light exposure, even though the total exposure to the intermittent bright light represented only 23% of the 6.5-h continuous exposure. These results demonstrate that a single sequence of intermittent bright light pulses can phase delay the human circadian pacemaker and show that intermittent pulses have a greater resetting efficacy on a per minute basis than does continuous exposure.

Basal circadian and pulsatile ACTH and cortisol secretion in patients with fibromyalgia and/or chronic fatigue syndrome

The objective of this study was to evaluate and compare the basal circadian and pulsatile architecture of the HPA axis in groups of patients with FMS, CFS, or both syndromes with individually matched control groups. Forty patients with either FMS (n = 13), FMS and CFS (n = 12), or CFS (n = 15) were matched by age (18-65), sex, and menstrual status to healthy controls. Subjects were excluded if they met criteria for major Axis I psychiatric disorders by structured clinical interview (SCID). Subjects were admitted to the General Clinical Research Center where meals and activities were standardized. Blood was collected from an intravenous line every 10 min over 24 h for analysis of ACTH and cortisol. Samples were evaluable for ACTH in 36 subject pairs and for cortisol in 37 subject pairs. There was a significant delay in the rate of decline from acrophase to nadir for cortisol levels in patients with FMS (P <.01). Elevation of cortisol in the late evening quiescent period was evident in half of the FMS patients compared with their control group, while cortisol levels were numerically, but not significantly, lower in the overnight period in patients with CFS compared with their control group. Pulsatility analyses did not reveal statistically significant differences between patient and control groups. We conclude that the pattern of differences for basal circadian architecture of HPA axis hormones differs between patients with FMS and CFS compared to their matched control groups. The abnormalities in FMS patients are consistent with loss of HPA axis resiliency.

A phase response curve to single bright light pulses in human subjects

The circadian pacemaker is differentially sensitive to the resetting effects of retinal light exposure, depending upon the circadian phase at which the light exposure occurs. Previously reported human phase response curves (PRCs) to single bright light exposures have employed small sample sizes, and were often based on relatively imprecise estimates of circadian phase and phase resetting. In the present study, 21 healthy, entrained subjects underwent pre- and post-stimulus constant routines (CRs) in dim light (approximately 2-7 lx) with maintained wakefulness in a semi-recumbent posture. The 6.7 h bright light exposure stimulus consisted of alternating 6 min fixed gaze (approximately 10 000 lx) and free gaze (approximately 5000-9000 lx) exposures. Light exposures were scheduled across the circadian cycle in different subjects so as to derive a PRC. Plasma melatonin was used to determine the phase of the onset, offset, and midpoint of the melatonin profiles during the CRs. Phase shifts were calculated as the difference in phase between the pre- and post-stimulus CRs. The resultant PRC of the midpoint of the melatonin rhythm revealed a characteristic type 1 PRC with a significant peak-to-trough amplitude of 5.02 h. Phase delays occurred when the light stimulus was centred prior to the critical phase at the core body temperature minimum, phase advances occurred when the light stimulus was centred after the critical phase, and no phase shift occurred at the critical phase. During the subjective day, no prolonged 'dead zone' of photic insensitivity was apparent. Phase shifts derived using the melatonin onsets showed larger magnitudes than those derived from the melatonin offsets. These data provide a comprehensive characterization of the human PRC under highly controlled laboratory conditions.

Bright light treatment used for adaptation to night work and re-adaptation back to day life. A field study at an oil platform in the North Sea

Night workers complain of sleepiness, reduced performance and disturbed sleep due to lack of adjustment of the circadian rhythm. In simulated night-work experiments scheduled exposure to bright light has been shown to reduce these complaints. Here we studied the effects of bright light treatment on the adaptation to 14 days of consecutive night work at an oil platform in the North Sea, and the subsequent readaptation to day life at home, using the Karolinska sleep/wake diary. Bright light treatment of 30 min per exposure was applied during the first 4 nights of the night-shift period and the first 4 days at home following the shift period. The bright light exposure was scheduled individually to phase delay the circadian rhythm. Bright light treatment modestly facilitated the subjective adaptation to night work, but the positive effect of bright light was especially pronounced during the re-adaptation back to day life following the return home. Sleepiness was reduced and the quality of day was rated better after exposure to bright light. The modest effect of bright light at the platform was, possibly, related to the finding that the workers seemed to adapt to night work within a few days even without bright light. These results suggest that short-term bright light treatment may help the adaptation to an extended night-work period, and especially the subsequent re-adaptation to day life.

Resetting the melatonin rhythm with light in humans

The endogenous circadian rhythm of melatonin in humans provides information regarding the resetting response of the human circadian timing system to changes in the light-dark (LD) cycle. Alterations in the LD cycle have both acute and chronic effects on the observed melatonin rhythm. Investigations to date have firmly established that the melatonin rhythm can be reentrained following an inversion of the LD cycle. Exposure to bright light and darkness given over a series of days can rapidly induce large-magnitude phase shifts of the melatonin rhythm. Even single pulses of bright light can shift the timing of the melatonin rhythm. Recent data have demonstrated that lower light intensities than originally believed are capable of resetting the melatonin rhythm and that stimulation of photopically sensitive photoreceptors (i.e., cones) is sufficient to reset the endogenous circadian melatonin rhythm. In addition to phase resetting, exposure to light of critical timing, strength, and duration can attenuate the amplitude of the endogenous circadian rhythm of melatonin. Measurement of melatonin throughout resetting trials provides a dynamic view of the resetting response of the human circadian pacemaker to light. Future studies of the melatonin rhythm in humans may further characterize the resetting response of the human circadian timing system to light.

Photopic transduction implicated in human circadian entrainment

Despite the preeminence of light as the synchronizer of the circadian timing system, the phototransductive machinery in mammals which transmits photic information from the retina to the hypothalamic circadian pacemaker remains largely undefined. To determine the class of photopigments which this phototransductive system uses, we exposed a group (n = 7) of human subjects to red light below the sensitivity threshold of a scotopic (i.e. rhodopsin/rod-based) system, yet of sufficient strength to activate a photopic (i.e. cone-based) system. Exposure to this light stimulus was sufficient to reset significantly the human circadian pacemaker, indicating that the cone pigments which mediate color vision can also mediate circadian vision.

Phase-shifting human circadian rhythms: influence of sleep timing, social contact and light exposure

1. Both the timing of behavioural events (activity, sleep and social interactions) and the environmental light-dark cycle have been reported to contribute to entrainment of human circadian rhythms to the 24 h day. Yet, the relative contribution of those putative behavioural synchronizers to that of light exposure remains unclear. 2. To investigate this, we inverted the schedule of rest, sedentary activity and social contact of thirty-two young men either with or without exposure to bright light. 3. On this inverted schedule, the endogenous component of the core temperature rhythm of subjects who were exposed to bright light showed a significant phase shift, demonstrating that they were adapting to the new schedule. In contrast, the core temperature rhythm of subjects who were not exposed to bright light moved on average 0.2 h later per day and after 10 days had not significantly adapted to the new schedule. 4. The direction of phase shift in the groups exposed to bright light was dependent on the time of bright light exposure, while control subjects drifted to a later hour regardless of the timing of their schedule of sleep timing, social contact and meals. 5. These results support the concept that the light-dark cycle is the most important synchronizer of the human circadian system. They suggest that inversion of the sleep-wake, rest-activity and social contact cycles provides relatively minimal drive for resetting the human circadian pacemaker. 6. These data indicate that interventions designed to phase shift human circadian rhythms for adjustment to time zone changes or altered work schedules should focus on properly timed light exposure.

Phase-amplitude resetting of the human circadian pacemaker via bright light: a further analysis

We present here an analysis of strong, weak, and critical bright-light resetting trials in humans, and report not only phase but also amplitude data for the first time. For this analysis, an appropriate iterative smoothing procedure for phase transition curves is introduced, in which the data are sequenced so as to minimize the perpendicular distance from the data to the smoothed fit. From these smoothed data, we create polar phase-amplitude resetting maps (PARMs) in order to fully illustrate the effects of the resetting stimuli on both circadian amplitude and phase, and thereby to determine whether these resetting results can be described by a phase-only model or whether a phase-amplitude model is required. Our results indicate that a single 5-hr episode of bright light induces weak type 1 resetting of the human circadian pacemaker. Two cycles of exposure to the same stimulus on consecutive days induce critical resetting, in which significant amplitude reduction may be observed. A three-cycle stimulus induces strong type 0 resetting with different effects on circadian amplitude, depending on the initial phase of the stimulus application. When a three-cycle stimulus is centered near the nadir of the temperature cycle, large phase shifts are achieved via amplitude suppression. However, when this stimulus is centered away from the temperature nadir, smaller phase shifts are achieved in which both small increases and small decreases in circadian amplitude are observed. These data indicate that the human circadian pacemaker is not a simple, phase-only oscillator. Instead, a full description of human circadian resetting responses to light requires analysis of both phase and amplitude data--a finding that is consistent with a phase-amplitude model of the circadian resetting mechanism.