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Flores RC, Yaffe R, Nhunzwi MM, Nguyen H, Rabinovich-Nikitin I. Maternal shift work during pregnancy and cardiovascular health impacts on mother and offspring. J Mol Cell Cardiol 2025; 199:126-132. [PMID: 39753391 DOI: 10.1016/j.yjmcc.2024.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2024] [Revised: 11/15/2024] [Accepted: 12/13/2024] [Indexed: 02/03/2025]
Abstract
Cardiovascular disease (CVD) is the leading cause of death for women worldwide. One of the risk factors for CVD in women is complications during pregnancy. Pregnancy complications include a wide arena of pathologies, including hypertension, preeclampsia, gestational diabetes, preterm delivery and miscarriage. Interestingly, increased evidence in recent years highlights a novel link between maternal shift work during pregnancy and increased risk for pregnancy complications, specifically hypertension and diabetes, while knowledge on other CVDs, such heart failure, atherosclerosis, ischemic heart disease, and stroke in pregnant shift working mothers is still scarce. Notably, shift work during pregnancy results in significant changes to the circadian rhythm of both the mother and fetus, therefore, engaging into shift work during pregnancy may adversely affect the cardiovascular health of both the mother and offspring, and carry into adulthood. Herein, we highlight the novel relationship between maternal shift work during pregnancy and the increased risk for pregnancy complications that may increase risk for CVD later in life. Furthermore, we provide mechanistic insights of the hemodynamic processes that are disrupted in response to maternal shift work and may explain the increased risk for cardiovascular disease. Understanding how shift work during pregnancy influences the prevalence for heart disease is of paramount clinical importance for minimizing the risk for cardiovascular disease for both the mother and offspring.
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Affiliation(s)
- Ruzzell C Flores
- Department of Physiology and Pathophysiology, Rady College of Medicine, Max Rady Faculty of Health Sciences, University of Manitoba, The Institute of Cardiovascular Sciences, St. Boniface Hospital Albrechtsen Research Centre, Winnipeg, Manitoba, Canada
| | - Rachel Yaffe
- Department of Physiology and Pathophysiology, Rady College of Medicine, Max Rady Faculty of Health Sciences, University of Manitoba, The Institute of Cardiovascular Sciences, St. Boniface Hospital Albrechtsen Research Centre, Winnipeg, Manitoba, Canada
| | - Munashe M Nhunzwi
- Department of Physiology and Pathophysiology, Rady College of Medicine, Max Rady Faculty of Health Sciences, University of Manitoba, The Institute of Cardiovascular Sciences, St. Boniface Hospital Albrechtsen Research Centre, Winnipeg, Manitoba, Canada
| | - Huong Nguyen
- Department of Physiology and Pathophysiology, Rady College of Medicine, Max Rady Faculty of Health Sciences, University of Manitoba, The Institute of Cardiovascular Sciences, St. Boniface Hospital Albrechtsen Research Centre, Winnipeg, Manitoba, Canada
| | - Inna Rabinovich-Nikitin
- Department of Physiology and Pathophysiology, Rady College of Medicine, Max Rady Faculty of Health Sciences, University of Manitoba, The Institute of Cardiovascular Sciences, St. Boniface Hospital Albrechtsen Research Centre, Winnipeg, Manitoba, Canada.
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Tyagi SC. Epigenetics of Homocystinuria, Hydrogen Sulfide, and Circadian Clock Ablation in Cardiovascular-Renal Disease. Curr Issues Mol Biol 2024; 46:13783-13797. [PMID: 39727952 PMCID: PMC11726923 DOI: 10.3390/cimb46120824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2024] [Revised: 11/08/2024] [Accepted: 11/11/2024] [Indexed: 12/28/2024] Open
Abstract
Morning-time heart attacks are associated with an ablation in the sleep-time dip in blood pressure, the mechanism of which is unknown. The epigenetic changes are the hallmark of sleep and circadian clock disruption and homocystinuria (HHcy). The homocystinuria causes ablation in the dip in blood pressure during sleep. Interestingly, HHcy is generated during the epigenetic gene turning off and turning on (i.e., imprinting) by methylation of the DNA promoter. The mitochondrial sulfur metabolism by 3-mercaptopyruvate sulfur transferase (3MST), ATP citrate lyase (ACYL), and epigenetic rhythmic methylation are regulated by folate 1-carbon metabolism (FOCM), i.e., the methionine (M)-SAM-SAH-Hcy, adenosine, and uric acid cycle. Epigenetic gene writer (DNMT), gene eraser (TET/FTO), and editor de-aminase (ADAR) regulate the rhythmic, i.e., reversible methylation/demethylation of H3K4, H3K9, H4K20, m6A, and m5C. The mitochondrial ATP citrate cycle and creatine kinase (CK) regulate chromatin transcription, maturation, and accessibility as well as muscle function. The transcription is regulated by methylation. The maturation and accessibility are controlled by acetylation. However, it is unclear whether a high fat dysbiotic diet (HFD) causes dysrhythmic expression of the gene writer, eraser, and editor, creating hyperuricemia and cardiac and renal dysfunction. We hypothesized that an HFD increases the gene writer (DNMT1) and editor (ADAR), decreases the eraser (TET/FTO), and increases uric acid to cause chronic diseases. This increases the levels of H3K4, H3K9, H4K20, m6A, and m5C. Interestingly, the DNMT1KO mitigates. Further, the DNMT1KO and ADAR inhibition attenuate HFD-induced NGAL/FGF23/TMPRSS2/MMP2, 9, 13, and uric acid levels and improve cardiac and renal remodeling. Although the novel role of nerve endings by the Piezo channels (i.e., the combination of ENaC, VDAC, TRPV, K+, and Mg2+ channels) in the interoception is suggested, interestingly, we and others have shown mechanisms independent of the nerve, by interoception, such as the cargo of the exosome in denervation models of heart failure. If proper and appropriate levels of these enzymes are available to covert homocysteine to hydrogen sulfide (H2S) during homocystinuria, then the H2S can potentially serve as a newer form of treatment for morning heart attacks and renal sulfur transsulfuration transport diseases.
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Affiliation(s)
- Suresh C Tyagi
- Department of Physiology, University of Louisville School of Medicine, Louisville, KY 40202, USA
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Tyagi SC, Pushpakumar S, Sen U, Akinterinwa OE, Zheng Y, Mokshagundam SPL, Kalra DK, Singh M. Role of circadian clock system in the mitochondrial trans-sulfuration pathway and tissue remodeling. Can J Physiol Pharmacol 2024; 102:105-115. [PMID: 37979203 DOI: 10.1139/cjpp-2023-0186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2023]
Abstract
Previous studies from our laboratory revealed that the gaseous molecule hydrogen sulfide (H2S), a metabolic product of epigenetics, involves trans-sulfuration pathway for ensuring metabolism and clearance of homocysteine (Hcy) from body, thereby mitigating the skeletal muscle's pathological remodeling. Although the master circadian clock regulator that is known as brain and muscle aryl hydrocarbon receptor nuclear translocator like protein 1 (i.e., BMAL 1) is associated with S-adenosylhomocysteine hydrolase (SAHH) and Hcy metabolism but how trans-sulfuration pathway is influenced by the circadian clock remains unexplored. We hypothesize that alterations in the functioning of circadian clock during sleep and wake cycle affect skeletal muscle's biology. To test this hypothesis, we measured serum matrix metalloproteinase (MMP) activities using gelatin gels for analyzing the MMP-2 and MMP-9. Further, employing casein gels, we also studied MMP-13 that is known to be influenced by the growth arrest and DNA damage-45 (GADD45) protein during sleep and wake cycle. The wild type and cystathionine β synthase-deficient (CBS-/+) mice strains were treated with H2S and subjected to measurement of trans-sulfuration factors from skeletal muscle tissues. The results suggested highly robust activation of MMPs in the wake mice versus sleep mice, which appears somewhat akin to the "1-carbon metabolic dysregulation", which takes place during remodeling of extracellular matrix during muscular dystrophy. Interestingly, the levels of trans-sulfuration factors such as CBS, cystathionine γ lyase (CSE), methyl tetrahydrofolate reductase (MTHFR), phosphatidylethanolamine N-methyltransferase (PEMT), and Hcy-protein bound paraoxonase 1 (PON1) were attenuated in CBS-/+ mice. However, treatment with H2S mitigated the attenuation of the trans-sulfuration pathway. In addition, levels of mitochondrial peroxisome proliferator-activated receptor-gamma coactivator 1-α (PGC 1-α) and mitofusin-2 (MFN-2) were significantly improved by H2S intervention. Our findings suggest participation of the circadian clock in trans-sulfuration pathway that affects skeletal muscle remodeling and mitochondrial regeneration.
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Affiliation(s)
- Suresh C Tyagi
- Department of Physiology, School of Medicine, University of Louisville, Louisville, KY 40202, USA
| | - Sathnur Pushpakumar
- Department of Physiology, School of Medicine, University of Louisville, Louisville, KY 40202, USA
| | - Utpal Sen
- Department of Physiology, School of Medicine, University of Louisville, Louisville, KY 40202, USA
| | - Oluwaseun E Akinterinwa
- Department of Physiology, School of Medicine, University of Louisville, Louisville, KY 40202, USA
| | - Yuting Zheng
- Department of Physiology, School of Medicine, University of Louisville, Louisville, KY 40202, USA
| | - Sri Prakash L Mokshagundam
- Division of Endocrinology, Metabolism and Diabetes and Robley Rex VA Medical Center, University of Louisville School of Medicine, Louisville, KY 40202, USA
| | - Dinesh K Kalra
- Division of Cardiovascular Medicine, University of Louisville School of Medicine, Louisville, KY 40202, USA
| | - Mahavir Singh
- Department of Physiology, School of Medicine, University of Louisville, Louisville, KY 40202, USA
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Liu JA, Walton JC, DeVries AC, Nelson RJ. Disruptions of Circadian Rhythms and Thrombolytic Therapy During Ischemic Stroke Intervention. Front Neurosci 2021; 15:675732. [PMID: 34177452 PMCID: PMC8222607 DOI: 10.3389/fnins.2021.675732] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 05/11/2021] [Indexed: 11/24/2022] Open
Abstract
Several endogenous and exogenous factors interact to influence stroke occurrence, in turn contributing to discernable daily distribution patterns in the frequency and severity of cerebrovascular events. Specifically, strokes that occur during the morning tend to be more severe and are associated with elevated diastolic blood pressure, increased hospital stay, and worse outcomes, including mortality, compared to strokes that occur later in the day. Furthermore, disrupted circadian rhythms are linked to higher risk for stroke and play a role in stroke outcome. In this review, we discuss the interrelation among core clock genes and several factors contributing to ischemic outcomes, sources of disrupted circadian rhythms, the implications of disrupted circadian rhythms in foundational stroke scientific literature, followed by a review of clinical implications. In addition to highlighting the distinct daily pattern of onset, several aspects of physiology including immune response, endothelial/vascular and blood brain barrier function, and fibrinolysis are under circadian clock regulation; disrupted core clock gene expression patterns can adversely affect these physiological processes, leading to a prothrombotic state. Lastly, we discuss how the timing of ischemic onset increases morning resistance to thrombolytic therapy and the risk of hemorrhagic transformation.
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Affiliation(s)
- Jennifer A Liu
- Department of Neuroscience, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States
| | - James C Walton
- Department of Neuroscience, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States
| | - A Courtney DeVries
- Department of Neuroscience, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States.,Department of Medicine, Division of Oncology/Hematology, West Virginia University, Morgantown, WV, United States.,West Virginia University Cancer Institute, West Virginia University, Morgantown, WV, United States
| | - Randy J Nelson
- Department of Neuroscience, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States
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Receno CN, Eassa BE, Cunningham CM, DeRuisseau LR. Young and middle-aged mouse breathing behavior during the light and dark cycles. Physiol Rep 2020; 7:e14060. [PMID: 31004390 PMCID: PMC6474843 DOI: 10.14814/phy2.14060] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 03/13/2019] [Indexed: 12/21/2022] Open
Abstract
Unrestrained barometric plethysmography is a common method used for characterizing breathing patterns in small animals. One source of variation between unrestrained barometric plethysmography studies is the segment of baseline. Baseline may be analyzed as a predetermined time‐point, or using tailored segments when each animal is visually calm. We compared a quiet, minimally active (no sniffing/grooming) breathing segment to a predetermined time‐point at 1 h for baseline measurements in young and middle‐aged mice during the dark and light cycles. Additionally, we evaluated the magnitude of change for gas challenges based on these two baseline segments. C57BL/6JEiJ x C3Sn.BliA‐Pde6b+/DnJ male mice underwent unrestrained barometric plethysmography with the following baselines used to determine breathing frequency, tidal volume (VT) and minute ventilation (VE): (1) 30‐sec of quiet breathing and (2) a 10‐min period from 50 to 60 min. Animals were also exposed to 10 min of hypoxic (10% O2, balanced N2), hypercapnic (5% CO2, balanced air) and hypoxic hypercapnic (10% O2, 5% CO2, balanced N2) gas. Both frequency and VE were higher during the predetermined 10‐min baseline versus the 30‐sec baseline, while VT was lower (P < 0.05). However, VE/VO2 was similar between the baseline time segments (P > 0.05) in an analysis of one cohort. During baseline, dark cycle testing had increased VT values versus those in the light (P < 0.05). For gas challenges, both frequency and VE showed higher percent change from the 30‐sec baseline compared to the predetermined 10‐min baseline (P < 0.05), while VT showed a greater change from the 10‐min baseline (P < 0.05). Dark cycle hypoxic exposure resulted in larger percent change in breathing frequency versus the light cycle (P < 0.05). Overall, light and dark cycle pattern of breathing differences emerged along with differences between the 30‐sec behavior observational method versus a predetermined time segment for baseline.
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Affiliation(s)
- Candace N Receno
- Department of Biological Sciences, Le Moyne College, Syracuse, New York
| | - Brianna E Eassa
- Department of Biological Sciences, Le Moyne College, Syracuse, New York
| | - Caitlin M Cunningham
- Department of Mathematics, Statistics and Computer Science, Le Moyne College, Syracuse, New York
| | - Lara R DeRuisseau
- Department of Biological Sciences, Le Moyne College, Syracuse, New York
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Chen L, Zhang B, Yang L, Bai YG, Song JB, Ge YL, Ma HZ, Cheng JH, Ma J, Xie MJ. BMAL1 Disrupted Intrinsic Diurnal Oscillation in Rat Cerebrovascular Contractility of Simulated Microgravity Rats by Altering Circadian Regulation of miR-103/Ca V1.2 Signal Pathway. Int J Mol Sci 2019; 20:ijms20163947. [PMID: 31416128 PMCID: PMC6720455 DOI: 10.3390/ijms20163947] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 07/17/2019] [Accepted: 08/06/2019] [Indexed: 12/11/2022] Open
Abstract
The functional and structural adaptations in cerebral arteries could be one of the fundamental causes in the occurrence of orthostatic intolerance after space flight. In addition, emerging studies have found that many cardiovascular functions exhibit circadian rhythm. Several lines of evidence suggest that space flight might increase an astronaut’s cardiovascular risks by disrupting circadian rhythm. However, it remains unknown whether microgravity disrupts the diurnal variation in vascular contractility and whether microgravity impacts on circadian clock system. Sprague-Dawley rats were subjected to 28-day hindlimb-unweighting to simulate the effects of microgravity on vasculature. Cerebrovascular contractility was estimated by investigating vasoconstrictor responsiveness and myogenic tone. The circadian regulation of CaV1.2 channel was determined by recording whole-cell currents, evaluating protein and mRNA expressions. Then the candidate miRNA in relation with Ca2+ signal was screened. Lastly, the underlying pathway involved in circadian regulation of cerebrovascular contractility was determined. The major findings of this study are: (1) The clock gene BMAL1 could induce the expression of miR-103, and in turn modulate the circadian regulation of CaV1.2 channel in rat cerebral arteries at post-transcriptional level; and (2) simulated microgravity disrupted intrinsic diurnal oscillation in rat cerebrovascular contractility by altering circadian regulation of BMAL1/miR-103/CaV1.2 signal pathway.
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Affiliation(s)
- Li Chen
- Department of Aerospace Physiology, Key Laboratory of Aerospace Medicine of Ministry of Education, Fourth Military Medical University, Xi'an 710032, China
| | - Bin Zhang
- Department of Aerospace Physiology, Key Laboratory of Aerospace Medicine of Ministry of Education, Fourth Military Medical University, Xi'an 710032, China
| | - Lu Yang
- Department of Physiology, Fourth Military Medical University, Xi'an 710032, China
| | - Yun-Gang Bai
- Department of Aerospace Physiology, Key Laboratory of Aerospace Medicine of Ministry of Education, Fourth Military Medical University, Xi'an 710032, China
| | - Ji-Bo Song
- Department of Aerospace Physiology, Key Laboratory of Aerospace Medicine of Ministry of Education, Fourth Military Medical University, Xi'an 710032, China
| | - Yi-Ling Ge
- First Cadet Brigade, Fourth Military Medical University, Xi'an 710032, China
| | - Hong-Zhe Ma
- Department of Aerospace Physiology, Key Laboratory of Aerospace Medicine of Ministry of Education, Fourth Military Medical University, Xi'an 710032, China
| | - Jiu-Hua Cheng
- Department of Aerospace Physiology, Key Laboratory of Aerospace Medicine of Ministry of Education, Fourth Military Medical University, Xi'an 710032, China
| | - Jin Ma
- Department of Aerospace Physiology, Key Laboratory of Aerospace Medicine of Ministry of Education, Fourth Military Medical University, Xi'an 710032, China
| | - Man-Jiang Xie
- Department of Aerospace Physiology, Key Laboratory of Aerospace Medicine of Ministry of Education, Fourth Military Medical University, Xi'an 710032, China.
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Koritala BSC, Çakmaklı S. The human circadian clock from health to economics. Psych J 2018; 7:176-196. [DOI: 10.1002/pchj.252] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 09/13/2018] [Accepted: 09/19/2018] [Indexed: 12/18/2022]
Affiliation(s)
- Bala S. C. Koritala
- Department of Biology; Rutgers, The State University of New Jersey; Camden New Jersey USA
- Center for Computational and Integrative Biology; Rutgers, The State University of New Jersey; Camden New Jersey USA
| | - Selim Çakmaklı
- Department of Economics; Rutgers, The State University of New Jersey; Camden New Jersey USA
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Rodrigo GC, Herbert KE. Regulation of vascular function and blood pressure by circadian variation in redox signalling. Free Radic Biol Med 2018; 119:115-120. [PMID: 29106991 DOI: 10.1016/j.freeradbiomed.2017.10.381] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 10/24/2017] [Accepted: 10/25/2017] [Indexed: 12/21/2022]
Abstract
There is accumulating evidence that makes the link between the circadian variation in blood pressure and circadian variations in vascular contraction. The importance of vascular endothelium-derived redox-active and redox-derived species in the signalling pathways involved in controlling vascular smooth muscle contraction are well known, and when linked to the circadian variations in the processes involved in generating these species, suggests a cellular mechanism for the circadian variations in blood pressure that links directly to the peripheral circadian clock. Relaxation of vascular smooth muscle cells involves endothelial-derived relaxing factor (EDRF) which is nitric oxide (NO) produced by endothelial NO synthase (eNOS), and endothelial-derived hyperpolarising factor (EDHF) which includes hydrogen peroxide (H2O2) produced by NADPH oxidase (Nox). Both of these enzymes appear to be under the direct control of the circadian clock mechanism in the endothelial cells, and disruption to the clock results in endothelial and vascular dysfunction. In this review, we focus on EDRF and EDHF and summarise the recent findings on the influence of the peripheral circadian clock mechanism on processes involved in generating the redox species involved and how this influences vascular contractility, which may account for some of the circadian variations in blood pressure and peripheral resistance. Moreover, the direct link between the peripheral circadian clock and redox-signalling pathways in the vasculature, has a bearing on vascular endothelial dysfunction in disease and aging, which are both known to lead to dysfunction of the circadian clock.
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Affiliation(s)
- Glenn C Rodrigo
- Department of Cardiovascular Sciences, University of Leicester, Glenfield General Hospital, Leicester, United Kingdom.
| | - Karl E Herbert
- Department of Cardiovascular Sciences, University of Leicester, Glenfield General Hospital, Leicester, United Kingdom
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James SM, Honn KA, Gaddameedhi S, Van Dongen HPA. Shift Work: Disrupted Circadian Rhythms and Sleep-Implications for Health and Well-Being. CURRENT SLEEP MEDICINE REPORTS 2017; 3:104-112. [PMID: 29057204 DOI: 10.1007/s40675-017-0071-6] [Citation(s) in RCA: 259] [Impact Index Per Article: 32.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW Our 24/7 society is dependent on shift work, despite mounting evidence for negative health outcomes from sleep displacement due to shift work. This paper reviews short- and long-term health consequences of sleep displacement and circadian misalignment due to shift work. RECENT FINDINGS We focus on four broad health domains: metabolic health; risk of cancer; cardiovascular health; and mental health. Circadian misalignment affects these domains by inducing sleep deficiency, sympathovagal and hormonal imbalance, inflammation, impaired glucose metabolism, and dysregulated cell cycles. This leads to a range of medical conditions, including obesity, metabolic syndrome, type II diabetes, gastrointestinal dysfunction, compromised immune function, cardiovascular disease, excessive sleepiness, mood and social disorders, and increased cancer risk. SUMMARY Interactions of biological disturbances with behavioral and societal factors shape the effects of shift work on health and well-being. Research is needed to better understand the underlying mechanisms and drive the development of countermeasures.
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Affiliation(s)
- Stephen M James
- Sleep and Performance Research Center, Washington State University, Spokane, WA, USA.,Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA
| | - Kimberly A Honn
- Sleep and Performance Research Center, Washington State University, Spokane, WA, USA.,Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA
| | - Shobhan Gaddameedhi
- Sleep and Performance Research Center, Washington State University, Spokane, WA, USA.,College of Pharmacy, Washington State University, Spokane, WA, USA
| | - Hans P A Van Dongen
- Sleep and Performance Research Center, Washington State University, Spokane, WA, USA.,Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA
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