Markers of physiological stress during exercise under conditions of normoxia, normobaric hypoxia, hypobaric hypoxia, and genuine high altitude

Untapped resource: the simulation-based healthcare environment as a means to study human stress

The effects of 'stress' within the healthcare professions are wide-reaching, not least of all within the field of simulation-based healthcare education. Whilst this popular method of experiential learning offers a 'safe space' for participants to develop their skillset, it also has a more surreptitious action; namely, the incubation of simulation-related stress. Currently, research concerning the complex relationship between stress, learning, and performance is ambiguous, leaving fertile ground for simulationists to debate what level of stress is appropriate for an optimised educational experience. In this narrative review, we examine the human response to stress and outline the various methods that have been used by researchers to measure stress in a quantifiable and standardised way. We then provide a brief overview of simulation-based healthcare education before describing why stress responses have been of interest to healthcare educationalists for some time. Finally, we outline how simulation education environments might provide an ideal environment for studying the human response to stress generally, with ramifications extending beyond the field of medical education.

Biological testing during acute psychological stress: A hindrance or an opportunity?

All humans deal with acute psychological stress periodically. Some individuals are affected by needle phobia in which a heightened sense of arousal is precipitated by venepuncture. Acute psychological stress invokes a range of physiological changes including activation of the sympathetic-adrenal-medullary and hypothalamic-pituitary-adrenal axes. In this review article, we first examine the human response to acute stress. We then provide an overview of how psychological stress in a subject is likely to be a source of pre-analytical variability for certain measurands, and the major biochemical markers that have been studied in research aiming to quantify stress. As such, we highlight how stress can be a hindrance to the accurate interpretation of certain laboratory results (particularly cortisol, prolactin, metanephrines and growth hormone), and point out the role that biochemical analysis might play in future studies looking at the effects of stress on human behaviour.

Reliability of Biomarkers of Physiological Stress at Rest and Post-exertional Heat Stress

The purpose of this study was to assess the reliability of blood biomarkers that can signify exercise-induced heat stress in hot conditions. Fourteen males completed two heat stress tests separated by 5-7 days. Venous blood was drawn pre- and post- heat stress for the concentration of normetanephrine, metanephrine, serum osmolality, copeptin, kidney-injury molecule 1, and neutrophil gelatinase-associated lipocalin. No biomarker, except copeptin, displayed systematic trial order bias (p≥0.05). Normetanephrine, copeptin and neutrophil gelatinase-associated lipocalin presented acceptable reliability (CV range: 0.9-14.3%), while greater variability was present in metanephrine, osmolality and kidney-injury molecule 1 (CV range: 28.6-43.2%). Normetanephrine exhibited the largest increase (p<0.001) in response to heat stress (trial 1=1048±461 pmol. L^-1; trial 2=1067±408 pmol. L^-1), whilst kidney-injury molecule 1 presented trivial changes (trial 1=-4±20 ng. L^-1; trial 2=2 ± 16 ng. L^-1, p>0.05). Normetanephrine, copeptin, and neutrophil gelatinase-associated lipocalin demonstrated good reliability and sensitivity to an acute bout of heat stress. These biomarkers may be suitable for application in laboratory and field research to understand the efficacy of interventions that can attenuate the risk of thermal injury whilst exercising in the heat.

The effect of exercise-induced fatigue and heat exposure on soccer-specific decision-making during high-intensity intermittent exercise

Global warming and the globalisation of sport has increased the prevalence of sports competitions being held in hot environments. However, there is currently limited research investigating the impact of the heat on soccer-specific decision-making skills during exercise reflective of the physical demands of match-play. Therefore, the effects of heat exposure on physical and soccer-specific decision-making performance, biological markers (i.e., metanephrines), appraisal (i.e., challenge vs. threat) and affective states, during prolonged high-intensity intermittent exercise were investigated. Nine well-trained male soccer players completed a 92-min cycling intermittent sprint protocol (CISP), whilst simultaneously responding to a series of soccer-specific decision-making trials at various time points, in two temperature conditions: hot (32°C, 50%rh) and temperate (18°C, 50%rh). Results showed that decision-making score (p = .030) was impaired in the hot compared to the temperate condition. There was a reduced workload in the second half during the hot condition (p = .016), which coincided with a heightened threat state (p = .007) and more unpleasant feelings (p = .008) experienced in the hot, compared to temperate, condition. Furthermore, plasma normetanephrine (NMET) was higher at half-time (p = .012) and post-CISP (p ≤ .001). Also, plasma metanephrine (MET) was higher post-CISP (p = .009) in the hot compared to temperate condition, reflecting a heightened stress response. Our findings highlight the need for practitioners to consider the detrimental effects heat exposure can have on both physical and decision-making performance when looking to facilitate performance in hot conditions.

The effects of normobaric and hypobaric hypoxia on cognitive performance and physiological responses: A crossover study

This partially randomised controlled, crossover study sought to investigate the effects of normobaric hypoxia (NH) and hypobaric hypoxia (HH) on cognitive performance, the physiological response at rest and after a 3-min step-test. Twenty healthy participants (10 females and 10 males, 27.6±6.2yrs, 73.6±13.7kg, 175.3±8.9cm) completed a cognitive performance test, followed by the modified Harvard-step protocol, in four environments: normobaric normoxia (NN; PiO2: 146.0±1.5mmHg), NH (PiO2: 100.9±1.3mmHg), HH at the first day of ascent (HH1: PiO2 = 105.6±0.4mmHg) and HH after an overnight stay (HH2: PiO2 = 106.0±0.5mmHg). At rest and/or exercise, SpO2, NIRS, and cardiovascular and perceptual data were collected. The cerebral tissue oxygenation index and the cognitive performance (throughput, accuracy, and reaction time) were not different between the hypoxic conditions (all p>0.05). In NH, SpO2 was higher compared to HH1 (ΔSpO2 NH vs HH1: 1.7±0.5%, p = 0.003) whilst heart rate (ΔHR NH vs HH2: 5.8±2.6 bpm, p = 0.03) and sympathetic activation (ΔSNSi NH vs HH2: 0.8±0.4, p = 0.03) were lower in NH compared to HH2. Heart rate (ΔHR HH1 vs HH2: 6.9±2.6 bpm, p = 0.01) and sympathetic action (ΔSNSi HH1 vs HH2: 0.9±0.4, p = 0.02) were both lower in HH1 compared to HH2. In conclusion, cognitive performance and cerebral oxygenation didn’t differ between the hypoxic conditions. SpO2 was only higher in NH compared to HH1. In HH2, heart rate and sympathetic activation were higher compared to both NH and HH1. These conclusions account for a PiO2 between 100–106 mmHg.

Acute Normobaric Hypoxia Lowers Executive Functions among Young Men despite Increase of BDNF Concentration

BACKGROUND

Decreased SpO₂ during hypoxia can cause cognitive function impairment, and the effects of acute hypoxia on high-order brain functions such as executive processing remain unclear. This study's goal was to examine the impact of an acute normobaric hypoxia breathing session on executive function and biological markers.

METHODS

Thirty-two healthy subjects participated in a blind study performing two sessions of single 30 min breathing bouts under two conditions (normoxia (NOR) and normobaric hypoxia (NH), FIO₂ = 0.135). The Stroop test was applied to assess cognitive function.

RESULTS

No significant difference was observed in the Stroop interference in the "reading" part of the test in either condition; however, there was a significant increase in the "naming" part under NH conditions (p = 0.003), which corresponded to a significant decrease in SpO₂ (p < 0.001). There was a significant increase (p < 0.013) in the brain-derived neurotrophic factor (BDNF) level after NH conditions compared to the baseline, which was not seen in NOR. In addition, a significant drop (p < 0.001) in cortisol levels in the NOR group and a slight elevation in the NH group was noticed.

CONCLUSIONS

According to these findings, acute hypoxia delayed cognitive processing for motor execution and reduced the neural activity in motor executive and inhibitory processing. We also noted that this negative effect was associated with decreased SpO₂ irrespective of a rise in BDNF.

Self-Paced Endurance Performance and Cerebral Hemodynamics of the Prefrontal Cortex: A Scoping Review of Methodology and Findings

Recent research has suggested that top-down executive function associated with the prefrontal cortex is key to the decision-making processes and pacing of endurance performance. A small but growing body of literature has investigated the neurological underpinnings of these processes by subjecting the prefrontal cortex to functional near-infrared spectroscopy (fNIRS) measurement during self-paced endurance task performance. Given that fNIRS measurement for these purposes is a relatively recent development, the principal aim of this review was to assess the methodological rigor and findings of this body of research. We performed a systematic literature search to collate research assessing prefrontal cortex oxygenation via fNIRS during self-paced endurance performance. A total of 17 studies met the criteria for inclusion. We then extracted information concerning the methodology and findings from the studies reviewed. Promisingly, most of the reviewed studies reported having adopted commonplace and feasible best practice guidelines. However, a lack of adherence to these guidelines was evident in some areas. For instance, there was little evidence of measures to tackle and remove artifacts from data. Lastly, the reviewed studies provide insight into the significance of cerebral oxygenation to endurance performance and the role of the prefrontal cortex in pacing behavior. Therefore, future research that better follows the guidelines presented will help advance our understanding of the role of the brain in endurance performance and aid in the development of techniques to improve or maintain prefrontal cortex (PFC) oxygenation to help bolster endurance performance.

Chronic Exposure to Normobaric Hypoxia Increases Testosterone Levels and Testosterone/Cortisol Ratio in Cyclists

The aim of this study was to analyze the effects of the “live high, train low” method (LH−TL) and intermittent hypoxic training (IHT) on testosterone (T) and cortisol (C) levels in cyclists. Thirty cyclists participated in the experiment. The LH−TL group (n = 10) was exposed to normobaric hypoxia (FiO2 = 16.3%) for 11−12 h a day and trained in normoxia for 3 weeks. In the IHT group (n = 10), participants followed the IHT routine three times a week for 3 weeks in normobaric hypoxia (FiO2 = 16.3%). The control group (N; n = 10) followed the same training protocol in normoxia. The LH−TL training was found to significantly increase (p < 0.05) T levels and the testosterone/cortisol (T/C) ratio during the experiment. The area under the curve (AUC) calculated for T levels over 4 weeks was significantly (p < 0.05) higher in the LH−TL group, by 25.6%, compared to the N group. The results also indicated a significant correlation (r = 0.53; p < 0.05) between AUC for T levels over 4 weeks and ∆ values of hemoglobin (HGB) in the LH−TL group. Overall, the findings show that LH−TL training at a moderate simulated altitude contributes to an increase in T levels and T/C ratio in athletes, which is a beneficial change stimulating anabolic processes and erythropoiesis.

Effects of Resistance Training in Hypobaric vs. Normobaric Hypoxia on Circulating Ions and Hormones

Hypobaric hypoxia (HH) seems to lead to different responses compared to normobaric hypoxia (NH) during physical conditioning. The aim of the study was to analyze the hormonal and circulating ion responses after performing high-intensity resistance training with different inter-set rest under HH and NH condition. Sixteen male volunteers were randomly divided into two training groups. Each group completed two counterbalanced resistance training sessions (three sets × ten repetitions, remaining two repetitions in reserve), with both one- and two-minute inter-set rest, under HH and NH. Blood samples were obtained to determine hormones and circulating ions (Ca²⁺, Pi, and HCO₃⁻) at baseline and after training sessions (5, 10, and 30 min). Resistance training with one-minute rest caused greater hormonal stress than with two-minute rest in cortisol and growth hormone, although the hypoxic environmental condition did not cause any significant alterations in these hormones. The short inter-set rest also caused greater alterations in HCO₃⁻ and Pi than the longer rest. Additionally, higher levels of Ca²⁺ and Pi, and lower levels of HCO₃⁻, were observed after training in HH compared to NH. Metabolic and physiological responses after resistance training are mediated by inter-set rest intervals and hypoxic environmental condition. According to the alterations observed in the circulating ions, HH could cause greater muscular fatigue and metabolic stress than NH.

Proactive Management of Intraoperative Hypotension Reduces Biomarkers of Organ Injury and Oxidative Stress during Elective Non-Cardiac Surgery: A Pilot Randomized Controlled Trial

Background: Intraoperative hypotension is associated with increased postoperative morbidity and mortality. Methods: We randomly assigned patients undergoing major general surgery to early warning system (EWS) and hemodynamic algorithm (intervention group, n = 20) or standard care (n = 20). The primary outcome was the difference in hypotension (defined as mean arterial pressure < 65 mmHg) and as secondary outcome surrogate markers of organ injury and oxidative stress. Results: The median number of hypotensive episodes was lower in the intervention group (−5.0 (95% CI: −9.0, −0.5); p < 0.001), with lower time spent in hypotension (−12.8 min (95% CI: −38.0, −2.3 min); p = 0.048), correspondent to −4.8% of total surgery time (95% CI: −12.7, 0.01%; p = 0.048).The median time-weighted average of hypotension was 0.12 mmHg (0.35) in the intervention group and 0.37 mmHg (1.11) in the control group, with a median difference of −0.25 mmHg (95% CI: −0.85, −0.01; p = 0.025). Neutrophil Gelatinase-Associated Lipocalin (NGAL) correlated with time-weighted average of hypotension (R = 0.32; p = 0.038) and S100B with number of hypotensive episodes, absolute time of hypotension, relative time of hypotension and time-weighted average of hypotension (p < 0.001 for all). The intervention group showed lower Neuronal Specific Enolase (NSE) and higher reduced glutathione when compared to the control group. Conclusions: The use of an EWS coupled with a hemodynamic algorithm resulted in reduced intraoperative hypotension, reduced NSE and oxidative stress.

Systemic ventricular function in Fontan patients at rest and after exercise at altitude

OBJECTIVE

Physical activity at high altitude is expected to pose risks for patients with Fontan circulation and to impair systemic ventricular function. This study aims to determine the effect of high-altitude hypoxia on ventricular function in Fontan patients at rest and after exercise. We hypothesize that systemic ventricular function deteriorates under hypoxic conditions in Fontan patients.

METHODS

In this prospective study, 21 Fontan patients (NYHA class I-II) and 21 age-, gender- and body mass index-matched healthy controls were enrolled (median age 17.9 and 16.9 years). Transthoracic echocardiography was performed at rest, after peak (PE) and after continuous exercise (CE) in normoxia and hypoxia at simulated altitude (2,500 m above sea level). The effect of hypoxia on echocardiographic parameters was quantified by linear mixed-effects models and the difference between normoxia and hypoxia (Δ= hypoxia-normoxia).

RESULTS

At rest, cardiac output (CO) estimated by outflow tract velocity time integral × heart rate and annular plane systolic excursion (APSE) were lower in hypoxia compared to normoxia in Fontan patients (CO: Δ = -12.0%, n.s.; APSE: Δ = -9.6%, p < 0.001), an increase was observed in controls (CO: Δ = 8.5%, n.s.; APSE: Δ = 2.5%, n.s.). Other parameters of systolic and diastolic function did not show relevant changes. After exercise under hypoxic conditions, Fontan patients did not show relevant deterioration of systolic function compared to normoxia. Late, active diastolic filling reflected by A-wave velocity remained unchanged in Fontan patients, but increased in controls. Under hypoxic conditions, CO and workload were higher after CE than PE in Fontan patients (CO: PE Δ = 1,530 vs. CE 1630), whereas controls showed higher work load and CO estimates after PE than CE as expected (CO: PE Δ = 2,302 vs. CE 2149).

CONCLUSION

Fontan patients clinically tolerated short-term altitude exposure up to two hours and exercise and showed no consistent deterioration of systolic systemic ventricular function, but parameters of myocardial contractility, heart rate and cardiac output did not increase as observed in controls. This is likely to be multifactorial and may include intrinsic cardiac dysfunction as well as preload inadequacy and the lack of augmented atrial contraction. CE may be better tolerated than PE.

No effect of patent foramen ovale on acute mountain sickness and pulmonary pressure in normobaric hypoxia

What is the central question to this study? Is there a relationship between a patent foramen ovale and the development of acute mountain sickness and an exaggerated increase in pulmonary pressure in response to 7-10 hours of normobaric hypoxia? What is the main finding and its importance? Patent foramen ovale presence did not increase susceptibility to acute mountain sickness or result in an exaggerated increase in pulmonary artery systolic pressure with normobaric hypoxia. This data suggest hypobaric hypoxia is integral to the increased susceptibility to acute mountain sickness previously reported in those with patent foramen ovale, and patent foramen ovale presence alone does not contribute to the hypoxic pulmonary pressor response. ABSTRACT: Acute mountain sickness (AMS) develops following rapid ascent to altitude, but its exact causes remain unknown. A patent foramen ovale (PFO) is a right-to-left intracardiac shunt present in ∼30% of the population that has been shown to increase AMS susceptibility with high altitude hypoxia. Additionally, high altitude pulmonary edema (HAPE), is a severe type of altitude illness characterized by an exaggerated pulmonary pressure response, and there is a greater prevalence of PFO in those with a history of HAPE. However, whether hypoxia, per se, is causing the increased incidence of AMS in those with a PFO and whether a PFO is associated with an exaggerated increase in pulmonary pressure in those without a history of HAPE is unknown. Participants (n = 36) matched for biological sex (18 female) and the presence or absence of a PFO (18 PFO+) were exposed to 7-10 hours of normobaric hypoxia equivalent to 4755 m. Presence and severity of AMS was determined using the Lake Louise AMS scoring system. Pulmonary artery systolic pressure, cardiac output, and total pulmonary resistance were measured using ultrasound. We found no significant association of PFO with incidence or severity of AMS and no association of PFO with arterial oxygen saturation. Additionally, there was no effect of a PFO on pulmonary pressure, cardiac output, or total pulmonary resistance. These data suggest that hypobaric hypoxia is necessary for those with a PFO to have increased incidence of AMS and that presence of PFO is not associated with an exaggerated pulmonary pressor response. This article is protected by copyright. All rights reserved.

Diagnosis, Investigation and Management of Patients with Acute and Chronic Myocardial Injury

The application of high-sensitivity cardiac troponins in clinical practice has led to an increase in the recognition of elevated concentrations in patients without myocardial ischaemia. The Fourth Universal Definition of Myocardial Infarction encourages clinicians to classify such patients as having an acute or chronic myocardial injury based on the presence or absence of a rise or a fall in cardiac troponin concentrations. Both conditions may be caused by a variety of cardiac and non-cardiac conditions, and evidence suggests that clinical outcomes are worse than patients with myocardial infarction due to atherosclerotic plaque rupture, with as few as one-third of patients alive at 5 years. Major adverse cardiovascular events are comparable between populations, and up to three-fold higher than healthy individuals. Despite this, no evidence-based strategies exist to guide clinicians in the investigation of non-ischaemic myocardial injury. This review explores the aetiology of myocardial injury and proposes a simple framework to guide clinicians in early assessment to identify those who may benefit from further investigation and treatment for those with cardiovascular disease.

Plasma free metanephrine and normethanephrine levels correlated to plasma catecholamine after acute running in amateur runner

Background

Catecholamine is a typical index of exercise intensity, but it is difficult to detect. Plasma metanephrine (MN) and normethanephrine (NMN) levels are more stable than those of catecholamines. This study aimed to investigate plasma MN and NMN levels during acute exercise running in amateur runners.

Methods

Samples were collected from eight healthy male participants. They were either sedentary or running at low or high intensity for 30 min. Blood samples were collected under these conditions. Measurements taken included plasma adrenaline, noradrenaline, MN, and NMN.

Results

Plasma adrenaline levels increased after high-intensity exercise compared with sedentary subjects. Plasma noradrenaline, MN, and NMN levels increased after both low- and high-intensity exercise compared with sedentary subjects. In addition, these levels were also significantly higher at high intensity than at low intensity. Plasma adrenaline and noradrenaline levels were positively correlated with plasma free MN and NMN levels after acute running, respectively.

Conclusion

This study revealed that plasma MN and NMN levels transiently increased depending on exercise intensity in amateur runners. In addition, plasma NMN levels are better markers than plasma MN levels because of their stronger correlation with plasma catecholamine levels.

Rate-Pressure Product Responses to Static Contractions Performed at Various Altitudes

Simmonds, Michael J., Surendran Sabapathy, and Jean-Marc Hero. Rate-pressure product responses to static contractions performed at various altitudes. High Alt Med Biol. 22: 166-173, 2021. Background: Adventure tourism has led to an unprecedented number of individuals being exposed to altitude, including those with subclinical cardiometabolic disorders. The disproportionate hemodynamic challenge associated with small-muscle static activities is potentially dangerous at altitude as these may compound the risk for cardiac events. We thus examined the cardiovascular response to, and during recovery from, static exercise performed at altitude. Methods: Eighteen individuals completed this study at three altitudes (sea level; ∼1,500 m; ∼3,000 m) in central Nepal. At each altitude, individuals performed two handgrip contractions for 2 minutes at the same intensity (30% maximal voluntary contraction [MVC]), with two distinct recovery periods: during control recovery was completed quietly at rest, while during ischemic challenge recovery was conducted with a cuff occluding the upper limb. Results: Oxygen saturation decreased during ascent to 1,500 m (-2%) and 3,000 m (-8%), compared with sea level. Handgrip MVC was not affected by altitude, although heart rate at rest (∼70 beat/min), during static exercise (range ∼90-95 beat/min), and during recovery in both conditions (each ∼70 beat/min) was significantly increased by ∼15% at 3,000 m, but not 1,500 m. The magnitude of the muscle metaboreflex during recovery from static exercise was unaffected by altitude; however, the rate-pressure product was significantly elevated by ∼10% during and following static exercise at 3,000 m. Conclusions: A significant increase in the rate-pressure product during static exercise was observed at altitude, which persisted during recovery. Individuals at risk for cardiac events should use awareness of static contractions while at altitude, especially considering that stress induced by static exercise is additive to that of dynamic activities such as hiking.

Decrease in Salivary Serotonin in Response to Probiotic Supplementation With Saccharomyces boulardii in Healthy Volunteers Under Psychological Stress: Secondary Analysis of a Randomized, Double-Blind, Placebo-Controlled Trial

BACKGROUND

Bacterial probiotics are thought to exert a serotonergic effect relevant to their potential antidepressant and pro-cognitive action, but yeast probiotics have not been tested. The aim of the present study was to determine whether 30-day supplementation with Saccharomyces boulardii affects the level of salivary serotonin under psychological stress and identify the factors associated with it.

METHODS

Healthy medical students were randomized to ingest Saccharomyces boulardii CNCM I-1079 or placebo before a stressful event. Salivary serotonin concentration was assessed before and at the end of supplementation. Moreover, obtained results were compared to psychological, biochemical, physiological and sociodemographic study participants data.

RESULTS

Data of thirty-two participants (22.8 ± 1.7 years of age, 16 males) was available for the main analysis. Supplementation with Saccharomyces boulardii decreased salivary serotonin concentration under psychological stress by 3.13 (95% CI 0.20 to 6.07) ng/mL, p = 0.037, as compared to placebo. Salivary serotonin was positively correlated with salivary metanephrine (β = 0.27, 95% CI 0.02 to 0.52, p = 0.031) and pulse rate (β = 0.28, 95% CI 0.05 to 0.50, p = 0.018), but insignificantly with anxiety, depression, eating attitudes and information retrieval.

CONCLUSIONS

Saccharomyces boulardii CNCM I-1079 may be distinct from bacterial probiotics in its salivary serotonergic effect, which appears positively linked to symapathoadrenal markers. The study requires cautious interpretation, and further investigation.

The Effects of Heat Exposure During Intermittent Exercise on Physical and Cognitive Performance Among Team Sport Athletes

This study investigated the effects of heat exposure on physical and cognitive performance during an intermittent exercise protocol so as to reflect the incremental fatigue experienced during team sports. Twelve well-trained male team sport players completed an 80-minute cycling intermittent sprint protocol (CISP), alongside computerized vigilance and congruent (i.e., simple) and incongruent (i.e., complex) Stroop tasks of cognitive functioning, in two counterbalanced temperature conditions; hot (32°C[50%rh]) and control (18°C[50%rh]). Incongruent Stroop accuracy declined over time (p = .002), specifically in the second (M^diff = –3.75, SD = 0.90%, p = .009) and third (M^diff = –4.58, SD = 1.22%, p = .019) quarters compared to the first quarter of the CISP; but there were no differences between temperature conditions. Congruent Stroop reaction time (RT) was quicker in the second quarter of exercise in the hot condition (M = 561.99, SD = 112.93 ms) compared to the control condition (M=617.80, SD = 139.71 ms; p = .022), but no differences were found for congruent Stroop accuracy nor vigilance measures. Additionally, peak power output was lower during the third quarter of the CISP in the hot condition (M = 861.31, SD = 105.20 W) compared to the control condition (M = 900.68, SD = 114.84 W; p < .001). Plasma normetanephrine and metanephrine concentrations increased from pre- to post-CISP (M^diff = +616.90, SD = 306.99, p < .001; and M^diff = +151.23, SD = 130.32, p = .002, respectively), with a marginal interaction suggesting a higher normetanephrine increase from pre- to post-CISP in the hot versus the control condition (p = .070). Our findings suggest that accuracy for more complex decisions suffered during prolonged high-intensity intermittent exercise, perhaps due to exercise-induced catecholamine increases. Athletes may have also reduced physical effort under increased heat exposure, indicating how cognitive performance may be sustained in physically demanding environments.

The multiple organs insult and compensation mechanism in mice exposed to hypobaric hypoxia

This study was first and systematically conducted to evaluate the hypoxia response of the brain, heart, lung, liver, and kidney of mice exposed to an animal hypobaric chamber. First, we examined the pathological damage of the above tissues by Hematoxylin & eosin (H&E) staining. Secondly, biochemical assays were used to detect oxidative stress indicators such as superoxide dismutase (SOD), malondialdehyde (MDA), reduced glutathione (GSH), and oxidized glutathione (GSSG). Finally, the hypoxia compensation mechanism of tissues was evaluated by expression levels of hypoxia-inducible factor 1 alpha (HIF-1α), erythropoietin (EPO), and vascular endothelial growth factor (VEGF). During the experiment, the mice lost weight gradually on the first 3 days, and then, the weight loss tended to remain stable, and feed consumption showed the inverse trend. H&E staining results showed that there were sparse and atrophic neurons and dissolved chromatin in the hypoxia group. And hyperemia occurred in the myocardium, lung, liver, and kidney. Meanwhile, hypoxia stimulated the enlargement of myocardial space, the infiltration of inflammatory cells in lung tissue, the swelling of epithelial cells in hepatic lobules and renal tubules, and the separation of basal cells. Moreover, hypoxia markedly inhibited the activity of SOD and GSH and exacerbated the levels of MDA and GSSG in the serum and five organs. In addition, hypoxia induced the expression of HIF-1α, EPO, and VEGF in five organs. These results suggest hypoxia leads to oxidative damage and compensation mechanism of the brain, heart, lung, liver, and kidney in varying degrees of mice.

A Focused Review on the Maximal Exercise Responses in Hypo- and Normobaric Hypoxia: Divergent Oxygen Uptake and Ventilation Responses

The literature suggests that acute hypobaric (HH) and normobaric (NH) hypoxia exposure elicits different physiological responses. Only limited information is available on whether maximal cardiorespiratory exercise test outcomes, performed on either the treadmill or the cycle ergometer, are affected differently by NH and HH. A focused literature review was performed to identify relevant studies reporting cardiorespiratory responses in well-trained male athletes (individuals with a maximal oxygen uptake, VO_2max > 50 mL/min/kg at sea level) to cycling or treadmill running in simulated acute HH or NH. Twenty-one studies were selected. The exercise tests in these studies were performed in HH (n = 90) or NH (n = 151) conditions, on a bicycle ergometer (n = 178) or on a treadmill (n = 63). Altitudes (simulated and terrestrial) varied between 2182 and 5400 m. Analyses (based on weighted group means) revealed that the decline in VO_2max per 1000 m gain in altitude was more pronounced in acute NH vs. HH (-7.0 ± 1.4% vs. -5.6 ± 0.9%). Maximal minute ventilation (VE_max) increased in acute HH but decreased in NH with increasing simulated altitude (+1.9 ± 0.9% vs. -1.4 ± 1.8% per 1000 m gain in altitude). Treadmill running in HH caused larger decreases in arterial oxygen saturation and heart rate than ergometer cycling in acute HH, which was not the case in NH. These results indicate distinct differences between maximal cardiorespiratory responses to cycling and treadmill running in acute NH or HH. Such differences should be considered when interpreting exercise test results and/or monitoring athletic training.

Effect of Supplementation with Saccharomyces Boulardii on Academic Examination Performance and Related Stress in Healthy Medical Students: A Randomized, Double-Blind, Placebo-Controlled Trial

In recent years, bacterial probiotic dietary supplementation has emerged as a promising way to improve cognition and to alleviate stress and anxiety; however, yeast probiotics have not been tested. The aim of the present study was to determine whether 30-day supplementation with Saccharomyces boulardii enhances academic performance under stress and affects stress markers. The trial was retrospectively registered at clinicaltrials.gov (NCT03427515). Healthy medical students were randomized to supplement their diet with Saccharomyces boulardii CNCM I-1079 or placebo before sitting for an academic examination, which served as a model of stress. The grades of a final examination adjusted to subject knowledge tested in non-stressful conditions was used as a primary outcome measure. Psychometrically evaluated state anxiety, cortisol and metanephrine salivary levels, and pulse rate were tested at a non-stressful time point before the intervention as well as just before the stressor. Fifty enrolled participants (22.6 ± 1.4 years of age, 19 males) completed the trial in the Saccharomyces and placebo arms. Supplementation with Saccharomyces did not significantly modify examination performance or increase in state anxiety, salivary cortisol, and metanephrine. However, the intervention resulted in higher increase in pulse rate under stress as compared to placebo by 10.4 (95% CI 4.2–16.6) min⁻¹ (p = 0.0018), and the effect positively correlated with increase in salivary metanephrine (Pearson’s r = 0.35, 95% CI 0.09–0.58, p = 0.012). An intention-to-treat analysis was in line with the per-protocol one. In conclusion, supplementation with Saccharomyces boulardii CNCM I-1079 appears largely ineffective in improving academic performance under stress and in alleviating some stress markers, but it seems to increase pulse rate under stress, which may hypothetically reflect enhanced sympathoadrenal activity.

Technical Feasibility and Physiological Relevance of Hypoxic Cell Culture Models

Hypoxia is characterized as insufficient oxygen delivery to tissues and cells in the body and is prevalent in many human physiology processes and diseases. Thus, it is an attractive state to experimentally study to understand its inner mechanisms as well as to develop and test therapies against pathological conditions related to hypoxia. Animal models in vivo fail to recapitulate some of the key hallmarks of human physiology, which leads to human cell cultures; however, they are prone to bias, namely when pericellular oxygen concentration (partial pressure) does not respect oxygen dynamics in vivo. A search of the current literature on the topic revealed this was the case for many original studies pertaining to experimental models of hypoxia in vitro. Therefore, in this review, we present evidence mandating for the close control of oxygen levels in cell culture models of hypoxia. First, we discuss the basic physical laws required for understanding the oxygen dynamics in vitro, most notably the limited diffusion through a liquid medium that hampers the oxygenation of cells in conventional cultures. We then summarize up-to-date knowledge of techniques that help standardize the culture environment in a replicable fashion by increasing oxygen delivery to the cells and measuring pericellular levels. We also discuss how these tools may be applied to model both constant and intermittent hypoxia in a physiologically relevant manner, considering known values of partial pressure of tissue normoxia and hypoxia in vivo, compared to conventional cultures incubated at rigid oxygen pressure. Attention is given to the potential influence of three-dimensional tissue cultures and hypercapnia management on these models. Finally, we discuss the implications of these concepts for cell cultures, which try to emulate tissue normoxia, and conclude that the maintenance of precise oxygen levels is important in any cell culture setting.

Exercise responses in children and adults with a Fontan circulation at simulated altitude

BACKGROUND

Traveling to high altitude has become more popular. High-altitude exposure causes hypobaric hypoxia. Exposure to acute high altitude, during air travel or mountain stays, seems to be safe for most patients with congenital heart disorders (CHD). Still, current guidelines for CHD patients express concerns regarding safety of altitude exposure for patients with a Fontan circulation. Therefore, investigating hemodynamic and pulmonary responses of acute high-altitude exposure (±2500 m) at rest and during maximal exercise in patients with Fontan circulation can provide clarity in this dispute and may contribute to improvement of clinical counseling.

METHODS

Twenty-one Fontan patients with 21 age-matched healthy controls, aged 8-40 years, were enrolled in an observational study. Participants performed two cardiopulmonary exercise tests on a cycle ergometer with breath-by-breath respiratory gas analyses combined with noninvasive impedance cardiac output measurements: one at sea level (±6 m) and one at simulated high altitude (±2500 m), respectively.

RESULTS

The effect of altitude exposure was different in rest for saturation (-2.3% vs -4.1%) between Fontan patients and healthy controls (P < .05). At peak exercise the effects of high altitude exposure was different on VO₂ (-5.1% vs 9.6%) and AvO₂ -diff (-0.3% vs -12.8%) between Fontan patients and healthy controls.

CONCLUSION

Although, acute high-altitude exposure has a detrimental effect on exercise capacity, the impact on pulmonary and hemodynamic responses of high-altitude exposure is comparable between Fontan patients and healthy controls.

Rhodiola crenulata attenuates apoptosis and mitochondrial energy metabolism disorder in rats with hypobaric hypoxia-induced brain injury by regulating the HIF-1α/microRNA 210/ISCU1/2(COX10) signaling pathway

ETHNOPHARMACOLOGICAL RELEVANCE

Rhodiola crenulata, a traditional Tibetan medicine, has shown promise in the treatment of hypobaric hypoxia (HH)-induced brain injury. However, the underlying mechanisms remain unclear. This study investigated the protective effects of R. crenulata aqueous extract (RCAE) on HH-induced brain injury in rats.

MATERIALS AND METHODS

An animal model of high-altitude hypoxic brain injury was established in SD rats using an animal decompression chamber for 24 h. Serum and hippocampus levels of superoxide dismutase (SOD), malondialdehyde (MDA), glutathione (GSH), oxidized glutathione (GSSG), and lactate dehydrogenase (LDH) were then determined using commercial biochemical kits. Neuron morphology and vitality were also evaluated using H&E and Nissl staining, and TUNEL staining was used to examine apoptosis. Gene and protein expression of HIF-1α, microRNA 210, ISCU1/2, COX10, Apaf-1, cleaved Caspase-3, Caspase-3, Bax, Bcl-2, and Cyto-c were determined by western blot, immunohistochemical and qRT-PCR analysis.

RESULTS

RCAE administration attenuated HH-induced brain injury as evidenced by decreased levels of MDA, LDH, and GSSG, increased GSH and SOD, improvements in hippocampus histopathological changes, increased cell vitality and ATP level, and reduced apoptotic cell numbers. RCAE treatment also enhanced HIF-1α, ISCU1/2, COX10, and Bcl-2 protein expression, while dramatically inhibiting expression of Apaf-1, Bax, Cyto-c, and cleaved Caspase-3. Treatment also increased gene levels of HIF-1α, microRNA 210, ISCU1/2, and COX10, and decreased Caspase-3 gene production.

CONCLUSIONS

RCAE attenuated HH-induced brain injury by regulating apoptosis and mitochondrial energy metabolism via the HIF-1α/microRNA 210/ISCU1/2 (COX10) signaling pathway.

Effects of periodic carbohydrate ingestion on endurance and cognitive performances during a 40-km cycling time-trial under normobaric hypoxia in well-trained triathletes

The purpose of this study was to examine CHO ingestion on a cognitive task using a field-simulated time-trial (TT) under hypoxia in well-trained triathletes. Ten male triathletes (age: 22.1 ± 1.1 years; VO₂max: 59.4 ± 1.4 ml/kg/min) participated in this double-blind/crossover/counter-balanced design study. Participants completed 3 TT trials: 1) normoxic placebo (NPLA; FiO₂ = 20.9%), 2) hypoxic placebo (HPLA; FiO₂ = 16.3%), and 3) hypoxic CHO (HCHO; 6% CHO provided as 2 ml/kg/15 min; FiO₂ = 16.3%). During the TT, physiological responses (SpO₂, HR, RPE, and blood glucose/lactate), cognitive performance, and cerebral haemodynamics were measured. Hypoxia reduced TT performance by ~3.5-4% (p < 0.05), but CHO did not affect TT performance under hypoxia. For the cognitive task, CHO slightly preserved exercise-induced cognitive reaction speed but did not affect response accuracy during hypoxic exercise. However, CHO did not preserve the decreased Hb-Diff (cerebral blood flow, CBF) and increased HHb in the prefrontal lobe (p < 0.05) during hypoxic exercise, and CHO failed to preserve hypoxia-suppressed prefrontal CBF and tissue oxygen saturation. In conclusion, the present study demonstrates that CHO is effective in sustaining reaction speed for a cognitive task but not promoting TT performance during hypoxic exercise, which would be important for strategy-/decision-making when athletes compete at moderate high-altitude.

Effects of altitude changes on mild-to-moderate closed-head injury in rats following acute high-altitude exposure

Mild-to-moderate closed-head injury (mmCHI) is an acute disease induced by high-altitudes. It is general practice to transfer patients to lower altitudes for treatment, but the pathophysiological changes at different altitudes following mmCHI remain unknown. The present study simulated acute high-altitude exposure (6,000 m above sea level) in rats to establish a model of mmCHI and recorded their vital signs. The rats were then randomly assigned into different altitude exposure groups (6,000, 4,500 and 3,000 m) and neurological severity score (NSS), body weight (BW), brain magnetic resonance imaging (MRI), brain water content (BWC) and the ratio of BW/BWC at 6, 12 and 24 h following mmCHI, and the glial fibrillary acidic protein levels were analysed in all groups. The results revealed that within the first 24 h following acute high-altitude exposure, mmCHI induced dehydration, brain oedema and neuronal damage. Brain injury in rats was significantly reversed following descent to 4,500 m compared with the results from 6,000 or 3,000 m. The results indicated that subjects should be transported as early as possible. Furthermore, avoiding large-span descent altitude was beneficial to reduce neurological impairment. The examination of brain-specific biomarkers and MRI may further be useful in determining the prognosis of high-altitude mmCHI. These results may provide guidance for rescuing high altitude injuries.

Modulations of Neuroendocrine Stress Responses During Confinement in Antarctica and the Role of Hypobaric Hypoxia

The Antarctic continent is an environment of extreme conditions. Only few research stations exist that are occupied throughout the year. The German station Neumayer III and the French-Italian Concordia station are such research platforms and human outposts. The seasonal shifts of complete daylight (summer) to complete darkness (winter) as well as massive changes in outside temperatures (down to -80°C at Concordia) during winter result in complete confinement of the crews from the outside world. In addition, the crew at Concordia is subjected to hypobaric hypoxia of ∼650 hPa as the station is situated at high altitude (3,233 m). We studied three expedition crews at Neumayer III (sea level) (n = 16) and two at Concordia (high altitude) (n = 15) to determine the effects of hypobaric hypoxia on hormonal/metabolic stress parameters [endocannabinoids (ECs), catecholamines, and glucocorticoids] and evaluated the psychological stress over a period of 11 months including winter confinement. In the Neumayer III (sea level) crew, EC and n-acylethanolamide (NAE) concentrations increased significantly already at the beginning of the deployment (p < 0.001) whereas catecholamines and cortisol remained unaffected. Over the year, ECs and NAEs stayed elevated and fluctuated before slowly decreasing till the end of the deployment. The classical stress hormones showed small increases in the last third of deployment. By contrast, at Concordia (high altitude), norepinephrine concentrations increased significantly at the beginning (p < 0.001) which was paralleled by low EC levels. Prior to the second half of deployment, norepinephrine declined constantly to end on a low plateau level, whereas then the EC concentrations increased significantly in this second period during the overwintering (p < 0.001). Psychometric data showed no significant changes in the crews at either station. These findings demonstrate that exposition of healthy humans to the physically challenging extreme environment of Antarctica (i) has a distinct modulating effect on stress responses. Additionally, (ii) acute high altitude/hypobaric hypoxia at the beginning seem to trigger catecholamine release that downregulates the EC response. These results (iii) are not associated with psychological stress.

Limitation of Maximal Heart Rate in Hypoxia: Mechanisms and Clinical Importance

The use of exercise intervention in hypoxia has grown in popularity amongst patients, with encouraging results compared to similar intervention in normoxia. The prescription of exercise for patients largely rely on heart rate recordings (percentage of maximal heart rate (HR_max) or heart rate reserve). It is known that HR_max decreases with high altitude and the duration of the stay (acclimatization). At an altitude typically chosen for training (2,000-3,500 m) conflicting results have been found. Whether or not this decrease exists or not is of importance since the results of previous studies assessing hypoxic training based on HR may be biased due to improper intensity. By pooling the results of 86 studies, this literature review emphasizes that HR_max decreases progressively with increasing hypoxia. The dose–response is roughly linear and starts at a low altitude, but with large inter-study variabilities. Sex or age does not seem to be a major contributor in the HR_max decline with altitude. Rather, it seems that the greater the reduction in arterial oxygen saturation, the greater the reduction in HRmax, due to an over activity of the parasympathetic nervous system. Only a few studies reported HR_max at sea/low level and altitude with patients. Altogether, due to very different experimental design, it is difficult to draw firm conclusions in these different clinical categories of people. Hence, forthcoming studies in specific groups of patients are required to properly evaluate (1) the HR_max change during acute hypoxia and the contributing factors, and (2) the physiological and clinical effects of exercise training in hypoxia with adequate prescription of exercise training intensity if based on heart rate.

Copeptin reflects physiological strain during thermal stress

PURPOSE

To prevent heat-related illnesses, guidelines recommend limiting core body temperature (T c) ≤ 38 °C during thermal stress. Copeptin, a surrogate for arginine vasopressin secretion, could provide useful information about fluid balance, thermal strain and health risks. It was hypothesised that plasma copeptin would rise with dehydration from occupational heat stress, concurrent with sympathoadrenal activation and reduced glomerular filtration, and that these changes would reflect T c responses.

METHODS

Volunteers (n = 15) were recruited from a British Army unit deployed to East Africa. During a simulated combat assault (3.5 h, final ambient temperature 27 °C), T c was recorded by radiotelemetry to differentiate volunteers with maximum T c > 38 °C versus ≤ 38 °C. Blood was sampled beforehand and afterwards, for measurement of copeptin, cortisol, free normetanephrine, osmolality and creatinine.

RESULTS

There was a significant (P < 0.05) rise in copeptin from pre- to post-assault (10.0 ± 6.3 vs. 16.7 ± 9.6 pmol L-1, P < 0.001). Although osmolality did not increase, copeptin correlated strongly with osmolality after the exposure (r = 0.70, P = 0.004). In volunteers with maximum T c > 38 °C (n = 8) vs ≤ 38 °C (n = 7) there were significantly greater elevations in copeptin (10.4 vs. 2.4 pmol L-1) and creatinine (10 vs. 2 μmol L-1), but no differences in cortisol, free normetanephrine or osmolality.

CONCLUSIONS

Changes in copeptin reflected T c response more closely than sympathoadrenal markers or osmolality. Dynamic relationships with tonicity and kidney function may help to explain this finding. As a surrogate for integrated physiological strain during work in a field environment, copeptin assay could inform future measures to prevent heat-related illnesses.

Heart rate variability and plasma nephrines in the evaluation of heat acclimatisation status

Purpose

Heat adaptation (HA) is critical to performance and health in a hot environment. Transition from short-term heat acclimatisation (STHA) to long-term heat acclimatisation (LTHA) is characterised by decreased autonomic disturbance and increased protection from thermal injury. A standard heat tolerance test (HTT) is recommended for validating exercise performance status, but any role in distinguishing STHA from LTHA is unreported. The aims of this study were to (1) define performance status by serial HTT during structured natural HA, (2) evaluate surrogate markers of autonomic activation, including heart rate variability (HRV), in relation to HA status.

Methods

Participants (n = 13) were assessed by HTT (60-min block-stepping, 50% VO₂peak) during STHA (Day 2, 6 and 9) and LTHA (Day 23). Core temperature (Tc) and heart rate (HR) were measured every 5 min. Sampling for HRV indices (RMSSD, LF:HF) and sympathoadrenal blood measures (cortisol, nephrines) was undertaken before and after (POST) each HTT.

Results

Significant (P < 0.05) interactions existed for Tc, logLF:HF, cortisol and nephrines (two-way ANOVA; HTT by Day). Relative to LTHA, POST results differed significantly for Tc (Day 2, 6 and 9), HR (Day 2), logRMSSD (Day 2 and Day 6), logLF:HF (Day 2 and Day 6), cortisol (Day 2) and nephrines (Day 2 and Day 9). POST differences in HRV (Day 6 vs. 23) were + 9.9% (logRMSSD) and − 18.6% (logLF:HF).

Conclusions

Early reductions in HR and cortisol characterised STHA, whereas LTHA showed diminished excitability by Tc, HRV and nephrine measures. Measurement of HRV may have potential to aid real-time assessment of readiness for activity in the heat.

Electronic supplementary material

The online version of this article (10.1007/s00421-017-3758-y) contains supplementary material, which is available to authorized users.

Effects of Dietary Nitrate Supplementation on Physiological Responses, Cognitive Function, and Exercise Performance at Moderate and Very-High Simulated Altitude

Purpose: Nitric oxide (NO) bioavailability is reduced during acute altitude exposure, contributing toward the decline in physiological and cognitive function in this environment. This study evaluated the effects of nitrate (NO3−) supplementation on NO bioavailability, physiological and cognitive function, and exercise performance at moderate and very-high simulated altitude.

Methods:Ten males (mean (SD): V˙O2max: 60.9 (10.1) ml·kg⁻¹·min⁻¹) rested and performed exercise twice at moderate (~14.0% O₂; ~3,000 m) and twice at very-high (~11.7% O₂; ~4,300 m) simulated altitude. Participants ingested either 140 ml concentrated NO3−-rich (BRJ; ~12.5 mmol NO3−) or NO3−-deplete (PLA; 0.01 mmol NO3−) beetroot juice 2 h before each trial. Participants rested for 45 min in normobaric hypoxia prior to completing an exercise task. Exercise comprised a 45 min walk at 30% V˙O2max and a 3 km time-trial (TT), both conducted on a treadmill at a 10% gradient whilst carrying a 10 kg backpack to simulate altitude hiking. Plasma nitrite concentration ([NO2−]), peripheral oxygen saturation (SpO₂), pulmonary oxygen uptake (V˙O2), muscle and cerebral oxygenation, and cognitive function were measured throughout.

Results: Pre-exercise plasma [NO2−] was significantly elevated in BRJ compared with PLA (p = 0.001). Pulmonary V˙O2 was reduced (p = 0.020), and SpO₂ was elevated (p = 0.005) during steady-state exercise in BRJ compared with PLA, with similar effects at both altitudes. BRJ supplementation enhanced 3 km TT performance relative to PLA by 3.8% [1,653.9 (261.3) vs. 1718.7 (213.0) s] and 4.2% [1,809.8 (262.0) vs. 1,889.1 (203.9) s] at 3,000 and 4,300 m, respectively (p = 0.019). Oxygenation of the gastrocnemius was elevated during the TT consequent to BRJ (p = 0.011). The number of false alarms during the Rapid Visual Information Processing Task tended to be lower with BRJ compared with PLA prior to altitude exposure (p = 0.056). Performance in all other cognitive tasks did not differ significantly between BRJ and PLA at any measurement point (p ≥ 0.141).

Conclusion: This study suggests that BRJ improves physiological function and exercise performance, but not cognitive function, at simulated moderate and very-high altitude.