Circadian variations and prednisolone-induced alterations of circulating lymphocyte subsets in man

Immunotherapy time of infusion impacts survival in head and neck cancer: A propensity score matched analysis

The adaptive immune response is physiologically regulated by the circadian rhythm. Data in lung and melanoma malignancies suggests immunotherapy infusions earlier in the day may be associated with improved response; however, the optimal time of administration for patients with head and neck squamous cell carcinoma (HNSCC) is not known. We aimed to evaluate the association of immunotherapy infusion time with overall survival (OS) and progression free survival (PFS) in patients with HNSCC in an Institutional Review Board-approved, retrospective cohort study. 113 patients met study inclusion criteria and 98 patients were included in a propensity score-matched cohort. In the full unmatched cohort (N = 113), each additional 20 % of infusions received after 1500 h conferred an OS hazard ratio (HR) of 1.35 (95 % C.I.1.2-1.6; p-value = 0.0003) and a PFS HR of 1.34 (95 % C.I.1.2-1.6; p-value < 0.0001). A propensity score-matched analysis of patients who did or did not receive ≥20 % of infusions after 1500 h showed that those who were administered ≥20 % of infusions after 1500 h trended towards a shorter OS (HR = 1.35; p-value = 0.26) and a shorter PFS (HR = 1.57, 95 % C.I. 1.02-2.42, p-value = 0.04). Each additional 20 % of infusions received after 1500 h remained robust in the matched cohort multivariable analysis and was associated with shorter OS (adjusted HR = 1.4 (95 % C.I.1.2-1.8), p-value < 0.001). Patients with advanced HNSCC who received more of their infusions in the afternoon were associated with shorter OS and PFS and scheduling immunotherapy infusions earlier in the day may be warranted.

Time-Dependent Efficacy of Checkpoint Inhibitor Nivolumab: Results from a Pilot Study in Patients with Metastatic Non-Small-Cell Lung Cancer

Simple Summary

Initial clinical observations revealed strikingly longer follow-up for metastatic non-small-cell lung cancer (NSCLC) patients receiving nivolumab infusions predominantly in the morning as compared to those treated in the afternoon. Prior experimental and human studies have demonstrated the temporal distributions of immune cells’ proliferation, trafficking, and antigen recognition and destruction over the 24 h. Here, we hypothesized that circadian timing could play an important role in nivolumab’s efficacy, as previously shown for the toxicity and/or efficacy of chronomodulated chemotherapy in colorectal and lung cancer patients. Following project validation by an internal scientific review board, the dosing times of each of the 1818 nivolumab infusions given to 95 consecutive patients as a standard treatment for metastatic NSCLC were retrieved from the day-hospital records. Adverse events and radiologically documented tumor responses were retrieved and reviewed from patients’ clinical charts. Patients were allocated to ‘morning’ (N = 48 patients) or ‘afternoon’ (N = 47 patients) groups, according to whether they had received the majority of nivolumab infusions before or after 12:54, i.e., the median time of all infusions, respectively. ‘Morning’ nivolumab dosing nearly quadrupled median progression-free and overall survival as compared to ‘afternoon’ dosing. ‘Morning’ nivolumab was significantly more effective irrespective of age, sex, performance status, prior treatments, tumor histology, or PD-L1 expression. In contrast, nivolumab primary resistance was most often observed following ‘afternoon’ dosing. Randomized trials are warranted both to further identify the optimal timing of checkpoint inhibitors in individual cancer patients, and to determine the main mechanisms that precisely drive immunotherapy efficacy and resistance along the circadian timescale.

Abstract

Hypothesis: Prior experimental and human studies have demonstrated the circadian organization of immune cells’ proliferation, trafficking, and antigen recognition and destruction. Nivolumab targets T(CD8) cells, the functions, and trafficking of which are regulated by circadian clocks, hence suggesting possible daily changes in nivolumab’s efficacy. Worse progression-free survival (PFS), and overall survival (OS) were reported for malignant melanoma patients receiving more than 20% of their immune checkpoint inhibitor infusions after 16:30 as compared to earlier in the day. Methods: Consecutive metastatic non-small-cell cancer (NSCLC) patients received nivolumab (240 mg iv q 2 weeks) at a daily time that was ‘randomly’ allocated for each course on a logistical basis by the day-hospital coordinators. The median time of all nivolumab administrations was computed for each patient. The study population was split into two timing groups based upon the median value of the median treatment times of all patients. CTCAE-toxicity rates, iRECIST-tumor responses, PFS and OS were computed according to nivolumab timing. PFS and OS curves were compared and hazard ratios (HR) were computed for all major categories of characteristics. Multivariable and sensitivity analyses were also performed. Results: The study accrued 95 stage-IV NSCLC patients (PS 0–1, 96%), aged 41–83 years. The majority of nivolumab administrations occurred between 9:27 and 12:54 for 48 patients (‘morning’ group) and between 12:55 and 17:14 for the other 47 (‘afternoon’ group). Median PFS (95% CL) was 11.3 months (5.5–17.1) for the ‘morning’ group and 3.1 months (1.5–4.6) for the ‘afternoon’ one (p < 0.001). Median OS was 34.2 months (15.1–53.3) and 9.6 months (4.9–14.4) for the ‘morning’ group and the ‘afternoon’ one, respectively (p < 0.001). Multivariable analyses identified ‘morning’ timing as a significant predictor of longer PFS and OS, with respective HR values of 0.26 (0.11–0.58) and 0.17 (0.08–0.37). The timing effect was consistent across all patient subgroups tested. Conclusions: Nivolumab was nearly four times as effective following ‘morning’ as compared to ‘afternoon’ dosing in this cohort of NSCLC patients. Prospective timing-studies are needed to minimize the risk of resistance and to maximize the benefits from immune checkpoint inhibitors.

Inflammatory markers before and after farrowing in healthy sows and in sows affected with postpartum dysgalactia syndrome

Background

The pathogenesis of postpartum dysgalactia syndrome (PDS) in sows is not fully elucidated and affected sows often present vague clinical signs. Accurate and timely diagnosis is difficult, and PDS is often recognized with a delay once piglets begin to starve. Increased rectal temperature of the sow is an important diagnostic parameter, but it may also be influenced by a number of other parameters and is thus difficult to interpret. Inflammatory markers may be important adjuncts to the clinical assessment of sows with PDS, but such markers have only been studied to a limited extent. The objective was to characterize the inflammatory response in healthy sows and in sows suffering from PDS, and to identify biomarkers that may assist in early identification of PDS-affected sows.

Results

Thirty-eight PDS-affected (PDS+) and 38 healthy (PDS-) sows underwent clinical examination and blood sampling every 24 h, from 60 h before the first piglet was born to 36 h after parturition. In both groups, inflammatory markers changed in relation to parturition. Most inflammatory markers changed 12-36 h after parturition [white blood cell counts (WBC), neutrophil counts, lymphocyte counts, tumor necrosis factor alpha (TNF-α), interleukin 6 (IL-6), serum amyloid A (SAA), C-reactive protein (CRP), haptoglobin (Hp), iron (Fe) and albumin (ALB)]. Changes in neutrophil counts, lymphocyte counts, CRP, Fe and ALB were observed -12 to 0 h before parturition. WBC, neutrophil and lymphocyte counts, serum concentrations of TNF-α, IL-6, Hp and Fe differed between PDS+ and PDS- sows. These differences were mainly apparent 12 to 36 h after parturition, but already at 12 h before parturition, PDS+ sows had lower lymphocyte counts than PDS- sows.

Conclusions

Parturition itself caused significant inflammatory changes, but PDS+ sows showed a more severe response than PDS- sows. WBC, neutrophil and lymphocyte counts, and concentrations of TNF-α, IL-6, Hp and Fe can be potential biomarkers for PDS. Lymphocyte counts may be used to detect PDS at pre-partum. To assess their diagnostic potential, these markers must be investigated further and most likely combined with assessment of clinical parameters and other biomarkers for improved identification of sows at risk of developing PDS.

Electronic supplementary material

The online version of this article (10.1186/s12917-018-1382-7) contains supplementary material, which is available to authorized users.

Methylprednisolone-Induced Lymphocytosis in Patients with Immune-Mediated Inflammatory Disorders

BACKGROUND

Transient acute reversible lymphopenia occurring within hours after glucocorticoid administration is a well-known phenomenon. The objective of this study was to establish the impact of chronic methylprednisolone (mPDN) administration on lymphocyte counts in patients with immune-mediated inflammatory disorders.

METHODS

The charts of 44 women and 17 men (median age, 59 years) with several immune-mediated inflammatory disorders receiving oral mPDN for at least 4 months were reviewed. Morning lymphocyte counts measured during treatment (LP) were compared with pretreatment values (LA). In addition, the acute effect of mPDN on lymphocyte counts was evaluated in 43 of these patients by quantifying lymphocyte subpopulations before and 8 hours after mPDN administration. Values are expressed as median with 25%-75% interquartile range.

RESULTS

The initial daily oral mPDN dose was 28 mg (12-32 mg). An increase in morning lymphocyte counts was detected 13 days (8.5-16 days) after initiation of mPDN treatment (LP: 2130/μL vs LA: 1650/μL; P = .0121) and persisted over time. Morning lymphocytosis (LP ≥4000/μL) was observed in 15 patients, including 7 with hyperlymphocytosis (LP ≥5000/μL). The increase in morning lymphocyte counts during treatment was most marked for CD4 T cells. In the subset of patients who agreed to a second blood test after mPDN absorption, a 49% decrease in the lymphocyte count (P <.0001) was transiently observed at the 8-hour time point.

CONCLUSIONS

A significant increase of the morning lymphocyte count is frequently observed in patients with immune-mediated inflammatory disorders chronically treated with oral mPDN. Heightened awareness that the timing of blood sampling in corticosteroid-treated patients affects lymphocyte counts, with possible hyperlymphocytosis before absorption, should help avoid unnecessary investigations and worry.

Biological variability of lymphocyte subsets of human adults' blood

BACKGROUND

Alterations in lymphocyte subpopulations are present in several immune diseases, and clinicians and researchers recognise the importance of investigating the distribution and changes in lymphocyte subsets over relatively long periods of time in order to evaluate the effectiveness of treatment and follow the course of disease. Yet further insight is required on the biological variability (BV) of lymphocyte subsets, which is crucial to the correct interpretation of longitudinal changes and provides essential information for setting desirable quality specifications and defining the usefulness of reference values.

METHODS

Four-colour-flow cytometry was used to investigate the BV of lymphocyte populations (LP) in the peripheral blood of 20 healthy adults recruited from our laboratory staff and followed for three months. The total lymphocyte count was measured, and the relative frequencies determined for T-cells (CD3+), T-helper cells (CD3+CD4+), cytolytic T-cells (CD3+CD8+), B-cells (CD3-CD19+), NK-cells (CD3-CD16+/56+), non-MHC restricted cytolytic T-cells (CD3+CD56+) and activated T-cells (CD3+HLA-DR+).

RESULTS AND CONCLUSIONS

Data on the components of BV were applied to set quality specifications for allowable precision, bias and total error. Analytical performances were established, and they were more than desirable for all the markers considered in our study. By comparing within-subject and between-subjects BV, we were able to define the uselessness of reference ranges in the evaluation of changes in CD serial results. Data on within-subject BV and analytical precision were thus used to determine the reference change values, in order to identify the significance of changes in serial results. The findings made in the present study provide further evidence of the relevance of BV in the evaluation of immunological markers of LP.

A single dose of rituximab does not deplete B cells in secondary lymphoid organs but alters phenotype and function

A single dose of the anti-CD20 monoclonal antibody rituximab induces a nearly complete B cell depletion in peripheral blood, but not in secondary lymphoid organs. Modulation of this remaining B cell population due to rituximab treatment may contribute to the therapeutic effects of rituximab. To assess the in vivo effects of rituximab we used lymph nodes (LNs) collected during renal transplant surgery in patients who had received rituximab 4 weeks earlier in preparation for an ABO-incompatible transplantation. Rituximab treatment resulted in a lower percentage of naïve (IgD(+)CD27(-)) and a higher percentage of switched memory (IgD(-)CD27(+)) B cells. Remarkably, transitional (CD24(++)CD38(++)) B cells were virtually lacking in the LNs of rituximab-treated patients. Moreover, LN-derived B cells from rituximab-treated patients produced different amounts of various Ig-subclasses after anti-CD40/IL-21 stimulation ex vivo. Finally, after stimulation of allogeneic T cells with LN-derived B cells from rituximab-treated patients, the proliferated T cells showed a decreased production of IL-17. In conclusion, after treatment with rituximab there remains a B cell population with different functional capacities. Consequently, the effect of rituximab on the immune response will not only be determined by the extent of B cell depletion, but also by the functional properties of the remaining B cells.

Expression of clock genes in human peripheral blood mononuclear cells throughout the sleep/wake and circadian cycles

The rhythmic expression of circadian clock genes in the neurons of the suprachiasmatic nucleus (SCN) underlies the manifestation of endogenous circadian rhythmicity in behavior and physiology. Recent evidence demonstrating rhythmic clock gene expression in non-SCN tissues suggests that functional clocks exist outside the central circadian pacemaker of the brain. In this investigation, the nature of an oscillator in peripheral blood mononuclear cells (PBMCs) is evaluated by assessing clock gene expression throughout both a typical sleep/wake cycle (LD) and during a constant routine (CR). Six healthy men and women aged (mean+/-SEM) 23.7+/-1.6 yrs participated in this five-day investigation in temporal isolation. Core body temperature and plasma melatonin concentration were measured as markers of the central circadian pacemaker. The expression of HPER1, HPER2, and HBMAL1 was quantified in PBMCs sampled throughout an uninterrupted 72 h period. The core body temperature minimum and the midpoint of melatonin concentration measured during the CR occurred 2:17+/-0:20 and 3:24 +/-0:09 h before habitual awakening, respectively, and were well aligned to the sleep/wake cycle. HPER1 and HPER2 expression in PBMCs demonstrated significant circadian rhythmicity that peaked early after wake-time and was comparable under LD and CR conditions. HBMAL1 expression was more variable, and peaked in the middle of the wake period under LD conditions and during the habitual sleep period under CR conditions. For the first time, bi-hourly sampling over three consecutive days is used to compare clock gene expression in a human peripheral oscillator under different sleep/wake conditions.

Biological and methodological variation of lymphocyte subsets in blood of human adults

Although lymphocyte populations are often monitored over time, information about the biological variation over time is limited. Three-colour-flow cytometry was used to investigate the biological and methodological variation of lymphocyte populations in blood. Fifteen healthy individuals (11 females and 4 males) were longitudinally monitored for 2-8 years. Blood samples were drawn monthly when possible. In total, 493 observations were included. Absolute counts and proportions were determined for T-cells (CD3(+)), T-helper cells (CD3(+) CD4(+)), cytolytic T-cells (CD3(+) CD8(+)), B-cells (CD3(-) CD19(+)) and NK-cells (CD3(-) CD16(+)/56(+)). As to variation over the year, ANOVA testing showed only a minor monthly variation for absolute counts of the CD8(+) population (p<0.05) for October compared with June and July, whereas no significant differences were found for the other populations or in the proportions of lymphocyte subsets. Although lower than the longitudinal variation, the methodological variation, expressed as coefficient of variation (CV %), was in a similar range as the variation over time, indicating that the normal biological variation should not be overestimated, while the methodological inter-assay should be taken into consideration in longitudinal studies or monitoring of patients.

Effect of 4 weeks of basic military training on peripheral blood leucocytes and urinary excretion of catecholamines and cortisol

In this study, we assessed the effects of a 4 week basic military physical training programme for male recruits of the Hellenic Air Force on the number and distribution of circulating immune cells and adrenergic and adrenocortical hormonal responses. One group of recruits (exercised, n = 48) participated in moderate intermittent physical exercise, whereas a second group (non-exercised controls, n = 9) performed only light work in the barracks. Both groups participated in the same non-physical, classroom-type training and testing. Military training by the exercised group resulted in significant increases in CD4+ T-lymphocytes, renal cortisol excretion and the urinary noradrenaline/adrenaline ratio, together with reductions in neutrophils and the neutrophil/lymphocyte ratio. In the exercised group, the urinary noradrenaline/adrenaline ratio correlated positively with the training-induced changes in CD4+ T-lymphocytes and negatively with changes in the neutrophil/lymphocyte ratio. No significant relationship was found between training-induced increases in cortisol excretion and any of the peripheral blood cell alterations. Our results indicate that 4 weeks of military training consisting of intermittent moderate exercise resulted in a significant increase in CD4+ T-lymphocytes and reduction in neutrophils. These changes were probably driven by alterations in hormonal status, including the significant impact of sympathetic nervous system activation.

Differential Pattern of Human Blood Neutrophil Activation After Stimulation With Organic Dust in Vitro and in Vivo

OBJECTIVE

To study activation of blood neutrophils in subjects after in vitro and in vivo stimulation.

METHODS

Blood from healthy volunteers was collected before and after their exposure to organic dust in a pig farm. Surface markers of neutrophil activation were analyzed by flow cytometry.

RESULTS

In vivo, there was a diurnal variation in basal levels of CD11b. Swine dust exposure increased the number of blood neutrophils and the levels of myeloperoxidase without effects on CD11b or Cys-X-Cys receptor 1 (CXCR-1) expression. However, a positive correlation between changes of myeloperoxidase and CD11b expression was observed. In vitro, N-formyl-methionyl-leucyl-phenylalanine (fMLP), lipopolysaccharide (LPS), leukotriene (LT)B4, LTD4, and swine dust stimulated the expression of CD11b. fMLP, LPS, and LTB4 diminished the expression of CXCR-1.

CONCLUSIONS

Exposure to swine dust in vitro activated neutrophils and inhalation of swine dust caused neutrophilia.

Prolonged suppression of the innate immune system in the horse following an 80 km endurance race

REASONS FOR PERFORMING STUDY

An increased susceptibility to bacterial and viral infections of the respiratory tract, which results in a loss of performance, has been reported in racehorses. Much research has focused on the influence of high-intensity exercise of a short duration on immune system function in horses, but scant attention has been given to prolonged endurance exercise as an immune modulator.

OBJECTIVES

The objective of this study was to evaluate the effect of an 80 km endurance race on the monocyte and neutrophil oxidative burst, serum cortisol, glutamine and plasma glucose concentrations in 8 endurance-trained horses (mean +/- s.d. age 9.4 +/- 2.2 years).

METHODS

Blood samples were drawn from the horses prior to and following an 80 km ride.

RESULTS

Mean time for completion of the 80 km race was 306 +/- 40 mins. Immediately post race mean serum cortisol concentration, blood monocyte and neutrophil counts were higher and blood lymphocyte counts and plasma glucose concentration were lower compared with prerace values (P < 0.05). Neutrophil and monocyte oxidative burst activity decreased following the race and had not regained prerace values after 3 days of rest (P < 0.05).

CONCLUSIONS

The present study indicates that long duration exercise in horses has a negative impact on the function of the innate immune system that lasts several days post race. Precise mechanisms instigating the fall in innate immune system function are unclear and multifactorial, but may be attributed, at least in part, to a high serum cortisol response during very prolonged exercise.

POTENTIAL CLINICAL RELEVANCE

A prolonged bout of exercise results in a long-term suppression of the innate immune system function in horses which may, in part, account for the observed increase of infectious episodes in horses during training.

Glucocorticoids and immune function

The prevailing notion has been that cytokines such as interleukin-1 released from sites of inflammation cross the blood-brain barrier and drive the hypothalamo-pituitary-adrenal (HPA) axis so that cortisol is released into the circulation to exert indiscriminate systemic anti-inflammatory effects. It is now clear that feedback from the HPA axis is subject to more subtle and localized regulation. The signal that activates cortisol release travels to the hypothalamus via vagal sensory afferents (so the brain 'knows' where the inflammation is), and the effects of the released cortisol are regulated within individual tissues via numerous mechanisms, including changes in the affinity of the cortisol receptors, and changes in the equilibrium point of the cortisol/cortisone shuttle (11 beta hydroxysteroid dehydrogenases 1 and 2). This equilibrium is locally regulated by cytokines. These mechanisms are central to the regulation of the balance of Th1 to Th2 cytokines within sites of inflammation, and to the appropriate or inappropriate termination of the inflammatory response in infections or autoimmunity.

Risk and safety of repetitive transcranial magnetic stimulation: report and suggested guidelines from the International Workshop on the Safety of Repetitive Transcranial Magnetic Stimulation, June 5-7, 1996

Single-pulse transcranial magnetic stimulation (TMS) is a safe and useful tool for investigating various aspects of human neurophysiology, particularly corticospinal function, in health and disease. Repetitive TMS (rTMS), however, is a more powerful and potentially dangerous modality, capable of regionally blocking or facilitating cortical processes. Although there is evidence that rTMS is useful for treating clinical depression, and possibly other brain disorders, it had caused 7 known seizures by 1996 and could have other undesirable effects. In June 1996 a workshop was organized to review the available data on the safety of rTMS and to develop guidelines for its safe use. This article summarizes the workshop's deliberations. In addition to issues of risk and safety, it also addresses the principles and applications of rTMS, nomenclature, and potential therapeutic effects of rTMS. The guidelines for the use of rTMS, which are summarized in an appendix, cover the ethical issues, recommended limits on stimulation parameters, monitoring of subjects (both physiologically and neuropsychologically), expertise and function of the rTMS team, medical and psychosocial management of induced seizures, and contra-indications to rTMS.