Publications

2012
Solarz DE, Mullington JM, Meier-Ewert HK. Sleep, inflammation and cardiovascular disease. Front Biosci (Elite Ed). 2012;4 :2490-501.Abstract
In data from prospective cohort studies, self report of insufficient or disturbed sleep is related to increased overall and cardiovascular morbidity. Inflammation is established as a key mechanism in the development of arteriosclerotic heart and vascular disease. Inflammation has been considered a possible link between short sleep and cardiovascular disease and morbidity. Measures of inflammation are increased by experimental sleep deprivation, but in cohort studies a relationship of sleep duration to inflammatory markers is less clear. In these studies the association of self reported short sleep to cardiac morbidity is confounded by many psychological and socioeconomic variables. More studies are needed to explain the link between short sleep duration and cardiac morbidity. Experimental studies of sleep deprivation mimicking habitual shortened sleep over long time intervals, and studies employing sleep extension in habitual short sleepers will allow better characterization of the health benefits of adequate sleep duration. Prospective cohort studies should include objective measures of sleep duration and should to control for the known confounding variables.
2011
Chokroverty S, Radtke RA, Mullington JM. Polysomnography: technical and clinical aspects. In: Schomer DL, Lopes Da Silva FH Niedermeyer's Electroencephalography: Basic Principles, Clinical Applications, and Related Fields. 6th ed. Philadelphia, PA, USA: Lippincott Williams & Wilkins ; 2011. pp. 817–846.
Mullington JM, Czeisler CA, Goel N, Krueger JM, Balkin TJ, Johns M, Shaw PJ. Panel discussion: current status of measuring sleepiness. J Clin Sleep Med. 2011;7 (5 Suppl) :S22-5.
2010
Mullington JM, Simpson NS, Meier-Ewert HK, Haack M. Sleep loss and inflammation. Best Pract Res Clin Endocrinol Metab. 2010;24 (5) :775-84.Abstract
Controlled, experimental studies on the effects of acute sleep loss in humans have shown that mediators of inflammation are altered by sleep loss. Elevations in these mediators have been found to occur in healthy, rigorously screened individuals undergoing experimental vigils of more than 24h, and have also been seen in response to various durations of sleep restricted to between 25 and 50% of a normal 8h sleep amount. While these altered profiles represent small changes, such sub-clinical shifts in basal inflammatory cytokines are known to be associated with the future development of metabolic syndrome disease in healthy, asymptomatic individuals. Although the mechanism of this altered inflammatory status in humans undergoing experimental sleep loss is unknown, it is likely that autonomic activation and metabolic changes play key roles.
2009
Mullington JM. Immune Function During Sleep and Sleep Deprivation. In: Squire, LR Encyclopedia of Neuroscience. London, UK, Burlington, MA, USA, San Diego, CA, USA: Elsevier ; 2009. pp. 103–107.
Mullington JM. Endocrine Function During Sleep and Sleep Deprivation. In: Squire LR Encyclopedia of Neuroscience. London, UK, Burlington, MA, USA, San Diego, CA, USA: Elsevier ; 2009. pp. 977–980.
Mullington JM. Let her sleep..but how much?. Sleep. 2009;32 (7) :841-2.
Haack M, Lee E, Cohen DA, Mullington JM. Activation of the prostaglandin system in response to sleep loss in healthy humans: potential mediator of increased spontaneous pain. Pain. 2009;145 (1-2) :136-41.Abstract
Insufficient duration of sleep is a highly prevalent behavioral pattern in society that has been shown to cause an increase in spontaneous pain and sensitivity to noxious stimuli. Prostaglandins (PGs), in particular PGE2, are key mediators of inflammation and pain, and we investigated whether PGE2 is a potential mediator in sleep-loss-induced changes in nociceptive processing. Twenty-four participants (7 females, age 35.1+/-7.1 years) stayed for 7 days in the Clinical Research Center. After two baseline days, participants were randomly assigned to either 3 days of 88 h of sleep deprivation (TSD, N=15) or 8h of sleep per night (N=9), followed by a night of recovery sleep. Participants rated the intensity of various pain-related symptoms every 2h across waking periods on computerized visual analog scales. PGE2 was measured in 24-h-urine collections during baseline and third sleep deprivation day. Spontaneous pain, including headache, muscle pain, stomach pain, generalized body pain, and physical discomfort significantly increased by 5-14 units on a 100-unit scale during TSD, compared to the sleep condition. Urinary PGE2 metabolite significantly increased by about 30% in TSD over sleep condition. TSD-induced increase in spontaneous pain, in particular headache and muscle pain, was significantly correlated with increase in PGE2 metabolite. Activation of the PGE2 system appears to be a potential mediator of increased spontaneous pain in response to insufficient sleep.
Mullington JM, Haack M, Toth M, Serrador JM, Meier-Ewert HK. Cardiovascular, inflammatory, and metabolic consequences of sleep deprivation. Prog Cardiovasc Dis. 2009;51 (4) :294-302.Abstract
That insufficient sleep is associated with poor attention and performance deficits is becoming widely recognized. Fewer people are aware that chronic sleep complaints in epidemiologic studies have also been associated with an increase in overall mortality and morbidity. This article summarizes findings of known effects of insufficient sleep on cardiovascular risk factors including blood pressure, glucose metabolism, hormonal regulation, and inflammation with particular emphasis on experimental sleep loss, using models of total and partial sleep deprivation, in healthy individuals who normally sleep in the range of 7 to 8 hours and have no sleep disorders. These studies show that insufficient sleep alters established cardiovascular risk factors in a direction that is known to increase the risk of cardiac morbidity.
2007
Schuld A, Haack M, Mullington J, Pollmächer T. Changes in Sleep and Behavior Following Experimental Immune Stimulation Using Bacterial Endotoxin in Humans. In: Pandi-Perumal SR, Cardinali DP, Chrousos GP Neuroimmunology of Sleep. New York, NY, USA: Springer ; 2007. pp. 227–231.
Haack M, Sanchez E, Mullington JM. Elevated inflammatory markers in response to prolonged sleep restriction are associated with increased pain experience in healthy volunteers. Sleep. 2007;30 (9) :1145-52.Abstract
CONTEXT: Sleep disturbances, pain, and inflammation co-occur in various medical conditions, but their interrelationships are poorly understood. OBJECTIVE: We investigated the effects of reduced sleep duration (by approximately 50%) to 4 h/night across 10 days, on peripherally circulating inflammatory mediators. In addition, we tested the prediction that degree of inflammation is quantitatively related to the extent to which pain is increased in response to prolonged sleep restriction. DESIGN: Randomized, 16 day controlled in-laboratory study conducted in GCRC. METHODS: Eighteen volunteers were randomly assigned to either 12 days of sleeping 8 h/night or 4 h/night. Participants rated mood and pain symptoms throughout experimental days. Urine was collected and blood was drawn frequently on the baseline day and after the 10th experimental day for 25 hours. OUTCOME MEASURES: Levels of plasma interleukin (IL)-6, serum C-reactive protein (CRP), plasma soluble tumor necrosis factor receptor p55 (sTNF-R p55), urinary levels of prostaglandin (PG) metabolites D2 and E2, subjective assessment of pain and tiredness-fatigue. RESULTS: IL-6 levels were elevated in the 4-h sleep condition over the 8-h sleep condition (P <0.05). CRP levels showed the same trend as IL-6, but did not differ significantly between groups (P = 0.11). Levels of sTNF-R p55 were unchanged in both groups. PG E2 and 11beta-F2alpha metabolite increased in 4-h sleepers, but did not differ significantly from the 8-h sleepers. Elevated IL-6 levels were strongly associated with increased pain ratings in response to sleep restriction (r = 0.67, P <0.01), and this association could not be explained by elevations in tiredness-fatigue. CONCLUSION: Insufficient sleep quantity may facilitate and/or exacerbate pain through elevations of IL-6. In disorders where sleep disturbances are common, insufficient sleep quantity itself may establish and maintain its co-occurrence with pain and increased inflammation.
2006
Casement MD, Broussard JL, Mullington JM, Press DZ. The contribution of sleep to improvements in working memory scanning speed: a study of prolonged sleep restriction. Biol Psychol. 2006;72 (2) :208-12.Abstract
Working memory scanning and motor response speeds were assessed in chronically sleep restricted participants using the Sternberg item recognition paradigm (SIRP). Twenty-two healthy volunteers (ages 21-30) living in a controlled hospital environment were allowed either 4h of sleep opportunity (50% of habitual sleep) or 8h of sleep opportunity (100% of habitual sleep) for 12 days. Working memory scanning efficiency (time taken to access an item in working memory) was tested for the first 9 days of sleep restriction and improved over time in participants permitted an 8h sleep period, but did not change significantly in participants permitted a 4h sleep period. Speed of motor response (reaction time independent of cognitive processing) did not change significantly in either group. These results indicate that the efficiency of working memory scanning can improve with repeated practice given sufficient sleep, and that prolonged sleep restriction to 50% of habitual sleep prevents this improvement.
Yano K, Liaw PC, Mullington JM, Shih S-C, Okada H, Bodyak N, Kang PM, Toltl L, Belikoff B, Buras J, et al. Vascular endothelial growth factor is an important determinant of sepsis morbidity and mortality. J Exp Med. 2006;203 (6) :1447-58.Abstract
Sepsis, the systemic inflammatory response to infection, is a leading cause of morbidity and mortality. The mechanisms of sepsis pathophysiology remain obscure but are likely to involve a complex interplay between mediators of the inflammatory and coagulation pathways. An improved understanding of these mechanisms should provide an important foundation for developing novel therapies. In this study, we show that sepsis is associated with a time-dependent increase in circulating levels of vascular endothelial growth factor (VEGF) and placental growth factor (PlGF) in animal and human models of sepsis. Adenovirus-mediated overexpression of soluble Flt-1 (sFlt-1) in a mouse model of endotoxemia attenuated the rise in VEGF and PlGF levels and blocked the effect of endotoxemia on cardiac function, vascular permeability, and mortality. Similarly, in a cecal ligation puncture (CLP) model, adenovirus-sFlt-1 protected against cardiac dysfunction and mortality. When administered in a therapeutic regimen beginning 1 h after the onset of endotoxemia or CLP, sFlt peptide resulted in marked improvement in cardiac physiology and survival. Systemic administration of antibodies against the transmembrane receptor Flk-1 but not Flt-1 protected against sepsis mortality. Adenovirus-mediated overexpression of VEGF but not PlGF exacerbated the lipopolysaccharide-mediated toxic effects. Together, these data support a pathophysiological role for VEGF in mediating the sepsis phenotype.
2005
Schuld A, Haack M, Hinze-Selch D, Mullington J, Pollmächer T. [Experimental studies on the interaction between sleep and the immune system in humans]. Psychother Psychosom Med Psychol. 2005;55 (1) :29-35.Abstract
Sleepiness and increased sleep pressure are typical symptoms of inflammation and infection. Moreover, it is a pre-scientific belief that sleep supports host defense. The present paper summarizes the experimental evidence regarding the interaction between sleep and the immune system in humans. Sleep-wake behavior is very sensitive to experimental host defense activation, for example, by bacterial endotoxin. When the injection of endotoxin is accompanied by fever and a prominent neuroendocrine activation, sleep continuity will be disturbed. When the production of inflammatory cytokines is stimulated by smaller amounts of endotoxin, but no fever and no neuroendocrine activation are apparent, the nonREM-sleep amount will increase. This is possibly due to changes in the biological activity of the tumor necrosis factor-alpha (TNF-alpha) system. Besides their important function in sleep regulation during acute immune response, cytokines also seem to be involved in physiological sleep regulation, although there still is not very much data on this issue. So far, it remains largely unknown whether or not sleep supports host defense. In humans, for example, acute sleep deprivation up to 55 hours has only minor effects on endotoxin-induced host responses. In contrast, there is preliminary and yet inconsistent evidence that sleep deprivation might impair antibody formation in response to viral challenges.
Haack M, Mullington JM. Sustained sleep restriction reduces emotional and physical well-being. Pain. 2005;119 (1-3) :56-64.Abstract
BACKGROUND: Chronic insufficient sleep is a common finding in many pain-related and other medical diseases and is frequently experienced in the general population. Prolonged curtailment of nocturnal sleep has been studied for its adverse effect on cognitive functioning and subjective tiredness, but relatively little is known about its effect on mood and physical symptoms. OBJECTIVE: In order to test whether sleep restriction to 50% of the habitual time over 12 days affects diurnal and day-to-day variation of subjective ratings of mood and physical symptoms, 108 adjectives and statements were self-rated using visual analog scales every 2h during the waking period. DESIGN: Randomized, 16-day controlled in-laboratory study. SETTING: General Clinical Research Center (GCRC). PARTICIPANTS: Forty healthy subjects aged 21-40 years (14 females, 26 males). INTERVENTION: Subjects were randomized to either 4h of sleep per night (11 pm-3 am, N=22) or 8h of sleep per night (11 pm-7 am, N=18) for 12 consecutive days. MAIN OUTCOME MEASURE: Changes in the factor-derived variables optimism-sociability, tiredness-fatigue, anger-aggression, bodily discomfort, and items constituting bodily discomfort were compared between groups. RESULTS: Optimism-sociability progressively declined over consecutive days of sleep restriction by 15%. Bodily discomfort showed a slight, but significant interindividual increase of 3% across days of sleep restriction due to significant increases of generalized body pain, back pain, and stomach pain. Optimism-sociability and tiredness-fatigue showed diurnal variations with a quadratic function period within each day in both conditions. CONCLUSION: The data suggest that chronic insufficient sleep may contribute to the onset and amplification of pain and affect health by compromising optimistic outlook and psychosocial functioning.
2004
Meier-Ewert HK, Ridker PM, Rifai N, Regan MM, Price NJ, Dinges DF, Mullington JM. Effect of sleep loss on C-reactive protein, an inflammatory marker of cardiovascular risk. J Am Coll Cardiol. 2004;43 (4) :678-83.Abstract
OBJECTIVES: We sought to investigate the effects of sleep loss on high-sensitivity C-reactive protein (CRP) levels. BACKGROUND: Concentrations of high-sensitivity CRP are predictive of future cardiovascular morbidity. In epidemiologic studies, short sleep duration and sleep complaints have also been associated with increased cardiovascular morbidity. Two studies were undertaken to examine the effect of acute total and short-term partial sleep deprivation on concentrations of high-sensitivity CRP in healthy human subjects. METHODS: In Experiment 1, 10 healthy adult subjects stayed awake for 88 continuous hours. Samples of high-sensitivity CRP were collected every 90 min for 5 consecutive days, encompassing the vigil. In Experiment 2, 10 subjects were randomly assigned to either 8.2 h (control) or 4.2 h (partial sleep deprivation) of nighttime sleep for 10 consecutive days. Hourly samples of high-sensitivity CRP were taken during a baseline night and on day 10 of the study protocol. RESULTS: The CRP concentrations increased during both total and partial sleep deprivation conditions, but remained stable in the control condition. Systolic blood pressure increased across deprivation in Experiment 1, and heart rate increased in Experiment 2. CONCLUSIONS: Both acute total and short-term partial sleep deprivation resulted in elevated high-sensitivity CRP concentrations, a stable marker of inflammation that has been shown to be predictive of cardiovascular morbidity. We propose that sleep loss may be one of the ways that inflammatory processes are activated and contribute to the association of sleep complaints, short sleep duration, and cardiovascular morbidity observed in epidemiologic surveys.
Haack M, Pollmächer T, Mullington JM. Diurnal and sleep-wake dependent variations of soluble TNF- and IL-2 receptors in healthy volunteers. Brain Behav Immun. 2004;18 (4) :361-7.Abstract
There is very little published information on the diurnal variation of cytokines and their receptors, in healthy individuals during normal sleep-wake patterns or during sustained wakefulness. The aim of the current investigation was to characterize concentrations of soluble tumor necrosis factor receptors (sTNF-Rs) and interleukin-2 receptor (sIL-2R) during normal sleep and wakefulness, as well as during a 24 h vigil. Plasma levels of the sTNF-R p55, sTNF-R p75, and sIL-2R did not differ significantly between nocturnal sleep and nocturnal wakefulness. Rhythmic analysis (2-h intervals) revealed significant diurnal variations for both sTNF-R p55 and sTNF-R p75, but not levels of sIL-2R. Diurnal variations of both sTNF-Rs were characterized by a single cosine curve with an average peak near 06:00 h in the morning. This peak occurred well before that of cortisol, and fluctuated inversely with the diurnal rhythm of temperature. These diurnal variations in sTNF-Rs levels are consistent with the hypothesis that the TNF system plays a role in normal diurnal temperature regulation.
2003
Van Dongen HPA, Maislin G, Mullington JM, Dinges DF. The cumulative cost of additional wakefulness: dose-response effects on neurobehavioral functions and sleep physiology from chronic sleep restriction and total sleep deprivation. Sleep. 2003;26 (2) :117-26.Abstract
OBJECTIVES: To inform the debate over whether human sleep can be chronically reduced without consequences, we conducted a dose-response chronic sleep restriction experiment in which waking neurobehavioral and sleep physiological functions were monitored and compared to those for total sleep deprivation. DESIGN: The chronic sleep restriction experiment involved randomization to one of three sleep doses (4 h, 6 h, or 8 h time in bed per night), which were maintained for 14 consecutive days. The total sleep deprivation experiment involved 3 nights without sleep (0 h time in bed). Each study also involved 3 baseline (pre-deprivation) days and 3 recovery days. SETTING: Both experiments were conducted under standardized laboratory conditions with continuous behavioral, physiological and medical monitoring. PARTICIPANTS: A total of n = 48 healthy adults (ages 21-38) participated in the experiments. INTERVENTIONS: Noctumal sleep periods were restricted to 8 h, 6 h or 4 h per day for 14 days, or to 0 h for 3 days. All other sleep was prohibited. RESULTS: Chronic restriction of sleep periods to 4 h or 6 h per night over 14 consecutive days resulted in significant cumulative, dose-dependent deficits in cognitive performance on all tasks. Subjective sleepiness ratings showed an acute response to sleep restriction but only small further increases on subsequent days, and did not significantly differentiate the 6 h and 4 h conditions. Polysomnographic variables and delta power in the non-REM sleep EEG-a putative marker of sleep homeostasis--displayed an acute response to sleep restriction with negligible further changes across the 14 restricted nights. Comparison of chronic sleep restriction to total sleep deprivation showed that the latter resulted in disproportionately large waking neurobehavioral and sleep delta power responses relative to how much sleep was lost. A statistical model revealed that, regardless of the mode of sleep deprivation, lapses in behavioral alertness were near-linearly related to the cumulative duration of wakefulness in excess of 15.84 h (s.e. 0.73 h). CONCLUSIONS: Since chronic restriction of sleep to 6 h or less per night produced cognitive performance deficits equivalent to up to 2 nights of total sleep deprivation, it appears that even relatively moderate sleep restriction can seriously impair waking neurobehavioral functions in healthy adults. Sleepiness ratings suggest that subjects were largely unaware of these increasing cognitive deficits, which may explain why the impact of chronic sleep restriction on waking cognitive functions is often assumed to be benign. Physiological sleep responses to chronic restriction did not mirror waking neurobehavioral responses, but cumulative wakefulness in excess of a 15.84 h predicted performance lapses across all four experimental conditions. This suggests that sleep debt is perhaps best understood as resulting in additional wakefulness that has a neurobiological "cost" which accumulates over time.
Mullington JM, Chan JL, Van Dongen HPA, Szuba MP, Samaras J, Price NJ, Meier-Ewert HK, Dinges DF, Mantzoros CS. Sleep loss reduces diurnal rhythm amplitude of leptin in healthy men. J Neuroendocrinol. 2003;15 (9) :851-4.Abstract
The aim of the current study was to investigate the effects of sleep loss on the diurnal rhythm of circulating leptin levels. An indwelling forearm catheter was used to sample blood at 90-min intervals for a total of 120 h, which included 88 h of sustained sleeplessness, in 10 healthy men. The diurnal amplitude of leptin was reduced during total sleep deprivation and returned toward normal during the period of recovery sleep. This finding provides evidence that sleep influences the nocturnal leptin profile, and may have implications for the understanding of the role of sleep in metabolic regulation and the aetiologies of obesity and the night eating syndrome.
2001
Meier-Ewert HK, Ridker PM, Rifai N, Price N, Dinges DF, Mullington JM. Absence of diurnal variation of C-reactive protein concentrations in healthy human subjects. Clin Chem. 2001;47 (3) :426-30.Abstract
BACKGROUND: The concentration of C-reactive protein (CRP) in otherwise healthy subjects has been shown to predict future risk of myocardial infarction and stroke. CRP is synthesized by the liver in response to interleukin-6, the serum concentration of which is subject to diurnal variation. METHODS: To examine the existence of a time-of-day effect for baseline CRP values, we determined CRP concentrations in hourly blood samples drawn from healthy subjects (10 males, 3 females; age range, 21-35 years) during a baseline day in a controlled environment (8 h of nighttime sleep). RESULTS: Overall CRP concentrations were low, with only three subjects having CRP concentrations >2 mg/L. Comparison of raw data showed stability of CRP concentrations throughout the 24 h studied. When compared with cutoff values of CRP quintile derived from population-based studies, misclassification of greater than one quintile did not occur as a result of diurnal variation in any of the subjects studied. Nonparametric ANOVA comparing different time points showed no significant differences for both raw and z-transformed data. Analysis for rhythmic diurnal variation using a method fitting a cosine curve to the group data was negative. CONCLUSIONS: Our data show that baseline CRP concentrations are not subject to time-of-day variation and thus help to explain why CRP concentrations are a better predictor of vascular risk than interleukin-6. Determination of CRP for cardiovascular risk prediction may be performed without concern for diurnal variation.

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