Heatstroke-induced coagulopathy: Biomarkers, mechanistic insights, and patient management

Severe heat stroke with multiorgan failure following collapse in a sauna

Heat stroke is characterised by hyperthermia and acute encephalopathy. We describe a rare case of classical heat stroke secondary to prolonged sauna use with multiorgan sequelae including seizures, liver injury, kidney injury, disseminated intravascular coagulation, rhabdomyolysis and type 2 myocardial infarction. The patient was treated with external cooling, intravenous fluid therapy and blood products, and made a full recovery without need for advanced organ support. We discuss the evidence base surrounding the immediate treatment of heat stroke in the emergency department.

Coexisting metabolic dysfunction-associated steatotic liver disease exacerbates in-hospital outcomes in patients with heat stroke

Purpose

This study aimed to investigate the impact of coexisting metabolic dysfunction-associated steatotic liver disease (MASLD) on in-hospital mortality and organ injury markers in patients with heat stroke (HS).

Approach

HS patients were retrospectively identified between July 1, 2022 and September 30, 2023 at West China Hospital, Sichuan University. Baseline characteristics, such as demographics, initial vital signs, and organ functional indicators were collected. Outcome events included organ injury and in-hospital mortality. The Least Absolute Shrinkage and Selection Operator (Lasso) method was employed to identify the optimal predictors for in-hospital mortality in HS patients. Subsequently, multivariable logistic regression analysis was performed to assess the relationship between the presence of MASLD and in-hospital mortality as well as organ function indicators.

Findings

A total of 112 patients were included in the study, in which 27 (24.1%) had coexisting MASLD. Compared to those without MASLD, patients with MASLD had higher levels of various organ injury markers such as aspartate aminotransferase, urea nitrogen, serum cystatin C, creatinine, uric acid, myoglobin, creatine kinase and its isoenzymes upon admission (P < 0.05). The multivariable Logistic regression analysis indicated that the presence of MASLD is an independent risk factor for in-hospital mortality in HS patients.

Conclusion

This study firstly indicated that coexisting MASLD may exacerbate organ injury in HS patients and serve as an independent risk factor for in-hospital mortality.

The mechanisms behind heatstroke-induced intestinal damage

With the frequent occurrence of heatwaves, heatstroke (HS) is expected to become one of the main causes of global death. Being a multi-organized disease, HS can result in circulatory disturbance and systemic inflammatory response, with the gastrointestinal tract being one of the primary organs affected. Intestinal damage plays an initiating and promoting role in HS. Multiple pathways result in damage to the integrity of the intestinal epithelial barrier due to heat stress and hypoxia brought on by blood distribution. This usually leads to intestinal leakage as well as the infiltration and metastasis of toxins and pathogenic bacteria in the intestinal cavity, which will eventually cause inflammation in the whole body. A large number of studies have shown that intestinal damage after HS involves the body's stress response, disruption of oxidative balance, disorder of tight junction proteins, massive cell death, and microbial imbalance. Based on these damage mechanisms, protecting the intestinal barrier and regulating the body's inflammatory and immune responses are effective treatment strategies. To better understand the pathophysiology of this complex process, this review aims to outline the potential processes and possible therapeutic strategies for intestinal damage after HS in recent years.

Exertional heat stroke with pronounced presentation of microangiopathic hemolytic anemia: A case report

BACKGROUND

Exertional heat stroke (EHS) is a critical condition arising from prolonged physical exertion in high temperatures that typically presents with normal hemoglobin levels. However, atypical presentations can also occur, leading to significant complications such as hemolytic anemia and organ dysfunction.

CASE SUMMARY

This case report describes a male patient who experienced moderate-to-severe anemia that was difficult to correct, with a confirmed diagnosis of microangiopathic hemolytic anemia accompanying multiple organ dysfunction syndrome, indicative of critical EHS. Despite intensive resuscitation efforts, the patient's condition deteriorated, necessitating admission to the intensive care unit for advanced management.

CONCLUSION

This case highlights the importance of recognizing atypical presentations of EHS, particularly that with significant hemolytic anemia and concurrent organ failure. Clinicians should maintain a high level of suspicion for these complications in patients displaying symptoms of heat-related illness, especially when caused by strenuous activity, as early diagnosis and intervention are crucial to improve patient outcomes.

How can heatstroke damage the brain? A mini review

Record-breaking heat waves over the past 20 years have led to a global increase in heat-related deaths, including heatstroke. Heat-related illnesses occur when the body cannot adapt to the elevated temperatures in the environment, leading to various symptoms. In severe situations, such as heatstroke, the body temperature can rise above 40°C, leading to significant injury to body systems, with particular susceptibility of the central nervous system (CNS). Neuroimaging studies conducted months or years after a heatstroke have revealed cellular damage in the cerebellum and other brain regions, including the hippocampus, midbrain, and thalamus, with the potential for long-term neurological complications in survivors of a heatstroke. This mini review aimed to describe the mechanisms and pathways underlying the development of brain injury induced by heatstroke and identify diagnostic imaging tools and biomarkers for injury to the CNS due to a heatstroke.

Exertional Heatstroke Encephalopathy With Chronic Neurological Deficit

Heat exhaustion progresses to heat stroke and then on to heatstroke encephalopathy, a serious illness. Extreme hyperthermia (over 40.5 °C), central nervous system failure, multiorgan dysfunction, and hypovolemic shock are the hallmarks of the clinical presentation of heatstroke. A 27-year-old male was presented to the causality with loss of consciousness followed by altered sensorium while working outdoors (outside temperature was 40°C), low blood pressure (70/50 mmHg), hyperthermia (41°C), tachycardia, focal seizures (1 episode), hypovolemic shock. At presentation, the Glasgow Coma Scale was E1V1M1, and he was intubated, moved to the intensive care unit, and monitored closely. He was treated with antibiotics, anticonvulsants, intravenous fluids, vasopressor supports, and body surface cooling methods. The hematological investigations showed thrombocytopenia, deranged liver, and renal function tests. On day 1, magnetic resonance imaging (MRI) of the brain showed normal study. As the patient's neurological status showed no improvement MRI of the brain was repeated on day 8 which showed restricted diffusion with hyperintensities involving bilateral caudate nuclei, anterior aspects of bilateral putamen, and insular cortex, suggesting to rule out infective encephalopathy. Based on history, clinical presentation, laboratory, and radiological investigations this case has been diagnosed as exertional heatstroke encephalopathy.

Heat stress-induced platelet dysfunction is associated with loss of fibrinogen and is improved by fibrinogen supplementation

INTRODUCTION

Heatstroke is a critical heat-related condition characterized by coagulopathy and multiple organ dysfunction. One of the most severe complications of heatstroke is disseminated intravascular coagulation. This condition manifests as excessive clot formation and bleeding that are primarily due to platelet depletion and dysfunction. Fibrinogen plays a crucial role in hemostasis because it links integrin αIIbβ3 on adjacent platelets, thereby promoting the platelet activation and aggregation necessary for clot formation. However, reduced fibrinogen levels may impair the formation of the initial platelet plug and increase the risk of bleeding. The current study explored the effect of fibrinogen on platelet dysfunction in a heatstroke model.

MATERIALS AND METHODS

Male Wistar rats were subjected to heat stress, and subsequent changes in hemodynamic, biochemical, and coagulation parameters were analyzed. Platelet viability, aggregation, adhesion, spreading and fibrin clot retraction were assessed.

RESULTS

The rats with heatstroke exhibited a variety of clinical symptoms, including hypotension, tachycardia, multiple organ dysfunction, and coagulopathy. Platelet viability in the heatstroke group was comparable to that in the healthy control group. However, the heatstroke group exhibited significant reductions in plasma fibrinogen levels and platelet aggregation, adhesion, spreading, and fibrin clot retraction. Notably, fibrinogen supplementation markedly augmented the aggregation responses of platelets in the heatstroke group. The impairment of platelet adhesion, spreading, and fibrin clot retraction in the rats with heatstroke was partially ameliorated by fibrinogen supplementation.

CONCLUSIONS

An early use of fibrinogen replacement may serve as a therapeutic intervention to alleviate platelet hyporeactivity and prevent the complications in patients with heatstroke.

APTT and D-dimer as biomarkers for heatstroke in patients with severe heat-related illnesses

The objective of this study was to analyze the changes of activated partial thromboplastin time (APTT) and D-dimer in severe heatstroke (HS) patients and their value in identifying HS patients and to analyze clinical features and early laboratory test results of heat-related illnesses. Forty-five patients with heat-related illnesses who were admitted to the Department of Emergency and Intensive Care Medicine of Suining Central Hospital from June 2022 to April 2023 were retrospectively analyzed. Patients were divided into 3 groups based on their clinical diagnosis: classic HS group, exertional HS group, and control group. General date and laboratory test results were collected, especially APTT and D-dimer. The receiver operating characteristic curve was used to analyze D-dimer and APTT. : There were differences in gender distribution among the 3 groups. Exertional HS was dominated by male patients, and classic HS was dominated by elderly patients. Binary logistic regression analysis of coagulation index showed a significant correlation between D-dimer and APTT and HS. The receiver operating characteristic curve results showed that APTT and D-dimer had high sensitivity and specificity in the identification of HS with an area under the curve (AUC) of 0.846, sensitivity of 97%, and specificity of 58.3% for APTT and an AUC of 0.861, sensitivity of 72%, and specificity of 91.7% for D-dimer (D-dimer + APTT [AUC, 0.929; sensitivity, 81.8%-91.7%; P < .001]). : The mortality rate of HS is high, and early diagnosis is particularly important. APTT and D-dimer may be used as markers assisting in identifying HS.

Cardiovascular magnetic resonance feature tracking derived strain analysis can predict return to training following exertional heatstroke

BACKGROUND

Exertional heatstroke (EHS) is increasingly common in young trained soldiers. However, prognostic markers in EHS patients remain unclear. The objective of this study was to evaluate cardiovascular magnetic resonance (CMR) feature tracking derived left ventricle (LV) strain as a biomarker for return to training (RTT) in trained soldiers with EHS.

METHODS

Trained soldiers (participants) with EHS underwent CMR cine sequences between June 2020 and August 2023. Two-dimensional (2D) LV strain parameters were derived. At 3 months after index CMR, the participants with persistent cardiac symptoms including chest pain, dyspnea, palpitations, syncope, and recurrent heat-related illness were defined as non-RTT. Multivariable logistic regression analysis was used to develop a predictive RTT model. The performance of different models was compared using the area under curve (AUC).

RESULTS

A total of 80 participants (median age, 21 years; interquartile range (IQR), 20-23 years) and 27 health controls (median age, 21 years; IQR, 20-22 years) were prospectively included. Of the 77 participants, 32 had persistent cardiac symptoms and were not able to RTT at 3 months follow-up after experiencing EHS. The 2D global longitudinal strain (GLS) was significantly impaired in EHS participants compared to the healthy control group (-15.8 ± 1.7% vs -16.9 ± 1.2%, P = 0.001), which also showed significant statistical differences between participants with RTT and non-RTT (-15.0 ± 3.5% vs -16.5 ± 1.4%, P < 0.001). 2D-GLS (≤ -15.0%) (odds ratio, 1.53; 95% confidence interval: 1.08, 2.17; P = 0.016) was an independent predictor for RTT even after adjusting known risk factors. 2D-GLS provided incremental prognostic value over the clinical model and conventional CMR parameters model (AUCs: 0.72 vs 0.88, P = 0.013; 0.79 vs 0.88, P = 0.023; respectively).

CONCLUSION

Two-dimensional global longitudinal strain (≤ -15.0%) is an incremental prognostic CMR biomarker to predict RTT in soldiers suffering from EHS.

Hemostasis Testing in the Emergency Department: A Narrative Review

Routine laboratory screening is typically performed at initial evaluation of the vast majority of presentations to the emergency department (ED). These laboratory results are crucial to the diagnostic process, as they may influence up to 70% of clinical decisions. However, despite the usefulness of biological assessments, many tests performed are inappropriate or of doubtful clinical relevance. This overutilization rate of laboratory testing in hospitals, which represents a significant medical-economic burden, ranges from 20 to 67%, with coagulation tests at the top of the list. While reviews frequently focus on nonintensive care units, there are few published assessments of emergency-specific interventions or guidelines/guidance to date. The aim of this review is to highlight current recommendations for hemostasis evaluation in the emergency setting with a specific analysis of common situations leading to ED admissions, such as suspected venous thrombosis or severe bleeding. We revisit the evidence related to the assessment of patient's hemostatic capacity based on comprehensive history taking and physical examination as well as best practice recommendations for blood sample collection to ensure the reliability of results. This review also includes an examination of various currently available point of care tests and a comprehensive discussion on indications, limitations, and interpretation of these tests.

Heatstroke Comorbid with SARS-CoV-2 Infection: A Case Report and Literature Review

Background

Hyperthermia and multiple organ dysfunction syndrome (MODS) are the main characteristics of heatstroke and COVID-19. Differentiating between these illnesses is crucial during a summer COVID-19 pandemic, but cases of heatstroke comorbid with COVID-19 are rarely reported.

Case description

We report the first case of heatstroke comorbid with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection in a 52-year-old male. After receiving intravenous antibiotics, organ protection measures, and treatment for coagulation disorders, his fever and coma resolved. However, he developed dyspnea and cerebral hemorrhage after several days. This patient experienced a multi-pathogen pulmonary infection and an intractable coagulopathy that ultimately resulted in MODS and death.

Conclusion

The combination of heatstroke and SARS-CoV-2 infection exacerbated inflammation, immune abnormalities, and coagulation disorders. The interaction between inflammation and coagulation disturbances contributed to the underlying mechanism in this case, highlighting the importance of early anti-infection, treatment for coagulopathy, immune regulation, and organ protection as crucial interventions.

"Unravelling the impacts of climatic heat events on cardiovascular health in animal models"

Climate change has led to an increase in high ambient temperatures, causing extreme heat events worldwide. According to the World Meteorological Organization (WMO), July 2023 marked a historic milestone as the Earth reached its hottest recorded temperature, precisely hitting the critical threshold of 1.5 °C set by the Paris Agreement. This distressing development led to a stark warning from the United Nations, signaling the dawn of what they call "an era of global boiling". The increasing global temperatures can result in high heat stress which leads to various physiological and biochemical alterations in the human body. Given that cardiovascular diseases (CVDs) are a leading cause of morbidity and mortality globally, heat events exacerbate this public health issue. While clinical and in-vitro studies have suggested a range of pathophysiological and biochemical mechanisms underlying the body's response to heat stress, the complex nature of organ-system level interactions makes precise investigation challenging. To address this knowledge gap effectively, the use of animal models exposed to acute or chronic heat stress can be invaluable. These models can closely replicate the multifaceted effects observed in humans during heat stress conditions. Despite extensive independent reviews, limited focus has been shed on the high heat-induced cardiovascular complications and their mechanisms, particularly utilizing animal models. Therefore, in this comprehensive review, we highlight the crucial biomarkers altered during heat stress, contributing significantly to various CVDs. We explore potential mechanisms underlying heat-induced cardiovascular dysfunction and damage, delving into various animal models. While traditional rodent models are commonly employed, we also examine less conventional models, including ruminants, broilers, canines, and primates. Furthermore, we delve into various potential therapeutic approaches and preventive measures. These insights hold significant promise for the development of more effective clinical interventions against the effects of heat stress on the human cardiovascular system.

DNAJA1‑knockout alleviates heat stroke‑induced endothelial barrier disruption via improving thermal tolerance and suppressing the MLCK‑MLC signaling pathway

Endothelial barrier disruption plays a key role in the pathophysiology of heat stroke (HS). Knockout of DNAJA1 (DNAJA1‑KO) is thought to be protective against HS based on a genome‑wide CRISPR‑Cas9 screen experiment. The present study aimed to illustrate the function of DNAJA1‑KO against HS in human umbilical vein endothelial cells. DNAJA1‑KO cells were infected using a lentivirus to investigate the role of DNAJA1‑KO in HS‑induced endothelial barrier disruption. It was shown that DNAJA1‑KO could ameliorate decreased cell viability and increased cell injury, according to the results of Cell Counting Kit‑8 and lactate dehydrogenase assays. Moreover, HS‑induced endothelial cell apoptosis was inhibited by DNAJA1‑KO, as indicated by Annexin V‑FITC/PI staining and cleaved‑caspase‑3 expression using flow cytometry and western blotting, respectively. Furthermore, the endothelial barrier function, as measured by transepithelial electrical resistance and FITC‑Dextran, was sustained during HS. DNAJA1‑KO was not found to have a significant effect on the expression and distribution of cell junction proteins under normal conditions without HS. However, DNAJA1‑KO could effectively protect the HS‑induced decrease in the expression and distribution of cell junction proteins, including zonula occludens‑1, claudin‑5, junctional adhesion molecule A and occludin. A total of 4,394 proteins were identified using proteomic analysis, of which 102 differentially expressed proteins (DEPs) were activated in HS‑induced wild‑type cells and inhibited by DNAJA1‑KO. DEPs were investigated by enrichment analysis, which demonstrated significant enrichment in the 'calcium signaling pathway' and associations with vascular‑barrier regulation. Furthermore, the 'myosin light‑chain kinase (MLCK)‑MLC signaling pathway' was proven to be activated by HS and inhibited by DNAJA1‑KO, as expected. Moreover, DNAJA1‑KO mice and a HS mouse model were established to demonstrate the protective effects on endothelial barrier in vivo. In conclusion, the results of the present study suggested that DNAJA1‑KO alleviates HS‑induced endothelial barrier disruption by improving thermal tolerance and suppressing the MLCK‑MLC signaling pathway.

Thromboinflammation and microcirculation damage in heatstroke

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.

A newly proposed heatstroke-induced coagulopathy score in patients with heat illness: A multicenter retrospective study in China

PURPOSE

In patients with heatstroke, disseminated intravascular coagulation (DIC) is associated with greater risk of in-hospital mortality. However, time-consuming assays or a complex diagnostic system may delay immediate treatment. Therefore, the present study proposes a new heatstroke-induced coagulopathy (HIC) score in patients with heat illness as an early warning indicator for DIC.

METHODS

This retrospective study enrolled patients with heat illness in 24 Chinese hospitals from March 2021 to May 2022. Patients under 18 years old, with a congenital clotting disorder or liver disease, or using anticoagulants were excluded. Data were collected on demographic characteristics, routine blood tests, conventional coagulation assays and biochemical indexes. The risk factors related to coagulation function in heatstroke were identified by regression analysis, and used to construct a scoring system for HIC. The data of patients who met the diagnostic criteria for HIC and International Society on Thrombosis and Haemostasis defined-DIC were analyzed. All statistical analyses were performed using SPSS 26.0.

RESULTS

The final analysis included 302 patients with heat illness, of whom 131 (43.4%) suffered from heatstroke, including 7 death (5.3%). Core temperature (OR = 1.681, 95% CI 1.291 - 2.189, p < 0.001), prothrombin time (OR = 1.427, 95% CI 1.175 - 1.733, p < 0.001) and D-dimer (OR = 1.242, 95% CI 1.049 - 1.471, p = 0.012) were independent risk factors for heatstroke, and therefore used to construct an HIC scoring system because of their close relation with abnormal coagulation. A total score ≥ 3 indicated HIC, and HIC scores correlated with the score for International Society of Thrombosis and Hemostasis -DIC (r = 0.8848, p < 0.001). The incidence of HIC (27.5%) was higher than that of DIC (11.2%) in all of 131 heatstroke patients. Meanwhile, the mortality rate of HIC (19.4%) was lower than that of DIC (46.7%). When HIC developed into DIC, parameters of coagulation dysfunction changed significantly: platelet count decreased, D-dimer level rose, and prothrombin time and activated partial thromboplastin time prolonged (p < 0.05).

CONCLUSIONS

The newly proposed HIC score may provide a valuable tool for early detection of HIC and prompt initiation of treatment.

Thromboinflammation in acute injury: infections, heatstroke, and trauma

Tissue microcirculation is essential for the maintenance of organ homeostasis. Following acute infections, activation of coagulation and inflammation, which are critical interconnected responses, lead to thromboinflammation and microthrombosis, thereby contributing to multiorgan dysfunction. Sepsis is the most common underlying disease and has been extensively studied. However, the COVID-19 pandemic further illustrated the pathomechanisms of diseases in which thromboinflammation plays a critical role. During thromboinflammation, injury to monocytes, neutrophils, platelets, and endothelial cells, along with coagulation and complement activation, was further characterized. Thrombin is pivotal in orchestrating thrombosis and inflammation and has long been considered a potential therapeutic target in sepsis. Although thromboprophylaxis for venous thromboembolism with heparins is part of standard management for COVID-19, it also potentially attenuates organ dysfunction due to thrombotic sequela. In contrast, the effectiveness of anticoagulation with heparin, antithrombin, or thrombomodulin to reduce mortality has not conclusively been proven in sepsis. Nonetheless, thromboinflammation has also been reported as an important pathophysiologic mechanism in other critical illnesses, including heatstroke, trauma, and ischemia/reperfusion injury, and may provide a potential therapeutic target for future clinical studies.

"COAGULATION": a mnemonic device for treating coagulation disorders following traumatic brain injury-a narrative-based method in the intensive care unit

Introduction

Coagulopathy associated with isolated traumatic brain injury (C-iTBI) is a frequent complication associated with poor outcomes, primarily due to its role in the development or progression of haemorrhagic brain lesions. The independent risk factors for its onset are age, severity of traumatic brain injury (TBI), volume of fluids administered during resuscitation, and pre-injury use of antithrombotic drugs. Although the pathophysiology of C-iTBI has not been fully elucidated, two distinct stages have been identified: an initial hypocoagulable phase that begins within the first 24 h, dominated by platelet dysfunction and hyperfibrinolysis, followed by a hypercoagulable state that generally starts 72 h after the trauma. The aim of this study was to design an acronym as a mnemonic device to provide clinicians with an auxiliary tool in the treatment of this complication.

Methods

A narrative analysis was performed in which intensive care physicians were asked to list the key factors related to C-iTBI. The initial sample was comprised of 33 respondents. Respondents who were not physicians, not currently working in or with experience in coagulopathy were excluded. Interviews were conducted for a month until the sample was saturated. Each participant was asked a single question: Can you identify a factor associated with coagulopathy in patients with TBI? Factors identified by respondents were then submitted to a quality check based on published studies and proven evidence. Because all the factors identified had strong support in the literature, none was eliminated. An acronym was then developed to create the mnemonic device.

Results and conclusion

Eleven factors were identified: cerebral computed tomography, oral anticoagulant & antiplatelet use, arterial blood pressure (Hypotension), goal-directed haemostatic therapy, use fluids cautiously, low calcium levels, anaemia-transfusion, temperature, international normalised ratio (INR), oral antithrombotic reversal, normal acid-base status, forming the acronym "Coagulation." This acronym is a simple mnemonic device, easy to apply for anyone facing the challenge of treating patients of moderate or severe TBI on a daily basis.

Construction and Validation of the Nomogram Based on von Willebrand Factor Predicting Mortality in Patients with Heatstroke

Heatstroke (HS), a severe condition, can develop multiple organ dysfunction syndrome and death. However, at present, no early reliable index exists for risk stratification and prognosis. von Willebrand factor (vWF), a marker of vascular endothelial injury, is a key regulatory target of inflammation and coagulation, which is closely associated with the pathogenesis of HS. vWF was reported as a prognostic marker in several infectious and noninfectious severe illness such as COVID-19, sepsis, and trauma. Although early increased level of vWF is seen in HS, the relationship between vWF and mortality is to be elucidated. Clinical data of patients with HS in a tertiary hospital were recorded and analyzed. It was shown that plasma vWF concentrations at admission were significantly increased in the nonsurvivors (351% ± 105%) compared with survivors (278% ± 104%, p = 0.021). After multivariate logistic regression analysis it was shown that vWF (odds ratio [OR] = 1.010; 95% confidence interval [CI], 1.002-1.18; p = 0.017), hemoglobin (Hb) (OR = 0.954; 95% CI, 0.931-0.979; p < 0.001), and hematocrit (HCT) in blood (OR = 0.859; 95% CI, 0.790-0.934; p < 0.001) were independent factors of in-hospital mortality in HS. The nomogram based on vWF and Hb was constructed in patients with HS. The area under curve under the receiver operating characteristic of this prediction model was 0.860 (95% CI, 0.773-0.923) and cutoff was 0.15, with Youden index 0.5840, which were not significantly different to sequential organ failure assessment (p = 0.0644), Acute Physiology and Chronic Health Evaluation II (APACHE II) (p = 0.7976), and systemic inflammatory response syndrome (SIRS) scores (p = 0.3274). The prediction model that integrated vWF and Hb showed a better predicting efficiency than single variable, and a higher specificity (81.48%) than APACHE II (72.84%) and SIRS (72.84%) scores. In summary, vWF, as an independent risk factor for in-hospital mortality, combined with Hb, could effectively prognosis the mortality in HS patients at early stage.

The role of platelets in heat-related illness and heat-induced coagulopathy

Heat-related illness is becoming more problematic due to ongoing global warming. Heat-related injury causes systemic inflammation and coagulopathy, due to leukocyte, platelet, and vascular endothelial cell activation and injury. Hyperthermia directly modulates platelet function and can induce cellular damage. Meanwhile, heat also affects platelet function via activated coagulation, excess inflammation, production of cytokines, and heat shock proteins. Aberrant hyperthermia-induced interactions between leukocytes and endothelial cells are also involved in platelet regulation. Heat-induced coagulopathy commonly progresses to disseminated intravascular coagulation (DIC), leading to multiple organ failure and in some cases enhanced bleeding. Consequently, platelet count, prothrombin time, and DIC score are useful for evaluating the severity of heat-related illness in addition to other organ damage markers such as Glasgow Coma Scale, creatinine, and bilirubin. Despite the increasing risk, therapeutic modalities targeting platelets are limited and no established therapy exists. In this review, we summarize the current knowledge about the role of platelets in the pathogenesis, diagnosis, and management of heat-related illness.

Endothelial glycocalyx injury is involved in heatstroke-associated coagulopathy and protected by N-acetylcysteine

Introduction

Damage to endothelial glycocalyx (EGCX) can lead to coagulation disorders in sepsis. Heat stroke (HS) resembles sepsis in many aspects; however, it is unclear whether EGCX injury is involved in its pathophysiology. The purpose of this study was to examine the relationship between the damage of EGCX and the development of coagulation disorders during HS.

Methods

We retrospectively collected 159 HS patients and analyzed coagulation characteristics and prognosis of HS patients with or without disseminated intravascular coagulation (DIC). We also replicated a rat HS model and measured coagulation indexes, pulmonary capillary EGCX injury in HS rats. Finally, we evaluated the effect of the antioxidant N-acetylcysteine (NAC) on HS-initiated EGCX injury and coagulation disorders.

Results

Clinical data showed that HS patients complicated with DIC had a higher risk of death than HS patients without DIC. In a rat HS model, we found that rats subjected to heat stress developed hypercoagulability and platelet activation at the core body temperature of 43°C, just before the onset of HS. At 24 h of HS, the rats showed a consumptive hypo-coagulation state. The pulmonary capillary EGCX started to shed at 0 h of HS and became more severe at 24 h of HS. Importantly, pretreatment with NAC substantially alleviated EGCX damage and reversed the hypo-coagulation state in HS rats. Mechanically, HS initiated reactive oxidative species (ROS) generation, while ROS could directly cause EGCX damage. Critically, NAC protected against EGCX injury by attenuating ROS production in heat-stressed or hydrogen peroxide (H2O2)-stimulated endothelial cells.

Discussion

Our results indicate that the poor prognosis of HS patients correlates with severe coagulation disorders, coagulation abnormalities in HS rats are associated with the damage of EGCX, and NAC improves HS-induced coagulopathy, probably through its protection against EGCX injury by preventing ROS generation.

Sound and Light Waves in Healthy Environments

Architects need the freedom to design their projects with the assurance that they will be inspiring aesthetic as well as healthy places, i.e., buildings, streets, parks, avenues, and squares that offer a complete living experience in an environment that takes into account light, sound, vibration, climate, and all those aspects that can disturb people's well-being. We know that prolonged exposure to noise can cause discomfort and sleep disorders, which affect the quality of life. This noise is not the only pollutant as there are other sound waves such as infrasound and ultrasound that are not perceptible but potentially harmful to health. Not forgetting electromagnetic waves, the light that reaches our bodies and which has regulated our lives throughout the existence of the species. The invention of electric lighting had the consequence that people spend practically all day indoors. Days are poorly illuminated, and the nights have too much light. On the other hand, the intensity of artificial light is a fraction of that of daylight and the spectral composition is also different.

Nomogram for predicting disseminated intravascular coagulation in heatstroke patients: A 10 years retrospective study

Background

Disseminated intravascular coagulation (DIC) can lead to multiple organ failure and death in patients with heatstroke. This study aimed to identify independent risk factors of DIC and construct a predictive model for clinical application.

Methods

This retrospective study included 87 patients with heatstroke who were treated in the intensive care unit of our hospital from May 2012 to October 2022. Patients were divided into those with DIC (n = 23) or without DIC (n = 64). Clinical and hematological factors associated with DIC were identified using a random forest model, least absolute shrinkage and selection operator (LASSO) regression and support vector machine-recursive feature elimination (SVM-RFE). Overlapping factors were used to develop a nomogram model, which was diagnostically validated. Survival at 30 days after admission was compared between patients with or without DIC using Kaplan-Meier analysis.

Results

Random forest, LASSO, and SVM-RFE identified a low maximum amplitude, decreased albumin level, high creatinine level, increased total bilirubin, and aspartate transaminase (AST) level as risk factors for DIC. Principal component analysis confirmed that these independent variables differentiated between patients who experienced DIC or not, so they were used to construct a nomogram. The nomogram showed good predictive power, with an area under the receiver operating characteristic curve of 0.976 (95% CI 0.948–1.000) and 0.971 (95% CI, 0.914–0.989) in the internal validation. Decision curve analysis indicated clinical utility for the nomogram. DIC was associated with significantly lower 30 days survival for heatstroke patients.

Conclusion

A nomogram incorporating coagulation-related risk factors can predict DIC in patients with heatstroke and may be useful in clinical decision-making.

Inflammation, coagulation, and cellular injury in heat-induced shock

BACKGROUND

The number of heatstroke victims hit record numbers in 2022 as global warming continues. In heat-induced injuries, circulatory shock is the most severe and deadly complication. This review aims to examine the mechanisms and potential approaches to heat-induced shock and the life-threatening complications of heatstroke.

METHODS

A computer-based online search was performed using the PubMed database and Web of Science database for published articles concerning heatstroke, shock, inflammation, coagulopathy, endothelial cell, cell death, and heat shock proteins.

RESULTS

Dehydration and heat-induced cardiomyopathy were reported as the major causes of heat-induced shock, although other heat-induced injuries are also involved in the pathogenesis of circulatory shock. In addition to dehydration, the blood volume decreases considerably due to the increased vascular permeability as a consequence of endothelial damage. Systemic inflammation is induced by factors that include elevated cytokine and chemokine levels, dysregulated coagulation/fibrinolytic responses, and the release of damage-associated molecular patterns (DAMPs) from necrotic cell death that cause distributive shock. The cytoprotective heat shock proteins can also facilitate circulatory disturbance under excess heat stress.

CONCLUSIONS

Multiple mechanisms are involved in the pathogenesis of heat-induced shock. In addition to dehydration, heat stress-induced cardiomyopathy due to the thermal damage of mitochondria, upregulated inflammation via damage-associated molecular patterns released from oncotic cells, unbalanced coagulation/fibrinolysis, and endothelial damage are the major factors that are related to circulatory shock.

ZBP1 and heatstroke

Heatstroke, which is associated with circulatory failure and multiple organ dysfunction, is a heat stress-induced life-threatening condition characterized by a raised core body temperature and central nervous system dysfunction. As global warming continues to worsen, heatstroke is expected to become the leading cause of death globally. Despite the severity of this condition, the detailed mechanisms that underlie the pathogenesis of heatstroke still remain largely unknown. Z-DNA-binding protein 1 (ZBP1), also referred to as DNA-dependent activator of IFN-regulatory factors (DAI) and DLM-1, was initially identified as a tumor-associated and interferon (IFN)-inducible protein, but has recently been reported to be a Z-nucleic acid sensor that regulates cell death and inflammation; however, its biological function is not yet fully understood. In the present study, a brief review of the main regulators is presented, in which the Z-nucleic acid sensor ZBP1 was identified to be a significant factor in regulating the pathological characteristics of heatstroke through ZBP1-dependent signaling. Thus, the lethal mechanism of heatstroke is revealed, in addition to a second function of ZBP1 other than as a nucleic acid sensor.

A prehospital risk assessment tool predicts clinical outcomes in hospitalized patients with heat-related illness: a Japanese nationwide prospective observational study

We previously developed a risk assessment tool to predict outcomes after heat-related illness (J-ERATO score), which consists of six binary prehospital vital signs. We aimed to evaluate the ability of the score to predict clinical outcomes for hospitalized patients with heat-related illnesses. In a nationwide, prospective, observational study, adult patients hospitalized for heat-related illnesses were registered. A binary logistic regression model and receiver operating characteristic (ROC) curve analysis were used to assess the relationship between the J-ERATO and survival at hospital discharge as a primary outcome. Among eligible patients, 1244 (93.0%) survived to hospital discharge. Multivariable logistic regression analysis revealed that the J-ERATO was an independent predictor for survival to discharge (adjusted odds ratio [OR] 0.47; 95% confidence interval [CI] 0.37-0.59) and occurrence of disseminated intravascular coagulation (DIC) on day 1 (adjusted OR 2.07; 95% CI 1.73-2.49). ROC analyses revealed an optimal J-ERATO cut-off of 5 for prediction of mortality at discharge (area under the curve [AUC] 0.742; 95% CI 0.691-0.787) and DIC development on day 1 (AUC 0.723; 95% CI 0.684-0.758). The J-ERATO obtained before transportation could be helpful in predicting the severity and mortality of hospitalized patients with heat-related illnesses.

The pathogenesis and therapeutic strategies of heat stroke-induced liver injury

Heat stroke (HS) is a life-threatening systemic disease characterized by an elevated core body temperature of more than 40 ℃ and subsequent multiple organ dysfunction syndrome. With the growing frequency of global heatwaves, the incidence rate of HS has increased significantly, which has caused a huge burden on people's lives and health. Liver injury is a well-documented complication of HS and usually constitutes the direct cause of patient death. In recent years, a lot of research has been carried out on the pathogenesis and treatment strategies of HS-induced liver injury. In this review, we summarized the important pathogenesis of HS-induced liver injury that has been confirmed so far. In addition to the comprehensive effect of systemic factors such as heat cytotoxicity, coagulopathy, and systemic inflammatory response syndrome, excessive hepatocyte cell pyroptosis, dysfunction of Kupffer cells, abnormal expression of heat shock protein expression, and other factors are also involved in the pathogenesis of HS-induced liver injury. Furthermore, we have also established the current therapeutic strategies for HS-induced liver injury. Our study is of great significance in promoting the understanding of the pathogenesis and treatment of HS-induced liver injury.

Platelet Hemostasis Reactions at Different Temperatures Correlate with Intracellular Calcium Concentration

Hypo- and hyperthermia affect both primary and secondary hemostasis; however, there are controversial data concerning platelet activation and the underlying mechanisms under hypo- and hyperthermia. The discrepancies in the data could be partly explained by different approaches to hemostatic reactions analysis. We applied a new LaSca-TMF laser particle analyzer for a simultaneous fluorescence and laser scattering analysis of platelet responses at different temperatures. Human platelets were activated by ADP in a wide range of temperatures, and platelet transformations (e.g., a shape change reaction, aggregation and clot formation) and the intracellular calcium concentration ([Ca²⁺]_i) were analyzed by LaSca-TMF and confocal microscopy. The platelet shape change reaction gradually increased with a rising temperature. The platelet aggregation strongly decreased at low ADP concentrations with the augmentation of the temperature and was independent of the temperature at high ADP concentrations. In contrast, the clotting time decreased with a temperature increase. Similar to the aggregation response, a rise in [Ca²⁺]_i triggered by low ADP concentrations was higher under hypothermic conditions and the differences were independent of the temperature at high ADP concentrations. We showed that the key reactions of cellular hemostasis are differentially regulated by temperature and demonstrated for the first time that an accelerated aggregation under hypothermic conditions directly correlated with an increased level in [Ca²⁺]_i in platelets.

Morphological Changes in Blood Cells in a Rat Model of Heatstroke: A Pilot Study

Despite the increasing threat of heatstroke with global warming, pathophysiologic injury continues to be defined. In addition, morphological changes of the peripheral blood cells in heatstroke have not been well characterized. We evaluated pathophysiologic changes in bone marrow and blood cells in a rat heatstroke model using a 39.5 °C climate chamber. After three hours of incubation, blood and bone marrow samples were collected for morphology, and the direct effects of heat on leukocytes in vitro were evaluated using time-lapse observation. The blood cell count and peripheral/bone marrow smear were examined either in a lethal model (core body temperature exceeded 42.5 °C) or in a sublethal model (<41.5 °C). Significant decreases in platelet and white blood counts occurred in the lethal model (>35% and >20% decreases, respectively) and changes were less in the sublethal model. Platelet clumping with the appearance of large platelets was observed. The neutrophils often demonstrated hyper-segmented nuclei, and lymphocytes showed reactive or blast-like changes. Further, the direct effect of heat on leukocytes noted apoptotic cell death at 41.5 °C, but subsequent necrosis at 43 °C. In summary, our rodent model showed that heatstroke causes platelet aggregation, leukocyte injury, and aponecrotic cell death. Such changes were milder and reversible in sublethal heatstroke. The appearance of immature cells may result from damage to the bone marrow microenvironment. These findings may provide useful information for potential diagnostic and therapeutic considerations.

Proposal of New Safety Limits for In Vivo Experiments of Magnetic Hyperthermia Antitumor Therapy

Simple Summary

Magnetic hyperthermia is a promising therapy for the treatment of certain types of tumors. However, it is not clear what the maximum limit of the magnetic field to which the organism can be subjected without severe and/or irreversible pathophysiological consequences is. This study aims to study the alterations at the physiological level that may occur after exposure to different combinations of frequency and intensity of the applied alternating magnetic field. Understanding the response to alternating magnetic field exposure will allow us to apply this type of antitumor treatment in a safer way for the patient, while achieving an optimal therapeutic result.

Abstract

Background: Lately, major advances in crucial aspects of magnetic hyperthermia (MH) therapy have been made (nanoparticle synthesis, biosafety, etc.). However, there is one key point still lacking improvement: the magnetic field-frequency product (H × f = 4.85 × 10⁸ Am⁻¹s⁻¹) proposed by Atkinson–Brezovich as a limit for MH therapies. Herein, we analyze both local and systemic physiological effects of overpassing this limit. Methods: Different combinations of field frequency and intensity exceeding the Atkinson–Brezovich limit (591–920 kHz, and 10.3–18 kA/m) have been applied for 21 min to WAG/RijHsd male rats, randomly distributed to groups of 12 animals; half of them were sacrificed after 12 h, and the others 10 days later. Biochemical serum analyses were performed to assess the general, hepatic, renal and/or pancreatic function. Results: MH raised liver temperature to 42.8 ± 0.4 °C. Although in five of the groups the exposure was relatively well tolerated, in the two of highest frequency (928 kHz) and intensity (18 kA/m), more than 50% of the animals died. A striking elevation in liver and systemic markers was observed after 12 h in the surviving animals, independently of the frequency and intensity used. Ten days later, liver markers were almost recovered in all of the animals. However, in those groups exposed to 591 kHz and 16 kA/m, and 700 kHz and 13.7 kA/m systemic markers remained altered. Conclusions: Exceeding the Atkinson–Brezovich limit up to 9.59 × 10⁹ Am⁻¹s⁻¹ seems to be safe, though further research is needed to understand the impact of intensity and/or frequency on physiological conditions following MH.

Complement Activation in Patients With Heat-Related Illnesses: Soluble CD59 Is a Novel Biomarker Indicating Severity of Heat-Related Illnesses

Although multiple organ dysfunction syndrome (MODS) is the main cause of death in patients with heat-related illnesses, its underlying pathophysiological mechanism remains elusive. Complement activation is considered one of the main causes of MODS in patients with sepsis and trauma. Considering the pathophysiological similarity of heat related-illnesses with sepsis and trauma, the complement system might be activated in patients with heat-related illnesses as well. Our aim was to investigate whether excessive complement activation occurs in patients with heat-related illnesses.

Exertional heat stroke: pathophysiology and risk factors

Exertional heat stroke, the third leading cause of mortality in athletes during physical activity, is the most severe manifestation of exertional heat illnesses. Exertional heat stroke is characterised by central nervous system dysfunction in people with hyperthermia during physical activity and can be influenced by environmental factors such as heatwaves, which extend the incidence of exertional heat stroke beyond athletics only. Epidemiological data indicate mortality rates of about 27%, and survivors display long term negative health consequences ranging from neurological to cardiovascular dysfunction. The pathophysiology of exertional heat stroke involves thermoregulatory and cardiovascular overload, resulting in severe hyperthermia and subsequent multiorgan injury due to a systemic inflammatory response syndrome and coagulopathy. Research about risk factors for exertional heat stroke remains limited, but dehydration, sex differences, ageing, body composition, and previous illness are thought to increase risk. Immediate cooling remains the most effective treatment strategy. In this review, we provide an overview of the current literature emphasising the pathophysiology and risk factors of exertional heat stroke, highlighting gaps in knowledge with the objective to stimulate future research.