Capnocytophaga canimorsus sepsis presenting as an acute abdomen in an asplenic patient.

Acute abdominal symptoms are frequently caused by surgical intra-abdominal problems. However, the differential diagnosis also includes several internal diseases. Overwhelming infections may present with acute abdominal signs, particularly in the immunocompromised host. Asplenic patients are highly susceptible to infections with encapsulated bacteria such as Streptococcus pneumoniae, Haemophilus influenzae and Neisseria meningitidis. Severe infections due to Capnocytophaga canimorsus (DF2), are also common in this group. C. canimorsus is a Gram-negative rod, present as a commensal organism in cat and dog saliva. We describe the atypical presentation of a fatal C. canimorsus-sepsis in a 46-year-old man, who underwent traumatic splenectomy two decades earlier.

The tumor promoting effect of constant light exposure on diethylnitrosamine-induced hepatocarcinogenesis in rats.

The hypothesis that light-induced circadian clock suppression exerts a promoting effect on liver carcinogenesis was investigated in rats. Sixty-five male Wistar rats were given diethylnitrosamine (DEN, 10 mg/kg/day p.o.) for 6 weeks and were randomized into 3 groups. Rats from group 1 (N=20) received DEN only. Rats from group 2 (N=22) also received phenobarbital (pheno, 30 mg/rat/day p.o.) for 4 weeks as a promoting agent and rats from group 3 (N=23) were exposed to continuous light. Three months after starting DEN treatment, urinary 6-sulfatoxymelatonin (alphaMT6s) excretion, a marker of circadian clock function, had lost its circadian rhythmicity in the LL group, with a 4-fold lower 24 h mean than that found in the LDpheno and LD groups (8.0 +/- 3.2 ng/ml, 33.6 +/- 3.1 ng/ml and 34.3 +/- 2.4 ng/ml respectively; p from ANOVA <0.001). Laparotomy was then performed. The proportion of rats with macroscopic nodules on liver surface was 72% (LD group), 89% (LDpheno group) and 95% (LL group) (p from chi2 = 0.1). Nodules were more numerous and larger both in the LL group and in the LDpheno one as compared to the LD group (p from chi2 <0.05). All the rats died with hepatocellular carcinomas, with a median survival of 5 months, similar in all 3 groups. Light-induced circadian clock suppression exerted a promoting effect similar to that caused by phenobarbital in this model, yet through different effects on circadian system function.

Pharmacologic restoration of suppressed temperature rhythms in rats by melatonin, melatonin receptor agonist, S20242, or 8-OH-DPAT.

Endogenous circadian rhythms in body temperature and locomotor activity rhythms are suppressed in Sprague-Dawley rats exposed to prolonged continuous light, possibly as a result of a profound alteration of the melatonin secretion rhythm. The ability to restore circadian system function with either exogenous melatonin, or melatonin receptor agonist S20242 (N-[2-(7-methoxy napth-1-yl)ethyl] propionamide), or 5-HT1A receptor agonist, 8-hydroxy-2-(di-n-propylamino)tetralin (8-OH-DPAT), was investigated under these conditions. Seven rats received a daily 6-h intravenous infusion of melatonin (0.01 mg kg(-1)) for 10 days, which generates a nearly physiological circadian rhythm of urinary 6-sulfatoxy-melatonin, the main urinary metabolite of melatonin. Nevertheless, there was no effect on body temperature or locomotor activity rhythms. Then, 49 rats received daily subcutaneous melatonin (0.01, 1 or 5 mg kg(-1) day(-1)), S20242 (1 or 5 mg kg(-1) day(-1)) or 8-OH-DPAT (5 mg kg(-1) day(-1)) for 30 days. The circadian rhythm in body temperature was restored by subcutaneous melatonin or by S20242 as a function of the dose or by 8-OH-DPAT. The effect started within the first 10 days of treatment and persisted for I to 3 weeks following the end of treatment in 8 of 10 rats receiving melatonin, in 9 of 11 rats treated with S20242 and in 1 of 4 rats treated with 8-OH-DPAT. Activity was less susceptible to entrainment than temperature with these drugs, since circadian rhythmicity was restored in only 2 of 6 rats treated with melatonin and in 1 of 4 rats treated with 8-OH-DPAT. These data demonstrate a specific action of subcutaneous melatonin, S20242 or 8-OH-DPAT on temperature rather than on activity rhythms. This differential effect on two major outputs of the suprachiasmatic nucleus further supports the existence of two independent oscillators in this hypothalamic circadian clock, which may be considered as separate pharmacological targets in the circadian system.

Melatonin high-affinity binding to alpha-1-acid glycoprotein in human serum.

The binding of 3H-melatonin to human serum proteins was investigated by equilibrium dialysis at 37 degrees C and pH 7.4. The binding to serum was moderate (53%) for physiological melatonin concentrations below 1 nmol/L. alpha 1-Acid glycoprotein and albumin bound melatonin with high 27 +/- 3 and low 1.5 +/- 0.1 (mmol/l)-1 affinity, respectively. Melatonin binding to other serum proteins, gamma-globulins and lipoproteins was not significant. The serum binding was characterized by a saturable and a nonsaturable component. The saturable component resulted from the high-affinity binding to alpha 1-acid glycoprotein and the nonsaturable component resulted from the low-affinity binding to albumin. The number of binding sites was 0.36/molecule of alpha 1-acid glycoprotein, when either pure alpha 1-acid glycoprotein or serum were studied, indicating that only a fraction of alpha 1-acid glycoprotein bound melatonin. The observed binding parameters did not enable simulation of the observed serum binding, and melatonin binding to an alpha 1-acid glycoprotein-albumin mixture was higher than that expected from the binding to each isolated protein. The high-affinity melatonin binding to alpha 1-acid glycoprotein might result from a potentiation of the binding interaction by albumin and the amount of melatonin bound in plasma might vary according to the alpha 1-acid glycoprotein concentration.

Persistent T lymphocyte rhythms despite suppressed circadian clock outputs in rats.

Circadian rhythms in circulating leukocyte and lymphocyte counts persisted with halved amplitudes in constant light (LL) of 300 lx intensity for 8 wk, whereas circadian rhythms in body temperature, locomotor activity, and plasma catecholamines were completely suppressed. Subsequent exposure to constant darkness (DD) normalized all circadian rhythms within 2 wk. Rhythms in circulating T lymphocyte subsets were studied in LL or DD using double labeling with monoclonal antibodies and flow cytometry. Circadian rhythms were suppressed for leukocytes and lymphocytes but were maintained for both T helper cells (Th) and T cytotoxic cells (Ts) lymphocytes after 11 wk in LL. A group 24-h rhythm was only validated for total lymphocytes after 16 wk in LL. However, individual total, Th, and Ts lymphocytes maintained their usual respective phase relationships in each rat. The alteration of immune cell circulatory rhythms likely stemmed from a progressive loss of circadian synchronization among rats kept in LL. Conversely, after 11 or 16 wk in DD, leukocytes and lymphocyte subsets circadian rhythms were maintained. Thus catecholamines do not drive circulatory T cell rhythms. The loss of coupling between T lymphocyte rhythms and three major outputs of the circadian system further supports the hypothesis of an independent immunologic oscillator.

Pharmacokinetically guided melatonin scheduling in rats with circadian system suppression.

To obtain a pharmacologic effect of melatonin in rats kept under prolonged continuous light exposure, conditions known to produce functional suppression of the circadian system, mimicking of the physiologic 24-h pattern of melatonin secretion, a hormonal signal of darkness exposure may be needed. The delivery scheme for melatonin was established in rats in the present studies. First, the plasma pharmacokinetics of [3H]melatonin were determined in rats kept under continuous light and in rats synchronized by exposure to alternating 12 h light and 12 h darkness (LD 12:12) in the early light span. The pharmacokinetics of total radioactivity were similar in both groups. Further quantitation of melatonin by thin-layer chromatography revealed differences dependent on light conditions. The mean plasma clearance and steady-state distribution volume were approximately twice as low with continuous light as with LD 12:12. Plasma protein binding of melatonin was approximately 33%, irrespective of group or sampling time. These pharmacokinetic parameters were used to devise a 24-h periodic delivery schedule consisting of a 6-h constant infusion of exogenous melatonin, followed by an 18-h melatonin-free interval. In a second study, the melatonin 24-h pattern was estimated from the measurement of 2-h fractions of urinary 6-sulfatoxymelatonin excretion for 4 days. 6 unrestrained rats kept under continuous light received melatonin for 2 days from 22:00 to 04:00 h through an indwelling jugular catheter, connected to a reservoir from a programmable pump. Only the administration of low doses (0.01 mg/kg/day) resulted in both a circadian pattern for 6-sulfatoxymelatonin excretion and normal physiological values during the infusion-free intervals. The resynchronizing efficacy of this schedule should be tested in rats with functional suppression of the circadian system.

[Analyses of rhythms of the body temperature in free running in rats]. / Analyses des rythmes de la température corporelle du rat en libre cours.

We have previously observed a light-induced suppression of circadian rhythms of body temperature and locomotor activity in 50/55 male Sprague Dawley rats (Am. J. Physiol., 1995). This study presents a description of 4 records of body temperature obtained by telemetry and compares three methods of period analysis (Fourier analysis, autocorrelation and cosinor). In case of persistant circadian rhythms, Fourier analysis and cosinor method agree and allow description of rhythm parameters. However, in case of an alteration of the circadian system in continuous light, these 2 methods can disagree on the dominant period. Autocorrelation analysis permits to conclude on the absence of circadian and ultradian rhythmicity. These results demonstrate the necessity to associate several methods for period analysis and plaids for the development of a strategy for data processing of longitudinal time series.

Light-induced suppression of the rat circadian system.

In a constant environment, circadian rhythms persist with slightly altered period lengths. Results of studies with continuous light exposure are less clear, because of short exposure durations and single-variable monitoring. This study sought to characterize properties of the oscillator(s) controlling the rat's circadian system by monitoring both body temperature and locomotor activity. We observed that prolonged exposure of male Sprague-Dawley rats to continuous light (LL) systematically induced complete suppression of body temperature and locomotor activity circadian rhythms and their replacement by ultradian rhythms. This was preceded by a transient loss of coupling between both functions. Continuous darkness (DD) restored circadian synchronization of temperature and activity circadian rhythms within 1 wk. The absence of circadian rhythms in LL coincided with a mean sixfold decrease in plasma melatonin and a marked dampening but no abolition of its circadian rhythmicity. Restoration of temperature and activity circadian rhythms in DD was associated with normalization of melatonin rhythm. These results demonstrated a transient internal desynchronization of two simultaneously monitored functions in the rat and suggested the existence of two or more circadian oscillators. Such a hypothesis was further strengthened by the observation of a circadian rhythm in melatonin, despite complete suppression of body temperature and locomotor activity rhythms. This rat model should be useful for investigating the physiology of the circadian timing system as well as to identify agents and schedules having specific pharmacological actions on this system.

In vitro chronopharmacology of recombinant mouse IL-3, mouse GM-CSF, and human G-CSF on murine myeloid progenitor cells.

Circadian changes in in vitro pharmacodynamic effects of recombinant mouse interleukin-3 (rmIL-3), rm granulocyte-macrophage colony-stimulating factor (rmGM-CSF), and recombinant human G-CSF (rhG-CSF) were investigated in 418 male B6D2F1 mice. Seven distinct experiments were staggered from July to December 1991. All mice were standardized for 3 weeks with a lighting schedule consisting of 12 hours of light and 12 hours of dark (LD12:12). In each experiment, bone marrow was sampled from separate groups of nine to 10 mice each every 4 hours for 24 hours. Data were analyzed with analysis of variance (ANOVA) and Cosinor. This latter method computes the probability of rhythm detection and its parameters. Femoral myeloid progenitors were quantified using the colony-forming units granulocyte/macrophage (CFU-GM) assay in the presence or absence of recombinant CSFs. For each CSF, the number of colonies is a function of circadian time of bone marrow exposure (ANOVA and Cosinor; p < 0.0001) with the values at peak time being double those found at the trough. Peak CSF efficacy occurred at 3 hours after light onset (HALO, early rest span) irrespective of CSF type or dose. Furthermore, in the absence of any added CSF, the number of clusters varied significantly according to sampling time, with a similar peak at 3 HALO (ANOVA and Cosinor; p < 0.001). Further in vivo chronopharmacologic experiments are needed to assess the relevance of these in vitro rhythms in bone marrow responsiveness to hematopoietic growth factors.

Circadian rhythm-modulated (CRM) chemotherapy of metastatic breast cancer with mitoxantrone, 5-fluorouracil, and folinic acid: preliminary results of a phase I trial.

A phase I feasibility trial with a 5-day schedule of circadian rhythm-modulated mitoxantrone (MIT), 5-fluorouracil (5-FU, 600 mg/m2/day), and folinic acid (FA, 300 mg/m2/day) was performed in patients with metastatic breast cancer. The MIT dose was escalated from 2 to 2.5 and 2.75 mg/m2/day in consecutive groups of six patients. All three drugs were infused intravenously with a multichannel ambulatory pump. Maximal delivery rate was programmed at 4.00 hours for 5-FU and FA and at 16.00 hours for MIT. Eighteen women with advanced metastatic breast cancer were included in the trial between April 1991 and July 1993. Seventeen of 18 patients had received previous chemotherapy, which contained anthracyling for 16 of them. Tolerability of the first treatment course was assessed 10 and 21 days after course onset. Neutropenia was dose dependent and the most frequent toxicity (grade 3: 4 patients; grade 4: 7 patients), yet only a single hospitalization was required for fever and neutropenia. A single patient exhibited grade 3 mucositis. No grade 3 or 4 diarrhea, nausea, or vomiting was encountered. This chronomodulated infusion of MIT, 5-FU, and FA showed acceptable toxicity in heavily pretreated patients. For the phase II evaluation of the antitumor activity of this circadian schedule, a dose of 2.75 mg/m2/day of MIT is recommended using a monthly regimen. Further dose escalation may be performed in patients without bone metastasis and good performance status.

The usefulness of CA15.3, mucin-like carcinoma-associated antigen and carcinoembryonic antigen in determining the clinical course in patients with metastatic breast cancer.

Levels of mucin-like carcinoma-associated antigen (MCA), CA15.3 and carcinoembryonic antigen (CEA) were measured in consecutive serum samples of 40 women with metastatic breast cancer. A change in antigen level of more than 25%, either an increase or a decrease, was considered to predict progressive or responsive disease respectively. A change of less than 25% was considered to predict stable disease. MCA, CA15.3 and CEA were elevated in the serum of 68%, 76% and 48% of the patients respectively (P < 0.05). The overall prediction of clinical course was similar for all three markers. A more than 25% increase of MCA, CA15.3, and CEA was observed in 61%, 54% and 36% respectively. The predictive value of a more than 25% increase was high for all three markers: 94%, 94%, 83%. Changes in marker levels were correlated with each other. Logistic regression analysis showed that combining MCA and CA15.3 did not improve the prediction further. In conclusion, these tumour markers may help in evaluating the disease course and there is no advantage in combining MCA and CA15.3.

Oxaliplatin activity against metastatic colorectal cancer. A phase II study of 5-day continuous venous infusion at circadian rhythm modulated rate.

Oxaliplatin (L-OHP) is a non-nephrotoxic third generation platinum complex with proven antitumoral activity and minimal haematological toxicity. Circadian scheduling has allowed significant increases in L-OHP dosage and dose intensity and decreases in its toxicities. This phase II trial has tested the antitumour activity of a 5-day circadian schedule of continuous venous infusion of L-OHP against metastatic colorectal cancer. Initial dose was 150 mg/m2/course. An intrapatient dose escalation scheme by 25 mg/m2/course was planned up to 200 mg/m2/course, according to toxicity criteria. The delivery rate of L-OHP was sinusoidally modulated along the 24-h time scale, and was highest at 1600 h. A programmable-in-time ambulatory pump was used, so that all patients could receive their treatment at home. 29 of 30 patients registered were eligible. 25 had failed previous chemotherapy. Three objective responses were observed (response rate: 10%), in patients progressive while on chemotherapy with 5-fluorouracil and folinic acid. Toxicity was moderate. Dose-limiting toxicities were diarrhoea and peripheral sensitive neuropathy. The latter adverse effect appeared to be cumulative. L-OHP, as delivered under this circadian schedule, exhibits clinical antitumour activity against metastatic colorectal cancer. These results, which await further confirmation, support the place of L-OHP in combination regimens including 5-fluorouracil.

A phase I trial of 21-day continuous venous infusion of alpha-interferon at circadian rhythm modulated rate in cancer patients.

The toxicity and/or the stimulation of natural killer cell activity that resulted from exposure to alpha-interferon varied according to circadian dosing time, both in mice and in human beings. Ten patients with advanced renal cell carcinoma or melanoma were treated with recombinant alpha-interferon-2b using a continuous 21-day intravenous schedule at circadian modulated rate. Patients received 15-20 MU/m2/day in an ambulatory care program. The drug was delivered via an external programmable-in-time pump. Thirty-nine courses of therapy were given (2-12 courses per patient). Severe side effects included World Health Organization grade III somnolence (one patient, 1 course) and grade III-IV neutropenia (five patients, 10 courses). Karnofsky performance status decreased by 40% in 3 patients (five courses). Two of these patients were withdrawn from the study because of toxicity. Disease was stabilized in four of the seven patients evaluable for response. Seven of the 10 patients are alive at 15 months' median follow-up. Two have continued with chronotherapy for 9+ and 13+ months, respectively. A large interpatient variability characterized the maximally tolerated dose. Two patients led their usual activities while receiving 20 MU/m2/day for three courses or more. Conversely, two patients exhibited severe side effects with 10 MU/m2/day. As compared with schedules of standard administration or continuous flat infusion, this circadian schedule of infusion allowed a large increment in total daily dose and dose intensity. A starting dose of 15 MU/m2/day was well tolerated by 8 of 10 patients and can be recommended using this circadian modulated schedule.