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Iba T, Maier CL, Levi M, Levy JH. Thromboinflammation and microcirculation damage in heatstroke. Minerva Med 2024; 115:191-202. [PMID: 38240696 DOI: 10.23736/s0026-4806.23.08919-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
Rising temperatures associated with climate change have significantly increased the risk of heatstroke. Unfortunately, the trend is anticipated to persist and increasingly threaten vulnerable populations, particularly older adults. According to Japan's environment ministry, over 1000 people died from heatstroke in 2021, and 86% of deaths occurred in those above 65. Since the precise mechanism of heatstroke is not fully understood, we examined the pathophysiology by focusing on the microcirculatory derangement. Online search of published medical literature through MEDLINE and Web of Science using the term "heatstroke," "heat-related illness," "inflammation," "thrombosis," "coagulation," "fibrinolysis," "endothelial cell," and "circulation." Articles were chosen for inclusion based on their relevance to heatstroke, inflammation, and thrombosis. Reference lists were reviewed to identify additional relevant articles. Other than preexisting conditions (genetic background, age, etc.), factors such as hydration status, acclimatization, dysregulated coagulation, and inflammation are the additional major factors that promote tissue malcirculation in heatstroke. The fundamental pathophysiologic mechanisms significantly overlap with those seen in the systemic inflammatory response to sepsis, and as a result, coagulation-predominant coagulopathy develops during heat stress. Although a bleeding tendency is not common, bleeding frequently occurs in the microcirculation, causing additional injury. Sterile inflammation is mediated by proinflammatory cytokines, chemokines, and other humoral mediators in concert with cellular factors, including monocytes, neutrophils, platelets, and endothelial cells. Excess inflammation results in inflammatory cell death, including pyroptosis and necroptosis, and the release of danger signals that further propagate systemic inflammation and coagulopathy. Consequently, thromboinflammation is the critical factor that induces microcirculatory disturbance in heatstroke.
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Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan -
| | - Cheryl L Maier
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Marcel Levi
- Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam, the Netherlands
- Department of Medicine, University College London Hospitals NHS Foundation Trust, London, UK
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care and Surgery, Duke University School of Medicine, Durham, NC, USA
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Liu Y, Li Y, Deng Z, Zhao Y, Yuan R, Yang M, Wang L, Fang Y, Ding D, Zhou F, Kang H. Protective and immunomodulatory effects of mesenchymal stem cells on multiorgan injury in male rats with heatstroke. J Therm Biol 2023; 118:103696. [PMID: 37871397 DOI: 10.1016/j.jtherbio.2023.103696] [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] [Received: 05/11/2022] [Revised: 08/01/2023] [Accepted: 08/25/2023] [Indexed: 10/25/2023]
Abstract
Heatstroke (HS) causes multiple organ dysfunction syndrome (MODS) with a mortality rate of 60% after hospitalization. Currently, there is no effective and targeted approach for the treatment of HS. Despite growing evidence that mesenchymal stem cells (MSCs) may reduce multiorgan damage and improve survival through immunomodulatory effects in several diseases, no one has tested whether MSCs have immunomodulatory effects in heatstroke. The present study focused on pathological changes and levels of the cytokines and immunoglobulins to investigate the mechanisms underlying the protective effect and the anti-inflammatory effects of MSCs. We found that MSCs treatment significantly reduced the 28-day mortality rate (P < 0.05), the levels of hepatic and renal function markers on day 1 (P < 0.01) and the pathological lesion scores of multiple organs in HS rats. The levels of IgG1, IgM, and IgA of the HS + MSC group was significantly higher than that in HS group on days 3 and 28(P < 0.05). In conclusion, MSCs contribute to protecting against multiorgan injury, reducing pro-inflammatory cytokines, stabilizing immunoglobulins, and reducing the mortality rate of HS rats.
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Affiliation(s)
- Yuyan Liu
- Medical School of Chinese People's Liberation Army (PLA), Beijing, China; Department of Critical Care Medicine, The First Medical Center, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Yun Li
- Medical School of Chinese People's Liberation Army (PLA), Beijing, China; Department of Critical Care Medicine, The First Medical Center, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Zihui Deng
- Medical School of Chinese People's Liberation Army (PLA), Beijing, China; Department of Basic Medicine, Graduate School, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Yan Zhao
- Department of Critical Care Medicine, The First Medical Center, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Rui Yuan
- Medical School of Chinese People's Liberation Army (PLA), Beijing, China; Department of Critical Care Medicine, The First Medical Center, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Mengmeng Yang
- Medical School of Chinese People's Liberation Army (PLA), Beijing, China; Department of Critical Care Medicine, The First Medical Center, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Lu Wang
- Medical School of Chinese People's Liberation Army (PLA), Beijing, China; Department of Critical Care Medicine, The First Medical Center, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Yuan Fang
- Medical School of Chinese People's Liberation Army (PLA), Beijing, China; Department of Critical Care Medicine, The First Medical Center, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Dengfeng Ding
- Medical School of Chinese People's Liberation Army (PLA), Beijing, China; Laboratory Animal Center, Chinese People's Liberation Army (PLA) General Hospital, Beijing, PR China
| | - Feihu Zhou
- Medical School of Chinese People's Liberation Army (PLA), Beijing, China; Laboratory Animal Center, Chinese People's Liberation Army (PLA) General Hospital, Beijing, PR China
| | - Hongjun Kang
- Medical School of Chinese People's Liberation Army (PLA), Beijing, China; Department of Critical Care Medicine, The First Medical Center, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China.
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Patel J, Boyer N, Mensah K, Haider S, Gibson O, Martin D, Walter E. Critical illness aspects of heatstroke: A hot topic. J Intensive Care Soc 2023; 24:206-214. [PMID: 37260431 PMCID: PMC10227888 DOI: 10.1177/17511437221148922] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023] Open
Abstract
Heatstroke represents the most severe end of the heat illness spectrum, and is increasingly seen in those undergoing exercise or exertion ('exertional heatstroke') and those exposed to high ambient temperatures, for example in heatwaves ('classical heatstroke'). Both forms may be associated with significant thermal injury, leading to organ dysfunction and the need for admission to an intensive care unit. The process may be exacerbated by translocation of bacteria or endotoxin through an intestinal wall rendered more permeable by the hyperthermia. This narrative review highlights the importance of early diagnosis, rapid cooling and effective management of complications. It discusses the incidence, clinical features and treatment of heatstroke, and discusses the possible role of intestinal permeability and advances in follow-up and recovery of this condition. Optimum treatment involves an integrated input from prehospital, emergency department and critical care teams, along with follow-up by rehabilitation teams and, if appropriate, sports or clinical physiologists.
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Affiliation(s)
- Jesal Patel
- Department of Intensive Care, Royal
Surrey County Hospital, Guildford, UK
| | - Naomi Boyer
- Department of Intensive Care, Royal
Surrey County Hospital, Guildford, UK
| | - Kwabena Mensah
- Department of Intensive Care, Royal
Surrey County Hospital, Guildford, UK
| | - Syeda Haider
- Department of Intensive Care, Royal
Surrey County Hospital, Guildford, UK
| | - Oliver Gibson
- Division of Sport, Health and Exercise
Sciences, Brunel University, London, UK
| | - Daniel Martin
- Department of Intensive Care, Derriford
Hospital, Plymouth, UK
- Peninsula Medical School, University of
Plymouth, UK
| | - Edward Walter
- Department of Intensive Care, Royal
Surrey County Hospital, Guildford, UK
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HSP70 mediates a crosstalk between the estrogen and the heat shock response pathways. J Biol Chem 2023; 299:102872. [PMID: 36610605 PMCID: PMC9926311 DOI: 10.1016/j.jbc.2023.102872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 12/24/2022] [Accepted: 12/27/2022] [Indexed: 01/06/2023] Open
Abstract
Cells respond to multiple signals from the environment simultaneously, which often creates crosstalk between pathways affecting the capacity to adapt to the changing environment. Chaperones are an important component in the cellular integration of multiple responses to environmental signals, often implicated in negative feedback and inactivation mechanisms. These mechanisms include the stabilization of steroid hormone nuclear receptors in the cytoplasm in the absence of their ligand. Here, we show using immunofluorescence, chromatin immunoprecipitation, and nascent transcripts production that the heat shock protein 70 (HSP70) chaperone plays a central role in a new crosstalk mechanism between the steroid and heat shock response pathways. HSP70-dependent feedback mechanisms are required to inactivate the heat shock factor 1 (HSF1) after activation. Interestingly, a steroid stimulation leads to faster accumulation of HSF1 in inactive foci following heat shock. Our results further show that in the presence of estrogen, HSP70 accumulates at HSF1-regulated noncoding regions, leading to deactivation of HSF1 and the abrogation of the heat shock transcriptional response. Using an HSP70 inhibitor, we demonstrate that the crosstalk between both pathways is dependent on the chaperone activity. These results suggest that HSP70 availability is a key determinant in the transcriptional integration of multiple external signals. Overall, these results offer a better understanding of the crosstalk between the heat shock and steroid responses, which are salient in neurodegenerative disorders and cancers.
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Horseman M, Panahi L, Udeani G, Tenpas AS, Verduzco Jr. R, Patel PH, Bazan DZ, Mora A, Samuel N, Mingle AC, Leon LR, Varon J, Surani S. Drug-Induced Hyperthermia Review. Cureus 2022; 14:e27278. [PMID: 36039261 PMCID: PMC9403255 DOI: 10.7759/cureus.27278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2022] [Indexed: 11/26/2022] Open
Abstract
Humans maintain core body temperature via a complicated system of physiologic mechanisms that counteract heat/cold fluctuations from metabolism, exertion, and the environment. Overextension of these mechanisms or disruption of body temperature homeostasis leads to bodily dysfunction, culminating in a syndrome analogous to exertional heat stroke (EHS). The inability of this thermoregulatory process to maintain the body temperature is caused by either thermal stress or certain drugs. EHS is a syndrome characterized by hyperthermia and the activation of systemic inflammation. Several drug-induced hyperthermic syndromes may resemble EHS and share common mechanisms. The purpose of this article is to review the current literature and compare exertional heat stroke (EHS) to three of the most widely studied drug-induced hyperthermic syndromes: malignant hyperthermia (MH), neuroleptic malignant syndrome (NMS), and serotonin syndrome (SS). Drugs and drug classes that have been implicated in these conditions include amphetamines, diuretics, cocaine, antipsychotics, metoclopramide, selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), and many more. Observations suggest that severe or fulminant cases of drug-induced hyperthermia may evolve into an inflammatory syndrome best described as heat stroke. Their underlying mechanisms, symptoms, and treatment approaches will be reviewed to assist in accurate diagnosis, which will impact the management of potentially life-threatening complications.
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Iba T, Connors JM, Levi M, Levy JH. Heatstroke-induced coagulopathy: Biomarkers, mechanistic insights, and patient management. EClinicalMedicine 2022; 44:101276. [PMID: 35128366 PMCID: PMC8792067 DOI: 10.1016/j.eclinm.2022.101276] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 12/27/2021] [Accepted: 01/07/2022] [Indexed: 12/19/2022] Open
Abstract
Heatstroke is increasingly becoming a significant concern due to global warming. Systemic inflammation and coagulopathy are the two major factors that provoke life-threatening organ dysfunction in heatstroke. Dysregulated thermo-control induces cellular injury, damage-associated molecular patterns release, hyperinflammation, and hypercoagulation with suppressed fibrinolysis to produce heatstroke-induced coagulopathy (HSIC). HSIC can progress to disseminated intravascular coagulation and multiorgan failure if severe enough. Platelet count, D-dimer, soluble thrombomodulin, and inflammation biomarkers such as interleukin-6 and histone H3 are promising markers for HSIC. In exertional heatstroke, the measurement of myoglobin is helpful to anticipate renal dysfunction. However, the optimal cutoff for each biomarker has not been determined. Except for initial cooling and hydration, effective therapy continues to be explored, and the use of antiinflammatory and anticoagulant therapies is under investigation. Despite the rapidly increasing risk, our knowledge is limited, and further study is warranted. In this review, we examine current information and what future efforts are needed to better understand and manage HSIC.
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Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo Bunkyo-ku, Tokyo 113-8421, Japan
- Corresponding author.
| | - Jean Marie Connors
- Hematology Division Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Marcel Levi
- Department of Medicine, University College London Hospitals NHS Foundation Trust, and Cardio-metabolic Programme-NIHR UCLH/UCL BRC London, United Kingdom
| | - Jerrold H. Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC, United States
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Walter E, W Watt P, Gibson OR, Wilmott AGB, Mitchell D, Moreton R, Maxwell NS. Exercise hyperthermia induces greater changes in gastrointestinal permeability than equivalent passive hyperthermia. Physiol Rep 2021; 9:e14945. [PMID: 34409760 PMCID: PMC8374382 DOI: 10.14814/phy2.14945] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 06/05/2021] [Accepted: 06/06/2021] [Indexed: 01/09/2023] Open
Abstract
Hyperthermia and exertional heat illness increase gastrointestinal (GI) permeability, although whether the latter is only via hyperthermia is unclear. The aim of this pilot study was to determine whether different changes in GI permeability, characterized by an increased plasma lactulose:rhamnose concentration ratio ([L:R]), occurred in exercise hyperthermia in comparison to equivalent passive hyperthermia. Six healthy adult male participants (age 25 ± 5 years, mass 77.0 ± 6.7 kg, height 181 ± 6 cm, peak oxygen uptake [ V · O 2 peak ] 48 ± 8 ml.kg-1 .min-1 ) underwent exercise under hot conditions (Ex-Heat) and passive heating during hot water immersion (HWI). Heart rate (HR), rectal temperature (TCORE ), rating of perceived exertion (RPE), and whole-body sweat loss (WBSL) were recorded throughout the trials. The L:R ratio, peak HR, change in HR, and change in RPE were higher in Ex-Heat than HWI, despite no differences in trial duration, peak core temperature or WBSL. L:R was strongly correlated (p < 0.05) with HR peak (r = 0.626) and change in HR (r = 0.615) but no other variable. The greater L:R in Ex-Heat, despite equal TCORE responses to HWI, indicates that increased cardiovascular strain occurred during exercise, and exacerbates hyperthermia-induced GI permeability at the same absolute temperature.
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Affiliation(s)
- Edward Walter
- Department of Intensive CareRoyal Surrey County HospitalGuildfordUK
- Environmental Extremes Lab, Sport and Exercise Science and Medicine Research and Enterprise GroupUniversity of BrightonEastbourneEast SussexUK
| | - Peter W Watt
- Environmental Extremes Lab, Sport and Exercise Science and Medicine Research and Enterprise GroupUniversity of BrightonEastbourneEast SussexUK
| | - Oliver R. Gibson
- Centre for Human Performance, Exercise and Rehabilitation (CHPER)Division of Sport, Health and Exercise SciencesCollege of Health, Medicine, and Life SciencesBrunel University LondonUxbridgeUK
| | - Ashley G. B. Wilmott
- Environmental Extremes Lab, Sport and Exercise Science and Medicine Research and Enterprise GroupUniversity of BrightonEastbourneEast SussexUK
- Cambridge Centre for Sport and Exercise Sciences (CCSES)School of Psychology and Sport ScienceAnglia Ruskin UniversityCambridgeUK
| | - Dominic Mitchell
- Environmental Extremes Lab, Sport and Exercise Science and Medicine Research and Enterprise GroupUniversity of BrightonEastbourneEast SussexUK
| | - Robert Moreton
- Environmental Extremes Lab, Sport and Exercise Science and Medicine Research and Enterprise GroupUniversity of BrightonEastbourneEast SussexUK
| | - Neil S. Maxwell
- Environmental Extremes Lab, Sport and Exercise Science and Medicine Research and Enterprise GroupUniversity of BrightonEastbourneEast SussexUK
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