Caffeine does not entrain the circadian clock but improves daytime alertness in blind patients with non-24-hour rhythms.

OBJECTIVE/BACKGROUND: Totally blind individuals are highly likely to suffer from Non-24-Hour Sleep-Wake Disorder due to a failure of light to reset the circadian pacemaker in the suprachiasmatic nuclei. In this outpatient case series, we investigated whether daily caffeine administration could entrain the circadian pacemaker in non-entrained blind patients to alleviate symptoms of non-24-hour sleep-wake disorder. PATIENTS/METHODS: Three totally blind males (63.0 ± 7.5 years old) were studied at home over ~4 months. Urinary 6-sulphatoxymelatonin (aMT6s) rhythms were measured for 48 h every 1-2 weeks. Participants completed daily sleep-wake logs, and rated their alertness and mood using nine-point scales every ~2-4 h while awake on urine sampling days. Caffeine capsules (150 mg per os) were self-administered daily at 10 a.m. for approximately one circadian beat cycle based on each participant's endogenous circadian period τ and compared to placebo (n = 2) or no treatment (n = 1) in a single-masked manner. RESULTS: Non-24-h aMT6s rhythms were confirmed in all three participants (τ range = 24.32-24.57 h). Daily administration of 150 mg caffeine did not entrain the circadian clock. Caffeine treatment significantly improved daytime alertness at adverse circadian phases (p <0.0001) but did not decrease the occurrence of daytime naps compared with placebo. CONCLUSIONS: Although caffeine was able to improve daytime alertness acutely and may therefore provide temporary symptomatic relief, the inability of caffeine to correct the underlying circadian disorder means that an entraining agent is required to treat Non-24-Hour Sleep-Wake Disorder in the blind appropriately.

Melatonin administration can entrain the free-running circadian system of blind subjects.

Although melatonin treatment has been shown to phase shift human circadian rhythms, it still remains ambiguous as to whether exogenous melatonin can entrain a free-running circadian system. We have studied seven blind male subjects with no light perception who exhibited free-running urinary 6-sulphatoxymelatonin (aMT6s) and cortisol rhythms. In a single-blind design, five subjects received placebo or 5 mg melatonin p.o. daily at 2100 h for a full circadian cycle (35-71 days). The remaining two subjects also received melatonin (35-62 days) but not placebo. Urinary aMT6s and cortisol (n=7) and core body temperature (n=1) were used as phase markers to assess the effects of melatonin on the During melatonin treatment, four of the seven free-running subjects exhibited a shortening of their cortisol circadian period (tau). Three of these had taus which were statistically indistinguishable from entrainment. In contrast, the remaining three subjects continued to free-run during the melatonin treatment at a similar tau as prior to and following treatment. The efficacy of melatonin to entrain the free-running cortisol rhythms appeared to be dependent on the circadian phase at which the melatonin treatment commenced. These results show for the first time that daily melatonin administration can entrain free-running circadian rhythms in some blind subjects assessed using reliable physiological markers of the circadian system.

Correlation between urinary cortisol and 6-sulphatoxymelatonin rhythms in field studies of blind subjects.

OBJECTIVE: Blind individuals have different types of circadian rhythm disorders. In order to study these in the field reliable markers of circadian phase are required. The aim of the present study was to determine the usefulness of urinary cortisol as a marker rhythm in field studies. This was assessed by investigating the relationship between the cortisol rhythms and the previously determined melatonin rhythms from a large sample of blind people with different types of circadian rhythm disorders. DESIGN: Field study SUBJECT: Registered blind subjects (n = 49) classified as having light perception or better (n = 19, 12 men, 7 women, aged 23-61 years) or having no conscious perception of light (n = 30, 24 men, 6 women, aged 19-72 years) were studied in their normal environment. MEASUREMENT: Sequential 4-hourly urine samples (plus an overnight sample) were collected for 48 h each week for 3-5 weeks. Urinary cortisol and 6-sulphatoxymelatonin were measured by radioimmunoassay. RESULT: Irrespective of the type of circadian rhythm (entrained or free-running), there was a significant correlation between the characteristics of the 6-sulphatoxymelatonin and cortisol rhythms in the blind subjects. CONCLUSION: Urinary cortisol is recommended as a useful marker of circadian phase in field studies in addition to urinary 6-sulphatoxymelatonin measurements.

Optic neuritis with residual tunnel vision in perchloroethylene toxicity.

CASE REPORT: In a 57-year-old female owner of a dry-cleaning shop, we describe the association of severe bilateral optic neuritis with unexpectedly high concentrations of perchloroethylene/metabolites in the blood and of chloroform in urine. Visual disturbances consisted of complete blindness for 9 days in the left eye, for 11 days in the right eye, with bright phosphenes and pain on eye rotation. Only central (2-3 degrees radius) vision recovered in the following months. CONCLUSION: Although environmental concentrations of perchloroethylene were within normal limits, we measured five-fold increases in vapors emitted when ironing freshly dry-cleaned fabrics, and suggest that inhalation of perchloroethylene vapors was the cause of this case of ocular nerve toxicity, recapitulating a previous report of major perchloroethylene toxicity.

Relationship between melatonin rhythms and visual loss in the blind.

Melatonin rhythms were assessed in 49 registered blind individuals by measurement of the urinary metabolite of melatonin, 6-sulfatoxymelatonin (aMT6s). Subjects had different causes of visual loss and were classified as having light perception or better (LP; n = 19) or having no perception of light (NPL; n = 30). Subjects collected four-hourly urine samples (eight-hourly overnight) for 48 h at weekly intervals for 3-5 weeks. The majority of LP subjects (14 of 19) had normally entrained aMT6s rhythms (mean acrophase range, 2.4-6.2 h), 4 were abnormally entrained to 24 h (mean acrophase range, 8.9-1.0 h), and 1 was unclassified. Conversely, most NPL subjects had abnormal rhythms (23 of 30), the incidence of which was greater in uni- and bilaterally enucleated subjects. The majority of NPL subjects (17 of 30) had free-running aMT6s rhythms period range, 24.13-24.79 h), 5 were abnormally entrained to 24 h (acrophase range, 7.2-20.6 h), and 1 was unclassified. Output (micrograms of aMT6s per 24 h) and amplitude (micrograms per h) of aMT6s production did not vary between LP and NPL subjects (mean 24-h output +/- SD, 12.7 +/- 7.5 and 9.4 +/- 6.4 micrograms aMT6s/24 h, respectively; mean amplitude +/- SD, 0.6 +/- 0.4 and 0.5 +/- 0.3 microgram/h, respectively). These results indicate that a higher proportion of NPL subjects have abnormal melatonin rhythms compared to those with LP.

D-2-hydroxyglutaric aciduria in neonate with seizures and CNS dysfunction.

D-2-Hydroxyglutaric aciduria was documented in a newborn who presented with seizures, hypotonia, cortical blindness, a movement disorder, and developmental delay. Her clinical presentation differs from that of patients with L-2-hydroxyglutaric aciduria and a single previously reported patient with D-2-hydroxyglutaric aciduria. Cerebrospinal fluid levels of gamma-aminobutyric acid were elevated, while biogenic amine metabolites were normal. The movement disorder in our patient and in those with L-2-hydroxyglutaric aciduria suggests involvement of the basal ganglia in the disease process. Prenatal diagnosis of an affected fetus was accomplished during a subsequent pregnancy.

Circadian and other variation in epinephrine and norepinephrine among several human populations, including healthy blinded and sighted subjects and patients with leprosy.

Urinary levels of epinephrine and norepinephrine were studied in three populations: presumably healthy young men who were studied twice, 8 years apart, and in the same month to avoid seasonal influences; blinded but otherwise healthy males and females; and patients with leprosy. Determinations of epinephrine and norepinephrine were done on urine samples collected at 3-hr intervals for 72 hr from the first two groups and for 10 days from patients with leprosy. The same chemist, method, and protocol were used in all studies. In one study of the group of healthy young men, the effect of meal timing and fasting on the rhythms was investigated. From these studies several generalizations can be made. Highly statistically significant population circadian rhythms characterize both epinephrine and norepinephrine in all three groups. In general, the rhythm in norepinephrine was "noisier" than that in epinephrine; in the blind subjects, both variables were characterized by noisier rhythms than in the sighted. The overall levels of epinephrine were much higher in blind than in sighted subjects. The overall levels of norepinephrine were much higher in blind males than in blind females. In the studies done with the group of healthy young men, the overall levels of epinephrine and norepinephrine increased significantly over a 10-year period. The amplitude of the rhythm also increased significantly with time. The average age of the group was 27 years at the time of the first study and 40 years at the time of the second. The patients with leprosy also showed strong circadian variation in both epinephrine and norepinephrine, but, because many of the subjects were on medication, comparisons with the other groups are questionable. In general the data raise some questions about, but do not refute, the commonly held view that the amplitude and mesor of the circadian rhythm in epinephrine decrease with age. Additional work is needed to resolve this question completely.

Evaluation of Hypo-test, a semiquantitative audio urine-glucose analyzer for blind diabetic individuals.

Hypo-test (Hypoguard Ltd., Suffolk, United Kingdom), a new semiquantitative audio urine-glucose analyzer for blind diabetic individuals, was tested for accuracy and reproducibility against a laboratory glucose method, and for ease of operation by two blind diabetic subjects. Hypo-test results were accurate for urine glucose in the range 0-0.75%, but there was a pronounced tendency for results to be too low at higher urine-glucose concentrations. The reproducibility at high urine-glucose concentrations was poor, and the meter was too sensitive to delays or decreases in the prescribed timing procedure. However, the two blind diabetic subjects found the instrument easy to operate.