The sleep switch: hypothalamic control of sleep and wakefulness

Napping and circadian sleep-wake regulation during healthy aging

STUDY OBJECTIVES

Daytime napping is frequently reported among the older population and has attracted increasing attention due to its association with multiple health conditions. Here, we tested whether napping in the aged is associated with altered circadian regulation of sleep, sleepiness, and vigilance performance.

METHODS

Sixty healthy older individuals (mean age: 69 years, 39 women) were recruited with respect to their napping habits (30 nappers, 30 non-nappers). All participants underwent an in-lab 40-hour multiple nap protocol (10 cycles of 80 minutes of sleep opportunity alternating with 160 minutes of wakefulness), preceded and followed by a baseline and recovery sleep period. Saliva samples for melatonin assessment, sleepiness, and vigilance performance were collected during wakefulness and electrophysiological data were recorded to derive sleep parameters during scheduled sleep opportunities.

RESULTS

The circadian amplitude of melatonin secretion was reduced in nappers, compared to non-nappers. Furthermore, nappers were characterized by higher sleep efficiencies and REM sleep proportion during day- compared to nighttime naps. The nap group also presented altered modulation in sleepiness and vigilance performance at specific circadian phases.

DISCUSSION

Our data indicate that napping is associated with an altered circadian sleep-wake propensity rhythm. They thereby contribute to the understanding of the biological correlates underlying napping and/or sleep-wake cycle fragmentation during healthy aging. Altered circadian sleep-wake promotion can lead to a less distinct allocation of sleep into nighttime and/or a reduced wakefulness drive during the day, thereby potentially triggering the need to sleep at adverse circadian phase.

Sleepiness and the transition from wakefulness to sleep

The transition from wakefulness to sleep is a progressive process that is reflected in the gradual loss of responsiveness, an alteration of cognitive functions, and a drastic shift in brain dynamics. These changes do not occur all at once. The sleep onset period (SOP) refers here to this period of transition between wakefulness and sleep. For example, although transitions of brain activity at sleep onset can occur within seconds in a given brain region, these changes occur at different time points across the brain, resulting in a SOP that can last several minutes. Likewise, the transition to sleep impacts cognitive and behavioral levels in a graded and staged fashion. It is often accompanied and preceded by a sensation of drowsiness and the subjective feeling of a need for sleep, also associated with specific physiological and behavioral signatures. To better characterize fluctuations in vigilance and the SOP, a multidimensional approach is thus warranted. Such a multidimensional approach could mitigate important limitations in the current classification of sleep, leading ultimately to better diagnoses and treatments of individuals with sleep and/or vigilance disorders. These insights could also be translated in real-life settings to either facilitate sleep onset in individuals with sleep difficulties or, on the contrary, prevent or control inappropriate sleep onsets.

Structural EEG signal analysis for sleep apnea classification

OBJECTIVES

Diagnosing the sleep apnea can be critical in preventing the person having sleep disorder from unhealthy results. The aim of this study is to obtain a sleep apnea scoring approach by comparing parametric and non-parametric power spectral density (PSD) estimation methods from EEG signals recorded from different brain regions (C4-M1 and O2-M1) for transient signal analysis of sleep apnea patients.

METHODS

Power Spectral Density (PSD) methods (Burg, Yule-Walker, periodogram, Welch and multi-taper) are examined for the detection of apnea transition states including pre-apnea, intra-apnea and post-apnea together with statistical methods.

RESULTS

In the experimental studies, EEG recordings available in the database were analyzed with PSD methods. Results showed that there are statistically significant differences between parametric and non-parametric methods applied for PSD analysis of apnea transition states in delta, theta, alpha and beta bands. Moreover, it was also revealed that PSD of EEG signals obtained from C4-M1 and O2-M1 channels were also found statistically different as proved by classification using the K-nearest neighbour (KNN) method.

CONCLUSIONS

It was concluded that not only applying different PSD methods, but also EEG signals from different brain regions provided different statistical results in terms of apnea transition states as obtained from KNN classification.

Clinical usefulness of dual orexin receptor antagonism beyond insomnia: Neurological and psychiatric comorbidities

Orexin is a neurotransmitter produced by a small group of hypothalamic neurons. Besides its well-known role in the regulation of the sleep-wake cycle, the orexin system was shown to be relevant in several physiological functions including cognition, mood and emotion modulation, and energy homeostasis. Indeed, the implication of orexin neurotransmission in neurological and psychiatric diseases has been hypothesized via a direct effect exerted by the projections of orexin neurons to several brain areas, and via an indirect effect through orexin-mediated modulation of sleep and wake. Along with the growing evidence concerning the use of dual orexin receptor antagonists (DORAs) in the treatment of insomnia, studies assessing their efficacy in insomnia comorbid with psychiatric and neurological diseases have been set in order to investigate the potential impact of DORAs on both sleep-related symptoms and disease-specific manifestations. This narrative review aimed at summarizing the current evidence on the use of DORAs in neurological and psychiatric conditions comorbid with insomnia, also discussing the possible implication of modulating the orexin system for improving the burden of symptoms and the pathological mechanisms of these disorders. Target searches were performed on PubMed/MEDLINE and Scopus databases and ongoing studies registered on Clinicaltrials.gov were reviewed. Despite some contradictory findings, preclinical studies seemingly support the possible beneficial role of orexin antagonism in the management of the most common neurological and psychiatric diseases with sleep-related comorbidities. However, clinical research is still limited and further studies are needed for corroborating these promising preliminary results.

Structural and Functional Neuroanatomy of Core Consciousness: A Primer for Disorders of Consciousness Clinicians

Understanding the structural and functional neuroanatomy of core consciousness (ie, wakefulness and awareness) is an asset to clinicians caring for persons with disorders of consciousness. This article provides a primer on the structural and functional neuroanatomy of wakefulness and awareness. The neuroanatomical structures supporting these elements of core consciousness functions are reviewed first, after which brief description of the clinically evaluable relationships between disruption of these structures and disorders of consciousness (ie, brain-behavior relationships) are outlined. Consideration of neuroanatomy at the mesoscale (ie, the mesocircuit hypothesis) as well as in relation to several large-scale neural networks is offered.

Orexin Receptor Antagonism: Normalizing Sleep Architecture in Old Age and Disease

Sleep is essential for human well-being, yet the quality and quantity of sleep reduce as age advances. Older persons (>65 years old) are more at risk of disorders accompanied and/or exacerbated by poor sleep. Furthermore, evidence supports a bidirectional relationship between disrupted sleep and Alzheimer's disease (AD) or related dementias. Orexin/hypocretin neuropeptides stabilize wakefulness, and several orexin receptor antagonists (ORAs) are approved for the treatment of insomnia in adults. Dysregulation of the orexin system occurs in aging and AD, positioning ORAs as advantageous for these populations. Indeed, several clinical studies indicate that ORAs are efficacious hypnotics in older persons and dementia patients and, as in adults, are generally well tolerated. ORAs are likely to be more effective when administered early in sleep/wake dysregulation to reestablish good sleep/wake-related behaviors and reduce the accumulation of dementia-associated proteinopathic substrates. Improving sleep in aging and dementia represents a tremendous opportunity to benefit patients, caregivers, and health systems.

Hormonal basis of sex differences in anesthetic sensitivity

General anesthesia-a pharmacologically induced reversible state of unconsciousness-enables millions of life-saving procedures. Anesthetics induce unconsciousness in part by impinging upon sexually dimorphic and hormonally sensitive hypothalamic circuits regulating sleep and wakefulness. Thus, we hypothesized that anesthetic sensitivity should be sex-dependent and modulated by sex hormones. Using distinct behavioral measures, we show that at identical brain anesthetic concentrations, female mice are more resistant to volatile anesthetics than males. Anesthetic sensitivity is bidirectionally modulated by testosterone. Castration increases anesthetic resistance. Conversely, testosterone administration acutely increases anesthetic sensitivity. Conversion of testosterone to estradiol by aromatase is partially responsible for this effect. In contrast, oophorectomy has no effect. To identify the neuronal circuits underlying sex differences, we performed whole brain c-Fos activity mapping under anesthesia in male and female mice. Consistent with a key role of the hypothalamus, we found fewer active neurons in the ventral hypothalamic sleep-promoting regions in females than in males. In humans, we demonstrate that females regain consciousness and recover cognition faster than males after identical anesthetic exposures. Remarkably, while behavioral and neurocognitive measures in mice and humans point to increased anesthetic resistance in females, cortical activity fails to show sex differences under anesthesia in either species. Cumulatively, we demonstrate that sex differences in anesthetic sensitivity are evolutionarily conserved and not reflected in conventional electroencephalographic-based measures of anesthetic depth. This covert resistance to anesthesia may explain the higher incidence of unintended awareness under general anesthesia in females.

Development of the sleep-wake switch in rats during the P2-P21 early infancy period

In early infancy, rats randomly alternate between the sleeping and waking states-from postnatal day 2-10 (P2-P10), sleep and wake bouts are both exponentially distributed with increasing means, while from P10-P21 sleep and wake bout means continue to increase, though there is a striking qualitative shift in the distribution of wake bouts from exponential to power law. The behavioral states of sleep and wakefulness correspond to the activity of sleep-active and wake-active neuronal brainstem populations, with reciprocal inhibition between the two ensuring that only one population is active at a time. The locus coeruleus (LC) forms a third component of this circuit that rises in prominence during the P10-P21 period, as experimental evidence shows that an as-of-yet undeciphered interaction of the LC with sleep-active and wake-active populations is responsible for the transformation of the wake bout distribution from exponential to power law. Interestingly, the LC undergoes remarkable physiological changes during the P10-P21 period-gap junctions within the LC are pruned and network-wide oscillatory synchrony declines and vanishes. In this work, we discuss a series of models of sleep-active, wake-active, and the LC populations, and we use these models to postulate the nature of the interaction between these three populations and how these interactions explain empirical observations of sleep and wake bout dynamics. We hypothesize a circuit in which there is reciprocal excitation between the LC and wake-active population with inhibition from the sleep-active population to the LC that suppresses the LC during sleep bouts. During the P2-P10 period, we argue that a noise-based switching mechanism between the sleep-active and wake-active populations provides a simple and natural way to account for exponential bout distributions, and that the locked oscillatory state of the LC prevents it from impacting bout distributions. From P10-P21, we use our models to postulate that, as the LC gradually shifts from a state of synchronized oscillations to a state of continuous firing, reciprocal excitation between the LC and the wake-active population is able to gradually transform the wake bout distribution from exponential to power law.

Neurobiological Underpinnings of Hyperarousal in Depression: A Comprehensive Review

Patients with major depressive disorder (MDD) exhibit an abnormal physiological arousal pattern known as hyperarousal, which may contribute to their depressive symptoms. However, the neurobiological mechanisms linking this abnormal arousal to depressive symptoms are not yet fully understood. In this review, we summarize the physiological and neural features of arousal, and review the literature indicating abnormal arousal in depressed patients. Evidence suggests that a hyperarousal state in depression is characterized by abnormalities in sleep behavior, physiological (e.g., heart rate, skin conductance, pupil diameter) and electroencephalography (EEG) features, and altered activity in subcortical (e.g., hypothalamus and locus coeruleus) and cortical regions. While recent studies highlight the importance of subcortical-cortical interactions in arousal, few have explored the relationship between subcortical-cortical interactions and hyperarousal in depressed patients. This gap limits our understanding of the neural mechanism through which hyperarousal affects depressive symptoms, which involves various cognitive processes and the cerebral cortex. Based on the current literature, we propose that the hyperconnectivity in the thalamocortical circuit may contribute to both the hyperarousal pattern and depressive symptoms. Future research should investigate the relationship between thalamocortical connections and abnormal arousal in depression, and explore its implications for non-invasive treatments for depression.

Sex and Sleep Disruption as Contributing Factors in Alzheimer's Disease

Alzheimer's disease (AD) affects more women than men, with women throughout the menopausal transition potentially being the most under researched and at-risk group. Sleep disruptions, which are an established risk factor for AD, increase in prevalence with normal aging and are exacerbated in women during menopause. Sex differences showing more disrupted sleep patterns and increased AD pathology in women and female animal models have been established in literature, with much emphasis placed on loss of circulating gonadal hormones with age. Interestingly, increases in gonadotropins such as follicle stimulating hormone are emerging to be a major contributor to AD pathogenesis and may also play a role in sleep disruption, perhaps in combination with other lesser studied hormones. Several sleep influencing regions of the brain appear to be affected early in AD progression and some may exhibit sexual dimorphisms that may contribute to increased sleep disruptions in women with age. Additionally, some of the most common sleep disorders, as well as multiple health conditions that impair sleep quality, are more prevalent and more severe in women. These conditions are often comorbid with AD and have bi-directional relationships that contribute synergistically to cognitive decline and neuropathology. The association during aging of increased sleep disruption and sleep disorders, dramatic hormonal changes during and after menopause, and increased AD pathology may be interacting and contributing factors that lead to the increased number of women living with AD.

Trazodone in the Management of Major Depression Among Elderly Patients with Dementia: A Narrative Review and Clinical Insights

Objective

Major depressive disorder (MDD) often co-occurs with dementia and other neurological disorders, and treatment with antidepressants can improve symptoms, quality of life, and survival in these patients. This narrative review provides an expert opinion about the role and effectiveness of trazodone in the treatment of older adults with MDD and cognitive impairment due to physical illnesses, such as dementia.

Results

Because of its mechanism of action, trazodone can treat several depression symptoms often seen in people with dementia, including insomnia, agitation, anxiety, cognitive impairment, and irritability.

Conclusion

Trazodone may be beneficial for patients with dementia or other neurological disorders comorbid with MDD, especially when the clinical picture of depression includes or is comorbid to symptoms of insomnia, irritability, inner tension, anxiety, or psychomotor agitation.

What is sleep exactly? Global and local modulations of sleep oscillations all around the clock

Wakefulness, non-rapid eye-movement (NREM) and rapid eye-movement (REM) sleep differ from each other along three dimensions: behavioral, phenomenological, physiological. Although these dimensions often fluctuate in step, they can also dissociate. The current paradigm that views sleep as made of global NREM and REM states fail to account for these dissociations. This conundrum can be dissolved by stressing the existence and significance of the local regulation of sleep. We will review the evidence in animals and humans, healthy and pathological brains, showing different forms of local sleep and the consequences on behavior, cognition, and subjective experience. Altogether, we argue that the notion of local sleep provides a unified account for a host of phenomena: dreaming in REM and NREM sleep, NREM and REM parasomnias, intrasleep responsiveness, inattention and mind wandering in wakefulness. Yet, the physiological origins of local sleep or its putative functions remain unclear. Exploring further local sleep could provide a unique and novel perspective on how and why we sleep.

Exploring the Role of Neuroplasticity in Development, Aging, and Neurodegeneration

Neuroplasticity refers to the ability of the brain to reorganize and modify its neural connections in response to environmental stimuli, experience, learning, injury, and disease processes. It encompasses a range of mechanisms, including changes in synaptic strength and connectivity, the formation of new synapses, alterations in the structure and function of neurons, and the generation of new neurons. Neuroplasticity plays a crucial role in developing and maintaining brain function, including learning and memory, as well as in recovery from brain injury and adaptation to environmental changes. In this review, we explore the vast potential of neuroplasticity in various aspects of brain function across the lifespan and in the context of disease. Changes in the aging brain and the significance of neuroplasticity in maintaining cognitive function later in life will also be reviewed. Finally, we will discuss common mechanisms associated with age-related neurodegenerative processes (including protein aggregation and accumulation, mitochondrial dysfunction, oxidative stress, and neuroinflammation) and how these processes can be mitigated, at least partially, by non-invasive and non-pharmacologic lifestyle interventions aimed at promoting and harnessing neuroplasticity.

Mechanisms of Activation of Brain's Drainage during Sleep: The Nightlife of Astrocytes

The study of functions, mechanisms of generation, and pathways of movement of cerebral fluids has a long history, but the last decade has been especially productive. The proposed glymphatic hypothesis, which suggests a mechanism of the brain waste removal system (BWRS), caused an active discussion on both the criticism of some of the perspectives and our intensive study of new experimental facts. It was especially found that the intensity of the metabolite clearance changes significantly during the transition between sleep and wakefulness. Interestingly, at the cellular level, a number of aspects of this problem have been focused on, such as astrocytes-glial cells, which, over the past two decades, have been recognized as equal partners of neurons and perform many important functions. In particular, an important role was assigned to astrocytes within the framework of the glymphatic hypothesis. In this review, we return to the "astrocytocentric" view of the BWRS function and the explanation of its activation during sleep from the viewpoint of new findings over the last decade. Our main conclusion is that the BWRS's action may be analyzed both at the systemic (whole-brain) and at the local (cellular) level. The local level means here that the neuro-glial-vascular unit can also be regarded as the smallest functional unit of sleep, and therefore, the smallest functional unit of the BWRS.

The Arousal-Related "Central Thalamus" Stimulation Site Simultaneously Innervates Multiple High-Level Frontal and Parietal Areas

In human and nonhuman primates, deep brain stimulation applied at or near the internal medullary lamina of the thalamus [a region referred to as "central thalamus," (CT)], but not at nearby thalamic sites, elicits major changes in the level of consciousness, even in some minimally conscious brain-damaged patients. The mechanisms behind these effects remain mysterious, as the connections of CT had not been specifically mapped in primates. In marmoset monkeys (Callithrix jacchus) of both sexes, we labeled the axons originating from each of the various CT neuronal populations and analyzed their arborization patterns in the cerebral cortex and striatum. We report that, together, these CT populations innervate an array of high-level frontal, posterior parietal, and cingulate cortical areas. Some populations simultaneously target the frontal, parietal, and cingulate cortices, while others predominantly target the dorsal striatum. Our data indicate that CT stimulation can simultaneously engage a heterogeneous set of projection systems that, together, target the key nodes of the attention, executive control, and working-memory networks of the brain. Increased functional connectivity in these networks has been previously described as a signature of consciousness.SIGNIFICANCE STATEMENT In human and nonhuman primates, deep brain stimulation at a specific site near the internal medullary lamina of the thalamus ["central thalamus," (CT)] had been shown to restore arousal and awareness in anesthetized animals, as well as in some brain-damaged patients. The mechanisms behind these effects remain mysterious, as CT connections remain poorly defined in primates. In marmoset monkeys, we mapped with sensitive axon-labeling methods the pathways originated from CT. Our data indicate that stimulation applied in CT can simultaneously engage a heterogeneous set of projection systems that, together, target several key nodes of the attention, executive control, and working-memory networks of the brain. Increased functional connectivity in these networks has been previously described as a signature of consciousness.

Interictal spikes in Alzheimer's disease: Preclinical evidence for dominance of the dentate gyrus and cholinergic control by the medial septum

Interictal spikes (IIS) are a common type of abnormal electrical activity in Alzheimer's disease (AD) and preclinical models. The brain regions where IIS are largest are not known but are important because such data would suggest sites that contribute to IIS generation. Because hippocampus and cortex exhibit altered excitability in AD models, we asked which areas dominate the activity during IIS along the cortical-CA1-dentate gyrus (DG) dorso-ventral axis. Because medial septal (MS) cholinergic neurons are overactive when IIS typically occur, we also tested the novel hypothesis that silencing the MS cholinergic neurons selectively would reduce IIS. We used mice that simulate aspects of AD: Tg2576 mice, presenilin 2 (PS2) knockout mice and Ts65Dn mice. To selectively silence MS cholinergic neurons, Tg2576 mice were bred with choline-acetyltransferase (ChAT)-Cre mice and offspring were injected in the MS with AAV encoding inhibitory designer receptors exclusively activated by designer drugs (DREADDs). We recorded local field potentials along the cortical-CA1-DG axis using silicon probes during wakefulness, slow-wave sleep (SWS) and rapid eye movement (REM) sleep. We detected IIS in all transgenic or knockout mice but not age-matched controls. IIS were detectable throughout the cortical-CA1-DG axis and occurred primarily during REM sleep. In all 3 mouse lines, IIS amplitudes were significantly greater in the DG granule cell layer vs. CA1 pyramidal layer or overlying cortex. Current source density analysis showed robust and early current sources in the DG, and additional sources in CA1 and the cortex also. Selective chemogenetic silencing of MS cholinergic neurons significantly reduced IIS rate during REM sleep without affecting the overall duration, number of REM bouts, latency to REM sleep, or theta power during REM. Notably, two control interventions showed no effects. Consistent maximal amplitude and strong current sources of IIS in the DG suggest that the DG is remarkably active during IIS. In addition, selectively reducing MS cholinergic tone, at times when MS is hyperactive, could be a new strategy to reduce IIS in AD.

Characterizing brain stage-dependent pupil dynamics based on lateral hypothalamic activity

Pupil dynamics presents varied correlation features with brain activity under different vigilant levels. The modulation of brain dynamic stages can arise from the lateral hypothalamus (LH), where diverse neuronal cell types contribute to arousal regulation in opposite directions via the anterior cingulate cortex (ACC). However, the relationship of the LH and pupil dynamics has seldom been investigated. Here, we performed local field potential (LFP) recordings at the LH and ACC, and whole-brain fMRI with simultaneous fiber photometry Ca2+ recording in the ACC, to evaluate their correlation with brain state-dependent pupil dynamics. Both LFP and functional magnetic resonance imaging (fMRI) data showed various correlations to pupil dynamics across trials that span negative, null, and positive correlation values, demonstrating brain state-dependent coupling features. Our results indicate that the correlation of pupil dynamics with ACC LFP and whole-brain fMRI signals depends on LH activity, suggesting a role of the latter in brain dynamic stage regulation.

How we sleep: From brain states to processes

All our lives, we alternate between wakefulness and sleep with direct consequences on our ability to interact with our environment, the dynamics and contents of our subjective experience, and our brain activity. Consequently, sleep has been extensively characterised in terms of behavioural, phenomenological, and physiological changes, the latter constituting the gold standard of sleep research. The common view is thus that sleep represents a collection of discrete states with distinct neurophysiological signatures. However, recent findings challenge such a monolithic view of sleep. Indeed, there can be sharp discrepancies in time and space in the activity displayed by different brain regions or networks, making it difficult to assign a global vigilance state to such a mosaic of contrasted dynamics. Viewing sleep as a multidimensional continuum rather than a succession of non-overlapping and mutually exclusive states could account for these local aspects of sleep. Moving away from the focus on sleep states, sleep can also be investigated through the brain processes that are present in sleep, if not necessarily specific to sleep. This focus on processes rather than states allows to see sleep for what it does rather than what it is, avoiding some of the limitations of the state perspective and providing a powerful heuristic to understand sleep. Indeed, what is sleep if not a process itself that makes up wake up every morning with a brain cleaner, leaner and less cluttered.

Astrocytes: new evidence, new models, new roles

Astrocytes have been in the limelight of active research for about 3 decades now. Over this period, ideas about their function and role in the nervous system have evolved from simple assistance in energy supply and homeostasis maintenance to a complex informational and metabolic hub that integrates data on local neuronal activity, sensory and arousal context, and orchestrates many crucial processes in the brain. Rapid progress in experimental techniques and data analysis produces a growing body of data, which can be used as a foundation for formulation of new hypotheses, building new refined mathematical models, and ultimately should lead to a new level of understanding of the contribution of astrocytes to the cognitive tasks performed by the brain. Here, we highlight recent progress in astrocyte research, which we believe expands our understanding of how low-level signaling at a cellular level builds up to processes at the level of the whole brain and animal behavior. We start our review with revisiting data on the role of noradrenaline-mediated astrocytic signaling in locomotion, arousal, sensory integration, memory, and sleep. We then briefly review astrocyte contribution to the regulation of cerebral blood flow regulation, which is followed by a discussion of biophysical mechanisms underlying astrocyte effects on different brain processes. The experimental section is closed by an overview of recent experimental techniques available for modulation and visualization of astrocyte dynamics. We then evaluate how the new data can be potentially incorporated into the new mathematical models or where and how it already has been done. Finally, we discuss an interesting prospect that astrocytes may be key players in important processes such as the switching between sleep and wakefulness and the removal of toxic metabolites from the brain milieu.

GABAergic modulation of sleep-wake states

Benzodiazepine, a classical medication utilized in the treatment of insomnia, operates by augmenting the activity of the GABAA receptor. This underscores the significance of GABAergic neurotransmission in both the initiation and maintenance of sleep. Nevertheless, an increasing body of evidence substantiates the notion that GABA-mediated neurotransmission also assumes a vital role in promoting wakefulness in specific neuronal circuits. Despite the longstanding belief in the pivotal function of GABA in regulating the sleep-wake cycle, there exists a dearth of comprehensive documentation regarding the specific regions within the central nervous system where GABAergic neurons are crucial for these functions. In this review, we delve into the involvement of GABAergic neurons in the regulation of sleep-wake cycles, with particular focus on those located in the preoptic area (POA) and ventral tegmental area (VTA). Recent research, including our own, has further underscored the importance of GABAergic neurotransmission in these areas for the regulation of sleep-wake cycles.

The neuropeptide receptor npr-38 regulates avoidance and stress-induced sleep in Caenorhabditis elegans

Although essential and conserved, sleep is not without its challenges that must be overcome; most notably, it renders animals vulnerable to threats in the environment. Infection and injury increase sleep demand, which dampens sensory responsiveness to stimuli, including those responsible for the initial insult. Stress-induced sleep in Caenorhabditis elegans occurs in response to cellular damage following noxious exposures the animals attempted to avoid. Here, we describe a G-protein-coupled receptor (GPCR) encoded by npr-38, which is required for stress-related responses including avoidance, sleep, and arousal. Overexpression of npr-38 shortens the avoidance phase and causes animals to initiate movement quiescence and arouse early. npr-38 functions in the ADL sensory neurons, which express neuropeptides encoded by nlp-50, also required for movement quiescence. npr-38 regulates arousal by acting on the DVA and RIS interneurons. Our work demonstrates that this single GPCR regulates multiple aspects of the stress response by functioning in sensory and sleep interneurons.

Clinical Neurobiology of Sleep and Wakefulness

OBJECTIVE

This article focuses on novel neuronal mechanisms of sleep and wakefulness and relates basic science developments with potential translational implications in circadian neurobiology, pharmacology, behavioral factors, and the recently integrated potential pathways of sleep-related motor inhibition.

LATEST DEVELOPMENTS

During the past decade, remarkable advances in the molecular biology of sleep and wakefulness have taken place, opening a promising path for the understanding of clinical sleep disorders. Newly gained insights include the role of astrocytes in sleep brain homeostasis through the glymphatic system, the promotion of memory consolidation during states of reduced cholinergic activity during slow wave sleep, and the differential functions of melatonin receptors involving regulation of both circadian rhythm and sleep initiation. Ongoing investigations exploring sleep and circadian rhythm disruptions are beginning to unlock pathophysiologic aspects of neurologic, psychiatric, and medical disorders.

ESSENTIAL POINTS

An understanding of sleep and circadian neurobiology provides coherent and biologically credible approaches to treatments, including the identification of potential targets for neuromodulation.

International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).

METHODS

Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.

RESULTS

The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.

CONCLUSION

This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Phenotypic Interindividual Differences in the Dynamic Structure of Sleep in Healthy Young Adults

Introduction

Evaluating the dynamic structure of sleep may yield new insights into the mechanisms underlying human sleep physiology.

Methods

We analyzed data from a 12-day, 11-night, strictly controlled laboratory study with an adaptation night, 3 iterations of a baseline night followed by a recovery night after 36 h of total sleep deprivation, and a final recovery night. All sleep opportunities were 12 h in duration (22:00-10:00) and recorded with polysomnography (PSG). The PSG records were scored for the sleep stages: rapid eye movement (REM) sleep; non-REM (NREM) stage 1 sleep (S1), stage 2 sleep (S2), and slow wave sleep (SWS); and wake (W). Phenotypic interindividual differences were assessed using indices of dynamic sleep structure - specifically sleep stage transitions and sleep cycle characteristics - and intraclass correlation coefficients across nights.

Results

NREM/REM sleep cycles and sleep stage transitions exhibited substantial and stable interindividual differences that were robust across baseline and recovery nights, suggesting that mechanisms underlying the dynamic structure of sleep are phenotypic. In addition, the dynamics of sleep stage transitions were found to be associated with sleep cycle characteristics, with a significant relationship between the length of sleep cycles and the degree to which S2-to-W/S1 and S2-to-SWS transitions were in equilibrium.

Discussion

Our findings are consistent with a model for the underlying mechanisms that involves three subsystems - characterized by S2-to-W/S1, S2-to-SWS, and S2-to-REM transitions - with S2 playing a hub-like role. Furthermore, the balance between the two subsystems within NREM sleep (S2-to-W/S1 and S2-to-SWS) may serve as a basis for the dynamic regulation of sleep structure and may represent a novel target for interventions aiming to improve sleep.

FABP7: a glial integrator of sleep, circadian rhythms, plasticity, and metabolic function

Sleep and circadian rhythms are observed broadly throughout animal phyla and influence neural plasticity and cognitive function. However, the few phylogenetically conserved cellular and molecular pathways that are implicated in these processes are largely focused on neuronal cells. Research on these topics has traditionally segregated sleep homeostatic behavior from circadian rest-activity rhythms. Here we posit an alternative perspective, whereby mechanisms underlying the integration of sleep and circadian rhythms that affect behavioral state, plasticity, and cognition reside within glial cells. The brain-type fatty acid binding protein, FABP7, is part of a larger family of lipid chaperone proteins that regulate the subcellular trafficking of fatty acids for a wide range of cellular functions, including gene expression, growth, survival, inflammation, and metabolism. FABP7 is enriched in glial cells of the central nervous system and has been shown to be a clock-controlled gene implicated in sleep/wake regulation and cognitive processing. FABP7 is known to affect gene transcription, cellular outgrowth, and its subcellular localization in the fine perisynaptic astrocytic processes (PAPs) varies based on time-of-day. Future studies determining the effects of FABP7 on behavioral state- and circadian-dependent plasticity and cognitive processes, in addition to functional consequences on cellular and molecular mechanisms related to neural-glial interactions, lipid storage, and blood brain barrier integrity will be important for our knowledge of basic sleep function. Given the comorbidity of sleep disturbance with neurological disorders, these studies will also be important for our understanding of the etiology and pathophysiology of how these diseases affect or are affected by sleep.

Structure and Function of Neuronal Circuits Linking Ventrolateral Preoptic Nucleus and Lateral Hypothalamic Area

To understand how sleep-wakefulness cycles are regulated, it is essential to disentangle structural and functional relationships between the preoptic area (POA) and lateral hypothalamic area (LHA), since these regions play important yet opposing roles in the sleep-wakefulness regulation. GABA- and galanin (GAL)-producing neurons in the ventrolateral preoptic nucleus (VLPO) of the POA (VLPOGABA and VLPOGAL neurons) are responsible for the maintenance of sleep, while the LHA contains orexin-producing neurons (orexin neurons) that are crucial for maintenance of wakefulness. Through the use of rabies virus-mediated neural tracing combined with in situ hybridization (ISH) in male and female orexin-iCre mice, we revealed that the vesicular GABA transporter (Vgat, Slc32a1)- and galanin (Gal)-expressing neurons in the VLPO directly synapse with orexin neurons in the LHA. A majority (56.3 ± 8.1%) of all VLPO input neurons connecting to orexin neurons were double-positive for Vgat and Gal Using projection-specific rabies virus-mediated tracing in male and female Vgat-ires-Cre and Gal-Cre mice, we discovered that VLPOGABA and VLPOGAL neurons that send projections to the LHA received innervations from similarly distributed input neurons in many brain regions, with the POA and LHA being among the main upstream areas. Additionally, we found that acute optogenetic excitation of axons of VLPOGABA neurons, but not VLPOGAL neurons, in the LHA of male Vgat-ires-Cre mice induced wakefulness. This study deciphers the connectivity between the VLPO and LHA, provides a large-scale map of upstream neuronal populations of VLPO→LHA neurons, and reveals a previously uncovered function of the VLPOGABA→LHA pathway in the regulation of sleep and wakefulness.SIGNIFICANCE STATEMENT We identified neurons in the ventrolateral preoptic nucleus (VLPO) that are positive for vesicular GABA transporter (Vgat) and/or galanin (Gal) and serve as presynaptic partners of orexin-producing neurons in the lateral hypothalamic area (LHA). We depicted monosynaptic input neurons of GABA- and galanin-producing neurons in the VLPO that send projections to the LHA throughout the entire brain. Their input neurons largely overlap, suggesting that they comprise a common neuronal population. However, acute excitatory optogenetic manipulation of the VLPOGABA→LHA pathway, but not the VLPOGAL→LHA pathway, evoked wakefulness. This study shows the connectivity of major components of the sleep/wake circuitry in the hypothalamus and unveils a previously unrecognized function of the VLPOGABA→LHA pathway in sleep-wakefulness regulation. Furthermore, we suggest the existence of subpopulations of VLPOGABA neurons that innervate LHA.

Different Alterations of Hippocampal and Reticulo-Thalamic GABAergic Parvalbumin-Expressing Interneurons Underlie Different States of Unconsciousness

We traced the changes in GABAergic parvalbumin (PV)-expressing interneurons of the hippocampus and reticulo-thalamic nucleus (RT) as possible underlying mechanisms of the different local cortical and hippocampal electroencephalographic (EEG) microstructures during the non-rapid-eye movement (NREM) sleep compared with anesthesia-induced unconsciousness by two anesthetics with different main mechanisms of action (ketamine/diazepam versus propofol). After 3 h of recording their sleep, the rats were divided into two experimental groups: one half received ketamine/diazepam anesthesia and the other half received propofol anesthesia. We simultaneously recorded the EEG of the motor cortex and hippocampus during sleep and during 1 h of surgical anesthesia. We performed immunohistochemistry and analyzed the PV and postsynaptic density protein 95 (PSD-95) expression. PV suppression in the hippocampus and at RT underlies the global theta amplitude attenuation and hippocampal gamma augmentation that is a unique feature of ketamine-induced versus propofol-induced unconsciousness and NREM sleep. While PV suppression resulted in an increase in hippocampal PSD-95 expression, there was no imbalance between inhibition and excitation during ketamine/diazepam anesthesia compared with propofol anesthesia in RT. This increased excitation could be a consequence of a lower GABA interneuronal activity and an additional mechanism underlying the unique local EEG microstructure in the hippocampus during ketamine/diazepam anesthesia.

EEG coherence and power spectra during REM sleep related to melatonin intake in mild-to-moderate Alzheimer's disease: a pilot study

It has been reported that melatonin diminishes rapid eye movement (REM) sleep latency in patients with Alzheimer's disease (AD). Pharmacological studies suggest that melatonin promotes prompt sleep installation through interaction with GABA receptors, and that it is associated with acute suppression of neural electrical activity. Nevertheless, melatonin's effects on electroencephalographic (EEG) activity related to REM sleep onset in AD patients have not been analyzed. Thus, in this pilot study we analyzed the effects of melatonin on EEG activity during the first episode of REM sleep in eight patients treated with 5-mg of fast-release melatonin.

During a single-blind, placebo-controlled study, polysomnographic recordings were obtained from frontal, central, temporal, and occipital scalp derivations. REM sleep latency, as well as the relative power (RP) and EEG coherences of six EEG bands, were compared between the placebo and melatonin conditions.

Results showed that melatonin intake in AD patients decreased REM sleep onset, and that this was associated with lower RP and coherence of the β and γ EEG bands.

The possibility that the inhibitory GABAergic pathways related to REM sleep generation are well-preserved in mild-to-moderate AD is discussed. We conclude that the short REM sleep onset related to melatonin intake in AD patients is associated with a significant decrease in both RP and EEG coherence, mainly in the fast frequencies.

REM sleep and muscle atonia in brainstem stroke: A quantitative polysomnographic and lesion analysis study

Important brainstem regions are involved in the regulation of rapid eye movement sleep. We hypothesized that brainstem stroke is associated with dysregulated rapid eye movement sleep and related muscle activity. We compared quantitative/qualitative polysomnography features of rapid eye movement sleep and muscle activity (any, phasic, tonic) between 15 patients with brainstem stroke (N = 46 rapid eye movement periods), 16 patients with lacunar/non-brainstem stroke (N = 40 rapid eye movement periods), 15 healthy controls (N = 62 rapid eye movement periods), and patients with Parkinson's disease and polysomnography-confirmed rapid eye movement sleep behaviour disorder. Further, in the brainstem group, we performed a magnetic resonance imaging-based lesion overlap analysis. The mean ratio of muscle activity to rapid eye movement sleep epoch in the brainstem group ("any" muscle activity 0.09 ± 0.15; phasic muscle activity 0.08 ± 0.14) was significantly lower than in the lacunar group ("any" muscle activity 0.17 ± 0.2, p < 0.05; phasic muscle activity 0.16 ± 0.19, p < 0.05), and also lower than in the control group ("any" muscle activity 0.15 ± 0.17, p < 0.05). Magnetic resonance imaging-based lesion analysis indicated an area of maximum overlap in the medioventral pontine region for patients with reduced phasic muscle activity index. For all groups, mean values of muscle activity were significantly lower than in the patients with Parkinson's disease and polysomnography-confirmed REM sleep behaviour disorder group ("any" activity 0.51 ± 0.26, p < 0.0001 for all groups; phasic muscle activity 0.42 ± 0.21, p < 0.0001 for all groups). For the tonic muscle activity in the mentalis muscle, no significant differences were found between the groups. In the brainstem group, contrary to the lacunar and the control groups, "any" muscle activity index during rapid eye movement sleep was significantly reduced after the third rapid eye movement sleep phase. This study reports on the impact of brainstem stroke on rapid eye movement atonia features in a human cohort. Our findings highlight the important role of the human brainstem, in particular the medioventral pontine regions, in the regulation of phasic muscle activity during rapid eye movement sleep and the ultradian distribution of rapid eye movement-related muscle activity.

Cardiovascular disease and lifestyle choices: Spotlight on circadian rhythms and sleep

The advent of electric lighting in the built environment has radically transformed the human experience of light and darkness, which is often insufficient to stimulate and synchronize the circadian system to the day-night cycle. The lack of circadian system entrainment leads to poor sleep and could be an important biophysical mechanism underlying increased incidence of certain types of diseases, including cardiovascular (CV) disease (CVD). This contribution proposes to carve out a niche for including daily exposures to light and darkness among lifestyle factors for reducing the risk and progression of CVD. The fundamental workings of the human circadian system and its primary outputs are described. The discussion then progresses to light's effects on the circadian system and its outputs, and how threats to circadian health pose risks for CV health. The contribution concludes with simple recommendations for incorporating regular, robust daily exposures in lifestyle adjustments to combat CVD risks and progression.

Mammalian NREM and REM sleep: Why, when and how

This report proposes that fish use the spinal-rhombencephalic regions of their brain to support their activities while awake. Instead, the brainstem-diencephalic regions support the wakefulness in amphibians and reptiles. Lastly, mammals developed the telencephalic cortex to attain the highest degree of wakefulness, the cortical wakefulness. However, a paralyzed form of spinal-rhombencephalic wakefulness remains in mammals in the form of REMS, whose phasic signs are highly efficient in promoting maternal care to mammalian litter. Therefore, the phasic REMS is highly adaptive. However, their importance is low for singletons, in which it is a neutral trait, devoid of adaptive value for adults, and is mal-adaptive for marine mammals. Therefore, they lost it. The spinal-rhombencephalic and cortical wakeful states disregard the homeostasis: animals only attend their most immediate needs: foraging defense and reproduction. However, these activities generate allostatic loads that must be recovered during NREMS, that is a paralyzed form of the amphibian-reptilian subcortical wakefulness. Regarding the regulation of tonic REMS, it depends on a hypothalamic switch. Instead, the phasic REMS depends on an independent proportional pontine control.

Current models of insomnia disorder: a theoretical review on the potential role of the orexinergic pathway with implications for insomnia treatment

Insomnia disorder is considered as a stress-related disorder associated with hyperarousal, stress and emotion dysregulation and the instability of the 'flip-flop' switch system. The orexinergic system is well known for its key role in sleep and arousal processes but also in the allostatic system regulating stress and emotions and may thus be of major interest for insomnia and its treatment. Accordingly, we discuss the potential role of orexins on sleep processes, brain systems modulating stress and emotions with potential implications for insomnia pathophysiology. We reviewed available data on the effect of dual orexin receptor antagonists (DORAs) on sleep and brain systems modulating stress/emotions with implications for insomnia treatment. We present our findings as a narrative review. Few data in animals and humans have reported that disrupted sleep and insomnia may be related to the overactivation of orexinergic system, while some more consistent data in humans and animals reported the overactivation of orexins in response to acute stress and in stress-related disorders. Taken together these findings may let us hypothesise that an orexins overactivation may be associated with stress-related hyperarousal and the hyperactivation of arousal-promoting systems in insomnia. On the other hand, it is possible that by rebalancing orexins with DORAs we may regulate both sleep and allostatic systems, in turn, contributing to a 'switch off' of hyperarousal in insomnia. Nevertheless, more studies are needed to clarify the role of the orexin system in insomnia and to evaluate the effects of DORAs on sleep, stress and emotions regulating systems.

Co-occurring insomnia and anxiety: a randomized controlled trial of internet cognitive behavioral therapy for insomnia versus internet cognitive behavioral therapy for anxiety

STUDY OBJECTIVES

Insomnia and anxiety are highly prevalent and frequently co-occur. Given limited therapeutic resources and time constraints, the aim of this study was to compare which treatment-internet cognitive behavioral therapy (CBT) for insomnia or internet CBT for anxiety-leads to the best outcomes in individuals with comorbid insomnia and anxiety.

METHODS

120 participants with comorbid insomnia and clinical anxiety (as defined by scores above the clinical cutoff on the insomnia severity index (ISI) and the generalized anxiety disorder 7-item scale (GAD-7)) were randomized to receive internet-based cognitive behavioral therapy (iCBT) for insomnia or iCBT for anxiety. The primary outcome measures were the ISI and the generalized anxiety disorder 7-item scale. Primary outcome measures were assessed before treatment, at mid-treatment, at post-treatment, and 3 months after treatment. Secondary outcome measures assessed depression symptoms, distress, and sleep diary parameters.

RESULTS

Participants in both groups experienced large reductions in symptoms of insomnia, anxiety, depression, and distress, as well as improvements in sleep efficiency and total sleep time. Improvements were maintained at follow-up. Crucially, at the end of treatment, the insomnia treatment was more effective in reducing symptoms of insomnia than the anxiety treatment, and equally effective in reducing symptoms of anxiety. Treatment gains were maintained at 3-month follow-up, however, there were no differences between groups at that time point.

CONCLUSIONS

These results suggest that in the common case of a patient presenting with comorbid insomnia and anxiety, treatment for insomnia may be the most efficient treatment strategy.

TRIAL REGISTRATION

The trial was registered with the Australian and New Zealand Clinical Trials Registry, https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12618001141235. Trial ID: ACTRN12618001141235. Trial name: a comparison of internet-based CBT for insomnia versus internet-based CBT for anxiety in a comorbid sample.

Neuro-orchestration of sleep and wakefulness

Although considered an inactive state for centuries, sleep entails many active processes occurring at the cellular, circuit and organismal levels. Over the last decade, several key technological advances, including calcium imaging and optogenetic and chemogenetic manipulations, have facilitated a detailed understanding of the functions of different neuronal populations and circuits in sleep-wake regulation. Here, we present recent progress and summarize our current understanding of the circuitry underlying the initiation, maintenance and coordination of wakefulness, rapid eye movement sleep (REMS) and non-REMS (NREMS). We propose a de-arousal model for sleep initiation, in which the neuromodulatory milieu necessary for sleep initiation is achieved by engaging in repetitive pre-sleep behaviors that gradually reduce vigilance to the external environment and wake-promoting neuromodulatory tone. We also discuss how brain processes related to thermoregulation, hunger and fear intersect with sleep-wake circuits to control arousal. Lastly, we discuss controversies and lingering questions in the sleep field.

Brain Mechanisms of Conscious Awareness: Detect, Pulse, Switch, and Wave

Consciousness is a fascinating field of neuroscience research where questions often outnumber the answers. We advocate an open and optimistic approach where converging mechanisms in neuroscience may eventually provide a satisfactory understanding of consciousness. We first review several characteristics of conscious neural activity, including the involvement of dedicated systems for content and levels of consciousness, the distinction and overlap of mechanisms contributing to conscious states and conscious awareness of transient events, nonlinear transitions and involvement of large-scale networks, and finally the temporal nexus where conscious awareness of discrete events occurs when mechanisms of attention and memory meet. These considerations and recent new experimental findings lead us to propose an inclusive hypothesis involving four phases initiated shortly after an external sensory stimulus: (1) Detect-primary and higher cortical and subcortical circuits detect the stimulus and select it for conscious perception. (2) Pulse-a transient and massive neuromodulatory surge in subcortical-cortical arousal and salience networks amplifies signals enabling conscious perception to proceed. (3) Switch-networks that may interfere with conscious processing are switched off. (4) Wave-sequential processing through hierarchical lower to higher cortical regions produces a fully formed percept, encoded in frontoparietal working memory and medial temporal episodic memory systems for subsequent report of experience. The framework hypothesized here is intended to be nonexclusive and encourages the addition of other mechanisms with further progress. Ultimately, just as many mechanisms in biology together distinguish living from nonliving things, many mechanisms in neuroscience synergistically may separate conscious from nonconscious neural activity.

NREM-REM alternation complicates transitions from napping to non-napping behavior in a three-state model of sleep-wake regulation

The temporal structure of human sleep changes across development as it consolidates from the polyphasic sleep of infants to the single nighttime sleep episode typical in adults. Experimental studies have shown that changes in the dynamics of sleep need may mediate this developmental transition in sleep patterning, however, it is unknown how sleep architecture interacts with these changes. We employ a physiologically-based mathematical model that generates wake, rapid eye movement (REM) and non-REM (NREM) sleep states to investigate how NREM-REM alternation affects the transition in sleep patterns as the dynamics of the homeostatic sleep drive are varied. To study the mechanisms producing these transitions, we analyze the bifurcations of numerically-computed circle maps that represent key dynamics of the full sleep-wake network model by tracking the evolution of sleep onsets across different circadian (∼ 24 h) phases. The maps are non-monotonic and discontinuous, being composed of branches that correspond to sleep-wake cycles containing distinct numbers of REM bouts. As the rates of accumulation and decay of the homeostatic sleep drive are varied, we identify the bifurcations that disrupt a period-adding-like behavior of sleep patterns in the transition between biphasic and monophasic sleep. These bifurcations include border collision and saddle-node bifurcations that initiate new sleep patterns, period-doubling bifurcations leading to higher-order patterns of NREM-REM alternation, and intervals of bistability of sleep patterns with different NREM-REM alternations. Furthermore, patterns of NREM-REM alternation exhibit variable behaviors in different regimes of constant sleep-wake patterns. Overall, the sequence of sleep-wake behaviors, and underlying bifurcations, in the transition from biphasic to monophasic sleep in this three-state model is more complex than behavior observed in models of sleep-wake regulation that do not consider the dynamics of NREM-REM alternation. These results suggest that interactions between the dynamics of the homeostatic sleep drive and the dynamics of NREM-REM alternation may contribute to the wide interindividual variation observed when young children transition from napping to non-napping behavior.

[Sleep regulation as a complex process]

A retrospective analysis of views on the regulation of the «sleep-wakefulness» cycle from the reticular theory of sleep to the Saper's model was carried out. A modified version of the Saper's trigger made it possible to use the results of a comparative analysis of drugs used in the treatment of sleep disorders to develop new, comprehensive, effective approaches to the pharmacotherapy of the most common sleep disorders. It seems that this approach will be useful in the development of effective pharmacotherapy for sleep disorders.

Repeated measures of hypocretin-1 in Danish and Italian patients with narcolepsy and in controls

STUDY OBJECTIVES

The assay currently used worldwide to measure cerebrospinal fluid hypocretin-1 (CSF-hcrt-1) for diagnosing narcolepsy uses a competitive radioimmunoassay with polyclonal anti-hcrt-1 antibodies. This assay detects multiple hypocretin-1 immunoreactive species in the CSF that are all derived from full-length hcrt-1. We aimed to revalidate CSF-hcrt-1 cut-offs for narcolepsy type 1 (NT1) diagnosis and to evaluate temporal changes in CSF-hcrt-1 levels in patients suspected of having central hypersomnia.

METHOD

We carried out a repeat lumbar puncture with a mean follow-up of 4.0 years, to measure CSF-hcrt-1 in patients suspected of having central hypersomnia in a follow-up study. Data from CSF samples of patients with NT1 and of controls without known hypersomnia, from the Italian-Stanford and Danish populations, were examined using a receiver-operating characteristic analysis.

RESULTS

The optimal CSF-hcrt-1 cut-offs for identifying NT1 were 129 pg/ml and 179 pg/ml for the Italian-Stanford and Danish populations, respectively. The sensitivity was 0.93-0.99 and the specificity was 1. Follow-up lumbar puncture measurements of CSF-hcrt-1 were obtained from 73 patients. 30 of 32 patients with low CSF-hcrt-1 levels continued to be categorized as low, with an unaltered diagnosis; two patients showed a marked increase in CSF-hcrt-1, attaining normal values at follow-up. One of these patients relapsed to low CSF-hcrt-1 after follow-up. All 41 patients with normal CSF-hcrt-1 at baseline had normal CSF-hcrt-1 at follow-up.

CONCLUSION

CSF-hcrt-1 measurement can provide an accurate test for diagnosing NT1, although it is important to validate the CSF-hcrt-1 cut-off for specific testing locations. Stable CSF-hcrt-1 levels support the already established prognosis of narcolepsy as permanent once the disorder has fully developed.

Understanding Sleep Regulation in Normal and Pathological Conditions, and Why It Matters

Sleep occupies a peculiar place in our lives and in science, being both eminently familiar and profoundly enigmatic. Historically, philosophers, scientists and artists questioned the meaning and purpose of sleep. If Shakespeare's verses from MacBeth depicting "Sleep that soothes away all our worries" and "relieves the weary laborer and heals hurt minds" perfectly epitomize the alleviating benefits of sleep, it is only during the last two decades that the growing understanding of the sophisticated sleep regulatory mechanisms allows us to glimpse putative biological functions of sleep. Sleep control brings into play various brain-wide processes occurring at the molecular, cellular, circuit, and system levels, some of them overlapping with a number of disease-signaling pathways. Pathogenic processes, including mood disorders (e.g., major depression) and neurodegenerative illnesses such Huntington's or Alzheimer's diseases, can therefore affect sleep-modulating networks which disrupt the sleep-wake architecture, whereas sleep disturbances may also trigger various brain disorders. In this review, we describe the mechanisms underlying sleep regulation and the main hypotheses drawn about its functions. Comprehending sleep physiological orchestration and functions could ultimately help deliver better treatments for people living with neurodegenerative diseases.

Understanding the roles of central and autonomic activity during sleep in the improvement of working memory and episodic memory

The last decade has seen significant progress in identifying sleep mechanisms that support cognition. Most of these studies focus on the link between electrophysiological events of the central nervous system during sleep and improvements in different cognitive domains, while the dynamic shifts of the autonomic nervous system across sleep have been largely overlooked. Recent studies, however, have identified significant contributions of autonomic inputs during sleep to cognition. Yet, there remain considerable gaps in understanding how central and autonomic systems work together during sleep to facilitate cognitive improvement. In this article we examine the evidence for the independent and interactive roles of central and autonomic activities during sleep and wake in cognitive processing. We specifically focus on the prefrontal-subcortical structures supporting working memory and mechanisms underlying the formation of hippocampal-dependent episodic memory. Our Slow Oscillation Switch Model identifies separate and competing underlying mechanisms supporting the two memory domains at the synaptic, systems, and behavioral levels. We propose that sleep is a competitive arena in which both memory domains vie for limited resources, experimentally demonstrated when boosting one system leads to a functional trade-off in electrophysiological and behavioral outcomes. As these findings inevitably lead to further questions, we suggest areas of future research to better understand how the brain and body interact to support a wide range of cognitive domains during a single sleep episode.

Circadian rhythms and disorders of the timing of sleep

The daily alternation between sleep and wakefulness is one of the most dominant features of our lives and is a manifestation of the intrinsic 24 h rhythmicity underlying almost every aspect of our physiology. Circadian rhythms are generated by networks of molecular oscillators in the brain and peripheral tissues that interact with environmental and behavioural cycles to promote the occurrence of sleep during the environmental night. This alignment is often disturbed, however, by contemporary changes to our living environments, work or social schedules, patterns of light exposure, and biological factors, with consequences not only for sleep timing but also for our physical and mental health. Characterised by undesirable or irregular timing of sleep and wakefulness, in this Series paper we critically examine the existing categories of circadian rhythm sleep-wake disorders and the role of the circadian system in their development. We emphasise how not all disruption to daily rhythms is driven solely by an underlying circadian disturbance, and take a broader, dimensional approach to explore how circadian rhythms and sleep homoeostasis interact with behavioural and environmental factors. Very few high-quality epidemiological and intervention studies exist, and wider recognition and treatment of sleep timing disorders are currently hindered by a scarcity of accessible and objective tools for quantifying sleep and circadian physiology and environmental variables. We therefore assess emerging wearable technology, transcriptomics, and mathematical modelling approaches that promise to accelerate the integration of our knowledge in sleep and circadian science into improved human health.

Chronobiology of epilepsy and sudden unexpected death in epilepsy

Epilepsy is a neurological disease characterized by spontaneous, unprovoked seizures. Various insults render the brain hyperexcitable and susceptible to seizure. Despite there being dozens of preventative anti-seizure medications available, these drugs fail to control seizures in nearly 1 in 3 patients with epilepsy. Over the last century, a large body of evidence has demonstrated that internal and external rhythms can modify seizure phenotypes. Physiologically relevant rhythms with shorter periodic rhythms, such as endogenous circadian rhythms and sleep-state, as well as rhythms with longer periodicity, including multidien rhythms and menses, influence the timing of seizures through poorly understood mechanisms. The purpose of this review is to discuss the findings from both human and animal studies that consider the effect of such biologically relevant rhythms on epilepsy and seizure-associated death. Patients with medically refractory epilepsy are at increased risk of sudden unexpected death in epilepsy (SUDEP). The role that some of these rhythms play in the nocturnal susceptibility to SUDEP will also be discussed. While the involvement of some of these rhythms in epilepsy has been known for over a century, applying the rhythmic nature of such phenomenon to epilepsy management, particularly in mitigating the risk of SUDEP, has been underutilized. As our understanding of the physiological influence on such rhythmic phenomenon improves, and as technology for chronic intracranial epileptiform monitoring becomes more widespread, smaller and less invasive, novel seizure-prediction technologies and time-dependent chronotherapeutic seizure management strategies can be realized.

Control of non-REM sleep by ventrolateral medulla glutamatergic neurons projecting to the preoptic area

Understanding the neural mechanisms underlying sleep state transitions is a fundamental goal of neurobiology and important for the development of new treatments for insomnia and other sleep disorders. Yet, brain circuits controlling this process remain poorly understood. Here we identify a population of sleep-active glutamatergic neurons in the ventrolateral medulla (VLM) that project to the preoptic area (POA), a prominent sleep-promoting region, in mice. Microendoscopic calcium imaging demonstrate that these VLM glutamatergic neurons display increased activity during the transitions from wakefulness to Non-Rapid Eye Movement (NREM) sleep. Chemogenetic silencing of POA-projecting VLM neurons suppresses NREM sleep, whereas chemogenetic activation of these neurons promotes NREM sleep. Moreover, we show that optogenetic activation of VLM glutamatergic neurons or their projections in the POA initiates NREM sleep in awake mice. Together, our findings uncover an excitatory brainstem-hypothalamic circuit that controls the wake-sleep transitions.

Monocarboxylate transporters (MCTs) in skeletal muscle and hypothalamus of less or more physically active mice exposed to aerobic training

AIMS

The synthesis of monocarboxylate transporters (MCTs) can be stimulated by aerobic training, but few is known about this effect associated or not with non-voluntary daily activities. We examined the effect of eight weeks of aerobic training in MCTs on the skeletal muscle and hypothalamus of less or more physically active mice, which can be achieved by keeping them in two different housing models, a small cage (SC) and a large cage (LC).

MAIN METHODS

Forty male C57BL/6J mice were divided into four groups. In each housing condition, mice were divided into untrained (N) and trained (T). For 8 weeks, the trained animals ran on a treadmill with an intensity equivalent to 80 % of the individual critical velocity (CV), considered aerobic capacity, 40 min/day, 5 times/week. Protein expression of MCTs was determined with fluorescence Western Blot.

KEY FINDINGS

T groups had higher hypothalamic MCT2 than N groups (ANOVA, P = 0.032). Significant correlations were detected between hypothalamic MCT2 and CV. There was a difference between the SC and LC groups in relation to MCT4 in the hypothalamus (LC > SC, P = 0.044). Trained mice housed in LC (but not SC-T) exhibited a reduction in MCT4 muscle (P < 0.001).

SIGNIFICANCE

Our findings indicate that aerobically trained mice increased the expression of MCT2 protein in the hypothalamus, which has been related to the uptake of lactate in neurons. Changes in energy metabolism in physically active mice (kept in LC) may be related to upregulation of hypothalamic MCT4, probably participating in the regulation of satiety.

Comprehensive analysis of locomotion dynamics in the protochordate Ciona intestinalis reveals how neuromodulators flexibly shape its behavioral repertoire

Vertebrate nervous systems can generate a remarkable diversity of behaviors. However, our understanding of how behaviors may have evolved in the chordate lineage is limited by the lack of neuroethological studies leveraging our closest invertebrate relatives. Here, we combine high-throughput video acquisition with pharmacological perturbations of bioamine signaling to systematically reveal the global structure of the motor behavioral repertoire in the Ciona intestinalis larvae. Most of Ciona’s postural variance can be captured by 6 basic shapes, which we term “eigencionas.” Motif analysis of postural time series revealed numerous stereotyped behavioral maneuvers including “startle-like” and “beat-and-glide.” Employing computational modeling of swimming dynamics and spatiotemporal embedding of postural features revealed that behavioral differences are generated at the levels of motor modules and the transitions between, which may in part be modulated by bioamines. Finally, we show that flexible motor module usage gives rise to diverse behaviors in response to different light stimuli.

Vertebrate nervous systems can generate a remarkable diversity of behaviors, but how did these evolve in the chordate lineage? A study of the protochordate Ciona intestinalis reveals novel insights into how a simple chordate brain uses neuromodulators to control its behavioral repertoire.

Constructing prediction models for excessive daytime sleepiness by nomogram and machine learning: A large Chinese multicenter cohort study

Objective

Although risk factors for excessive daytime sleepiness (EDS) have been reported, there are still few cohort-based predictive models for EDS in Parkinson’s disease (PD). This 1-year longitudinal study aimed to develop a predictive model of EDS in patients with PD using a nomogram and machine learning (ML).

Materials and methods

A total of 995 patients with PD without EDS were included, and clinical data during the baseline period were recorded, which included basic information as well as motor and non-motor symptoms. One year later, the presence of EDS in this population was re-evaluated. First, the baseline characteristics of patients with PD with or without EDS were analyzed. Furthermore, a Cox proportional risk regression model and XGBoost ML were used to construct a prediction model of EDS in PD.

Results

At the 1-year follow-up, EDS occurred in 260 of 995 patients with PD (26.13%). Baseline features analysis showed that EDS correlated significantly with age, age of onset (AOO), hypertension, freezing of gait (FOG). In the Cox proportional risk regression model, we included high body mass index (BMI), late AOO, low motor score on the 39-item Parkinson’s Disease Questionnaire (PDQ-39), low orientation score on the Mini-Mental State Examination (MMSE), and absence of FOG. Kaplan–Meier survival curves showed that the survival prognosis of patients with PD in the high-risk group was significantly worse than that in the low-risk group. XGBoost demonstrated that BMI, AOO, PDQ-39 motor score, MMSE orientation score, and FOG contributed to the model to different degrees, in decreasing order of importance, and the overall accuracy of the model was 71.86% after testing.

Conclusion

In this study, we showed that risk factors for EDS in patients with PD include high BMI, late AOO, a low motor score of PDQ-39, low orientation score of MMSE, and lack of FOG, and their importance decreased in turn. Our model can predict EDS in PD with relative effectivity and accuracy.

Sleep dysregulation in sympathetic-mediated diseases: implications for disease progression

The autonomic nervous system (ANS) plays an important role in the coordination of several physiological functions including sleep/wake process. Significant changes in ANS activity occur during wake-to-sleep transition maintaining the adequate cardiorespiratory regulation and brain activity. Since sleep is a complex homeostatic function, partly regulated by the ANS, it is not surprising that sleep disruption trigger and/or evidence symptoms of ANS impairment. Indeed, several studies suggest a bidirectional relationship between impaired ANS function (i.e. enhanced sympathetic drive), and the emergence/development of sleep disorders. Furthermore, several epidemiological studies described a strong association between sympathetic-mediated diseases and the development and maintenance of sleep disorders resulting in a vicious cycle with adverse outcomes and increased mortality risk. However, which and how the sleep/wake control and ANS circuitry becomes affected during the progression of ANS-related diseases remains poorly understood. Thus, understanding the physiological mechanisms underpinning sleep/wake-dependent sympathetic modulation could provide insights into diseases involving autonomic dysfunction. The purpose of this review is to explore potential neural mechanisms involved in both the onset/maintenance of sympathetic-mediated diseases (Rett syndrome, congenital central hypoventilation syndrome, obstructive sleep apnoea, type 2 diabetes, obesity, heart failure, hypertension, and neurodegenerative diseases) and their plausible contribution to the generation of sleep disorders in order to review evidence that may serve to establish a causal link between sleep disorders and heightened sympathetic activity.

Orexin neurons inhibit sleep to promote arousal

Humans and animals lacking orexin neurons exhibit daytime sleepiness, sleep attacks, and state instability. While the circuit basis by which orexin neurons contribute to consolidated wakefulness remains unclear, existing models posit that orexin neurons provide their wake-stabilizing influence by exerting excitatory tone on other brain arousal nodes. Here we show using in vivo optogenetics, in vitro optogenetic-based circuit mapping, and single-cell transcriptomics that orexin neurons also contribute to arousal maintenance through indirect inhibition of sleep-promoting neurons of the ventrolateral preoptic nucleus. Activation of this subcortical circuit rapidly drives wakefulness from sleep by differentially modulating the activity of ventrolateral preoptic neurons. We further identify and characterize a feedforward circuit through which orexin (and co-released glutamate) acts to indirectly target and inhibit sleep-promoting ventrolateral preoptic neurons to produce arousal. This revealed circuitry provides an alternate framework for understanding how orexin neurons contribute to the maintenance of consolidated wakefulness and stabilize behavioral state.