The pathopysiology of heat stroke: an integrative view of the final common pathway

Thromboelastometry for assessment of hemostasis and disease severity in 42 dogs with naturally-occurring heatstroke

BACKGROUND

Thromboelastometry (TEM) provides a comprehensive overview of the entire coagulation process and has not been evaluated in heatstroke-induced coagulopathies in dogs.

OBJECTIVES

To determine the diagnostic and prognostic utility of TEM in dogs with heatstroke.

ANIMALS

Forty-two client-owned dogs with heatstroke.

METHODS

Prospective observational study. Blood samples for intrinsic and extrinsic TEM (INTEM and EXTEM, respectively) were collected at presentation and every 12 to 24 hours for 48 hours. Coagulation phenotype (hypo-, normo-, or hypercoagulable) was defined based on TEM area under the 1st derivative curve (AUC).

RESULTS

Case fatality rate was 31%. Median TEM variables associated with death (P < .05 for all) included longer INTEM clotting time, lower AUC at presentation and at 12 to 24 hours postpresentation (PP), lower INTEM alpha angle, maximum clot firmness, and maximum lysis (ML) at 12 to 24 hours PP, and lower EXTEM ML at 12 to 24 hours PP. Most dogs were normo-coagulable on presentation (66% and 63% on EXTEM and INTEM, respectively), but hypo-coagulable 12 to 24 PP (63% for both EXTEM and INTEM). A hypo-coagulable INTEM phenotype was more frequent at presentation and 12 to 24 PP among nonsurvivors compared to survivors (55% vs 15% and 100% vs 50%, P = .045 and .026, respectively). AKI was more frequent (P = .015) in dogs with hypo-coagulable INTEM tracings at 12 to 24 hours. Disseminated intravascular coagulation was more frequent (P < .05) in dogs with a hypo-coagulable INTEM phenotype and in nonsurvivors at all timepoints.

CONCLUSIONS AND CLINICAL RELEVANCE

Hypocoagulability, based on INTEM AUC, is predictive of worse prognosis and occurrence of secondary complications.

Heatstroke: a multicenter study in Southwestern China

Background

An increase in Heatstroke cases occurred in southwest China in 2022 due to factors like global warming, abnormal temperature rise, insufficient power supply, and other contributing factors. This resulted in a notable rise in Heatstroke patients experiencing varying degrees of organ dysfunction. This descriptive study aims to analyze the epidemiology and clinical outcomes of Heatstroke patients in the ICU, providing support for standardized diagnosis and treatment, ultimately enhancing the prognosis of Heatstroke.

Methods

A retrospective, multicenter, descriptive analysis was conducted on Heatstroke patients admitted to ICUs across 83 hospitals in southwest China. Electronic medical records were utilized for data collection, encompassing various aspects such as epidemiological factors, onset symptoms, complications, laboratory data, concurrent infections, treatments, and patient outcomes.

Results

The dataset primarily comprised classic heatstroke, with 477 males (55% of total). The patient population had a median age of 72 years (range: 63-80 years). The most common initial symptoms were fever, mental or behavioral abnormalities, and fainting. ICU treatment involved respiratory support, antibiotics, sedatives, and other interventions. Among the 700 ICU admissions, 213 patients had no infection, while 487 were diagnosed with infection, predominantly lower respiratory tract infection. Patients presenting with neurological symptoms initially (n = 715) exhibited higher ICU mortality risk compared to those without neurological symptoms (n = 104), with an odds ratio of 2.382 (95% CI 1.665, 4.870) (p = 0.017).

Conclusion

In 2022, the majority of Heatstroke patients in southwest China experienced classical Heatstroke, with many acquiring infections upon admission to the ICU. Moreover, Heatstroke can result in diverse complications.

Fatal hyperthermia among children in school buses: Analysis of 47 cases in China

The school bus is an important mode of transportation for school-age children, and safety-related issues are always the focus of public concern. Fatal hyperthermia occurring in school buses is an uncommon type of school bus-related injury. An internet search using Chinese internet search engines based on various combinations of keywords including 'vehicles', 'school bus', 'children or babies', 'hyperthermia or heat stroke' and 'death' was performed. Forty-seven cases of fatal hyperthermia in children which occurred in school buses were retrieved in the study. High ambient temperature, younger age and poor management were identified as risk factors. There is a lack of consensus regarding the legal nature and liability for fatal hyperthermia occurring in school buses. Pre-employment education should be focused on awareness of the dangers of leaving children alone in a school bus. Most importantly, the relevant legislation and regulations on school buses should be implemented. An internal alarm-raising system is recommended to avoid this kind of tragedy.

A century of exercise physiology: concepts that ignited the study of human thermoregulation. Part 3: Heat and cold tolerance during exercise

In this third installment of our four-part historical series, we evaluate contributions that shaped our understanding of heat and cold stress during occupational and athletic pursuits. Our first topic concerns how we tolerate, and sometimes fail to tolerate, exercise-heat stress. By 1900, physical activity with clothing- and climate-induced evaporative impediments led to an extraordinarily high incidence of heat stroke within the military. Fortunately, deep-body temperatures > 40 °C were not always fatal. Thirty years later, water immersion and patient treatments mimicking sweat evaporation were found to be effective, with the adage of cool first, transport later being adopted. We gradually acquired an understanding of thermoeffector function during heat storage, and learned about challenges to other regulatory mechanisms. In our second topic, we explore cold tolerance and intolerance. By the 1930s, hypothermia was known to reduce cutaneous circulation, particularly at the extremities, conserving body heat. Cold-induced vasodilatation hindered heat conservation, but it was protective. Increased metabolic heat production followed, driven by shivering and non-shivering thermogenesis, even during exercise and work. Physical endurance and shivering could both be compromised by hypoglycaemia. Later, treatments for hypothermia and cold injuries were refined, and the thermal after-drop was explained. In our final topic, we critique the numerous indices developed in attempts to numerically rate hot and cold stresses. The criteria for an effective thermal stress index were established by the 1930s. However, few indices satisfied those requirements, either then or now, and the surviving indices, including the unvalidated Wet-Bulb Globe-Thermometer index, do not fully predict thermal strain.

Image Improved Intravoxel Incoherent Motion MRI With Optimized Trigger Delays Based on Strain Curve Analysis to Evaluate Myocardial Microvascular Dysfunction of Exertional Heat Illness

BACKGROUND

Intravoxel incoherent motion (IVIM) MRI has not been widely used and its role in evaluating exertional heat illness (EHI)-related myocardial involvement remains unknown.

PURPOSE

To investigate the feasibility of strain curve-derived trigger delay (TD) IVIM-MRI and its role in assessing myocardial diffusion and microvascular perfusion of EHI patients.

STUDY TYPE

Prospective.

SUBJECTS

A total of 42 male EHI patients (median age: 21 years) and 22 age- and sex-matched healthy controls (HC).

FIELD STRENGTH/SEQUENCE

A 3-T, diffusion-weighted spin-echo echo-planar-imaging sequence.

ASSESSMENT

IVIM-MRI was acquired by conventional TD method (group A) or strain curve-based TD method (group B) in random order. IVIM image quality was evaluated on a 3-point Likert scale (1, nondiagnostic; 2, moderate; 3, good). Technical success was defined as image quality score = 3. IVIM-MRI-derived parameters (pseudo diffusion in the capillaries [D*], perfusion fraction [f], and slow apparent diffusion coefficient [D]) were compared between EHI and HC.

STATISTICAL TESTS

Student's t-tests, chi-square tests, one-way analysis of variance, receiver operating characteristic (ROC) curve analysis, Pearson's correlation coefficient (r). The statistical significance level was set at P < 0.05.

RESULTS

IVIM-MRI image quality score (median [interquartile range]: 3 [2, 3] vs. 2 [1-3]) and technical success rate (61.9%[13/21] vs. 28.6%[6/21]) were significantly improved in group B. EHI patients showed significantly decreased D* (118.1 ± 23.3 × 10-3  mm2 /sec vs. 142.7 ± 42.6 × 10-3  mm2 /sec) and f values (0.42 ± 0.12 vs. 0.51 ± 0.11) and significantly higher D values (3.0 ± 0.9 × 10-3  mm2 /sec vs. 2.5 ± 0.6 × 10-3  mm2 /sec) compared to HC. Relative to D and D*, f showed the most robust efficacy for detecting EHI-related myocardial injury with the highest area under the ROC curve (0.906: 95% confidence interval, 0.799, 0.967) and sensitivity of 88.5% and specificity of 85.6%.

CONCLUSION

The strain curve-based TD method significantly improved image quality and technical success rate of IVIM-MRI, and f value may be an effective biomarker to assess myocardial microcirculation abnormalities of EHI patients.

EVIDENCE LEVEL

2.

TECHNICAL EFFICACY

Stage 3.

Development and validation of a prognostic model of survival for classic heatstroke patients: a multicenter study

Classic heatstroke (CHS) is a life-threatening illness characterized by extreme hyperthermia, dysfunction of the central nervous system and multiorgan failure. Accurate predictive models are useful in the treatment decision-making process and risk stratification. This study was to develop and externally validate a prediction model of survival for hospitalized patients with CHS. In this retrospective study, we enrolled patients with CHS who were hospitalized from June 2022 to September 2022 at 3 hospitals in Southwest Sichuan (training cohort) and 1 hospital in Central Sichuan (external validation cohort). Prognostic factors were identified utilizing least absolute shrinkage and selection operator (LASSO) regression analysis and multivariate Cox regression analysis in the training cohort. A predictive model was developed based on identified prognostic factors, and a nomogram was built for visualization. The areas under the receiver operator characteristic (ROC) curves (AUCs) and the calibration curve were utilized to assess the prognostic performance of the model in both the training and external validation cohorts. The Kaplan‒Meier method was used to calculate survival rates. A total of 225 patients (median age, 74 [68-80] years) were included. Social isolation, self-care ability, comorbidities, body temperature, heart rate, Glasgow Coma Scale (GCS), procalcitonin (PCT), aspartate aminotransferase (AST) and diarrhea were found to have a significant or near-significant association with worse prognosis among hospitalized CHS patients. The AUCs of the model in the training and validation cohorts were 0.994 (95% [CI], 0.975-0.999) and 0.901 (95% [CI], 0.769-0.968), respectively. The model's prediction and actual observation demonstrated strong concordance on the calibration curve regarding 7-day survival probability. According to K‒M survival plots, there were significant differences in survival between the low-risk and high-risk groups in the training and external validation cohorts. We designed and externally validated a prognostic prediction model for CHS. This model has promising predictive performance and could be applied in clinical practice for managing patients with CHS.

Normal gastrointestinal temperature values measured through ingestible capsules technology: a systematic review

Climate change has amplified the importance of continuous and precise body core temperature (Tcore) monitoring in the everyday life. In this context, assessing Tcore through ingestible capsules technology, i.e., gastrointestinal temperature (Tgastrointestinal), emerges as a good alternative to prevent heat-related illness. Therefore, we conducted a systematic review to point out values of normal Tgastrointestinal measured through ingestible capsules in healthy humans. The study followed PRISMA guidelines and searched the PubMed and Scielo databases from 1971 to 2023. Our search strategy included the descriptors ("gastrointestinal temperature") AND ("measurement"), and eligible studies had to be written in English and measured Tgastrointestinal using ingestible capsules or sensors in healthy adults aged 18-59 at rest. Two pairs of researchers independently reviewed titles and abstracts and identified 35 relevant articles out of 1,088 in the initial search. An average value of 37.13 °C with a standard deviation of 0.24 °C was observed, independently of the gender. The values measured ranged from 36.70 °C to 37.69 °C. In conclusion, this systematic review pointed out the mean value of 37.13 ± 0.24 °C measured by ingestible capsules as reference for resting Tgastrointestinal in healthy adult individuals.

Multiparametric cardiac magnetic resonance reveals persistent myocardial inflammation in patients with exertional heat illness

OBJECTIVES

To explore the clinical potential of multiparametric cardiac magnetic resonance (CMR) in evaluating myocardial inflammation in patients with exertional heat illness (EHI).

METHODS

This prospective study enrolled 28 males with EHI (18 patients with exertional heat exhaustion (EHE) and 10 with exertional heat stroke (EHS)) and 18 age-matched male healthy controls (HC). All subjects underwent multiparametric CMR, and 9 patients had follow-up CMR measurements 3 months after recovery from EHI. CMR-derived left ventricular geometry, function, strain, native T1, extracellular volume (ECV), T2, T2*, and late gadolinium enhancement (LGE) were obtained and compared among different groups.

RESULTS

Compared with HC, EHI patients showed increased global ECV, T2, and T2* values (22.6% ± 4.1 vs. 19.7% ± 1.7; 46.8 ms ± 3.4 vs. 45.1 ms ± 1.2; 25.5 ms ± 2.2 vs. 23.8 ms ± 1.7; all p < 0.05). Subgroup analysis showed that ECV was higher in the EHS patients than those in EHE and HC groups (24.7% ± 4.9 vs. 21.4% ± 3.2, 24.7% ± 4.9 vs. 19.7% ± 1.7; both p < 0.05). Repeated CMR measurements at 3 months after baseline CMR showed persistently higher ECV than HC (p = 0.042).

CONCLUSIONS

With multiparametric CMR, EHI patients demonstrated increased global ECV, T2, and persistent myocardial inflammation at 3-month follow-up after EHI episode. Therefore, multiparametric CMR might be an effective method in evaluating myocardial inflammation in patients with EHI.

CLINICAL RELEVANCE STATEMENT

This study showed persistent myocardial inflammation after an exertional heat illness (EHI) episode demonstrated by multiparametric CMR, which is a potential promising method to evaluate the severity of myocardial inflammation and guide return to work, play, or duty in EHI patients.

KEY POINTS

• EHI patients showed an increased global extracellular volume (ECV), late gadolinium enhancement, and T2 value, indicating myocardial edema and fibrosis. • ECV was higher in the exertional heat stroke patients than exertional heat exhaustion and healthy control groups (24.7% ± 4.9 vs. 21.4% ± 3.2, 24.7% ± 4.9 vs. 19.7% ± 1.7; both p < 0.05). • EHI patients showed persistent myocardial inflammation with higher ECV than healthy controls 3 months after index CMR (22.3% ± 2.4 vs. 19.7% ± 1.7, p = 0.042).

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.

Full neurological recovery from severe nonexertional heat stroke with multiple organ dysfunction: A case report

BACKGROUND

We report a rare case of full neurological recovery from severe nonexertional heat stroke in a 67-year-old woman with an initial Glasgow Coma Scale of 3. This report raises awareness among doctors that when heatstroke is diagnosed, comprehensive treatment should be implemented as soon as possible. Moreover, targeted temperature management, combination therapy with hemodialysis and hemoperfusion, and hyperbaric oxygen therapy may alleviate multiorgan failure and prevent neurological sequelae caused by heatstroke.

CASE SUMMARY

A previously healthy 67-year-old woman with an initial Glasgow Coma Scale of 3 was found lying prone on the road at noon on a summer day. Laboratory tests revealed multiorgan failure. As soon as heatstroke was diagnosed, comprehensive treatment was implemented. On hospital Day 3, the patient was extubated. Her initial Sequential Organ Failure Assessment score at hospitalization was 14 and decreased to 2 on hospital Day 4. On the seventh day following hospital admission, as the patient’s general condition improved, the levels of laboratory test findings decreased rapidly. Finally, the patient gradually recovered with no other neurological symptoms (the Glasgow Coma Scale at discharge was 15, and her ability to walk independently was restored).

CONCLUSION

This case demonstrated that targeted temperature management, combination therapy with hemodialysis and hemoperfusion, and hyperbaric oxygen therapy may alleviate multiorgan failure and prevent neurological sequelae caused by heatstroke.

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.

Severe heat stress modulated nuclear factor erythroid 2-related factor 2 and macrophage migration inhibitory factor pathway in rat liver

Heat stress impairs physiology and overall functionality of the body at tissue and organ level in animals. Liver being a vital organ performs more than hundreds regulatory functions of the body. Present study investigates the modulation of molecular pathways that are responsible for liver damage triggered by heat stress. Male Sprague dawley rats were exposed to heat stress (45 °C) in heat simulation chamber till core temperature reaches 40 °C and 42 °C in 25 and 42 min respectively. For in-depth evaluation of liver functions during severe heat stress, hepatic transcriptome and proteome were analysed by microarray and two dimensional gel electrophoresis respectively. Results revealed major alterations in redox status, inflammation, mitochondrial dysfunction and proteostasis related pathways. Data of molecular pathway analysis demonstrate that nuclear factor erythroid 2-related factor 2 (NRF-2) mediated oxidative stress response and macrophage migration inhibitory factor (MIF) regulated inflammatory pathways were upregulated in severe heat stressed liver. Expression levels of downstream molecules of above pathways such as heat shock protein 90AB 1, peroxiredoxin 5, Jun N-terminal kinases 1/2, heme-oxygenase 1, apolipoprotein 1 and interleukin 10 were examined and result suggested the upregulation of these genes modulates the NRF-2 and MIF regulated pathways in heat stressed liver. Irregularity in molecular signalling networks lead to mitochondrial dysfunction indicated by upregulation of ATP synthase β and peroxiredoxin 1 along with decreased levels of glucose-6-phosphate dehydrogenase and enhanced activity of cytochrome c in liver mitochondria. Thus, current study demonstrated heat induced alterations in key liver functions were regulated by NRF-2 and MIF pathways.

Heat stroke in dogs: Literature review

Heat stroke is a clinical emergency secondary to a severe temperature increase due to the inefficiencies of heat dissipation mechanisms, causing central nervous system dysfunctions, which may lead to multiple organ dysfunction syndrome. Heat disturbances can be classified as "classic" or "exertional" ones and several predisposing factors are involved in their development. This review provides a broad approach to the pathophysiological mechanisms of this syndrome, and the diagnostic and treatment methods to facilitate their approach in clinical routine and increase the survival rate of patients.

A Heart Rate Based Algorithm to Estimate Core Temperature Responses in Elite Athletes Exercising in the Heat

Purpose

Non-invasive non-obtrusive continuous and real-time monitoring of core temperature (Tc) may enhance pacing strategies, the efficacy of heat mitigation measures, and early identification of athletes at risk for heat-related disorders. The Estimated Core Temperature (ECTemp™) algorithm uses sequential heart rate (HR) values to predict Tc. We examined the validity of ECTemp™ among elite athletes exercising in the heat.

Methods

101 elite athletes performed an exercise test in simulated hot and humid environmental conditions (ambient temperature: 31.6 ± 1.0°C, relative humidity: 74 ± 5%). Tc was continuously measured using a validated ingestible telemetric temperature capsule system. In addition, HR was continuously measured and used to compute the estimated core temperature (Tc-est) using the ECTemp™ algorithm.

Results

Athletes exercised for 44 ± 10 min and n = 5,025 readouts of Tc (range: 35.8-40.4°C), HR (range: 45-207 bpm), and Tc-est (range: 36.7-39.9°C) were collected. Tc-est demonstrated a small yet significant bias of 0.15 ± 0.29°C (p < 0.001) compared to Tc, with a limit of agreement of ±0.45°C and a root mean square error of 0.35 ± 0.18°C. Utilizing the ECTemp™ algorithm as a diagnostic test resulted in a fair to excellent sensitivity (73-96%) and specificity (72-93%) for Tc-est thresholds between 37.75 and 38.75°C, but a low to very-low sensitivity (50-0%) for Tc-est thresholds >39.0°C, due to a high prevalence of false-negative observations.

Conclusion

ECTemp™ provides a valuable and representative indication of thermal strain in the low- to mid-range of Tc values observed during exercise in the heat. It may, therefore, be a useful non-invasive and non-obtrusive tool to inform athletes and coaches about the estimated core temperature during controlled hyperthermia heat acclimation protocols. However, the ECTemp™ algorithm, in its current form, should not solely be used to identify athletes at risk for heat-related disorders due to low sensitivity and high false-negative rate in the upper end of the Tc spectrum.

Use of extracorporeal therapy in a dog with heatstroke

OBJECTIVE

To describe the use of extracorporeal therapy (ECT) in the management of a dog with complications stemming from heatstroke.

CASE REVIEW

A 3-year-old intact male Rhodesian Ridgeback was presented for heat-related illness following strenuous exercise. Despite intensive supportive care, the dog developed progressive and refractory hyperkalemia, hypoglycemia, neurologic dysfunction, acute kidney injury (AKI), and pulmonary dysfunction. Four ECT sessions were performed in this dog, consisting of 4 intermittent hemodialysis (HD) sessions, the first 2 of which concurrently utilized hemoperfusion with a cytokine adsorption filter. Interleukin-6 (IL-6), IL-8, IL-10, and monocyte chemoattractant protein-1 were detected in samples collected during the first ECT session. Despite an initial decrease in their concentration, the concentrations of these cytokines ultimately rose over the course of the ECT session. Rapid and sustained glycemic and electrolyte control were achieved after the first ECT session, although AKI and muscle injury persisted. The dog survived to discharge and was nonazotemic 3 months following initial management.

NEW OR UNIQUE INFORMATION PROVIDED

Heatstroke is a common, potentially catastrophic, occurrence in dogs. To the authors' knowledge, this represents the first clinical use of ECT consisting of HD and cytokine adsorption in the management of severe heat-related illness in a dog. The use of ECT for the management of complications from severe heatstroke in dogs warrants further investigation.

Association of D-dimer and acute kidney injury associated with rhabdomyolysis in patients with exertional heatstroke: an over 10-year intensive care survey

Patients with rhabdomyolysis (RM) following exertional heatstroke (EHS) are often accompanied by dysfunction of coagulation and acute kidney injury (AKI). The purpose of this study was to investigate the relationship between D-dimer and AKI in patients with RM following EHS. A retrospective study was performed on patients with EHS admitted to the intensive care unit over 10-year. Data including baseline clinical information at admission, vital organ dysfunction, and 90-day mortality were collected. A total of 84 patients were finally included, of whom 41 (48.8%) had AKI. AKI patients had more severe organ injury and higher 90-day mortality (34.1 vs.0.0%, p < 0.001) than non-AKI patients. Multivariate logistic analysis showed that D-dimer (OR 1.3, 95% CI 1.1–1.7, p = 0.018) was an independent risk factor for AKI with RM following EHS. Curve fitting showed a curve relationship between D-dimer and AKI. Two-piecewise linear regression showed that D-dimer was associated with AKI in all populations (OR 1.3, 95% CI 1.2–1.5, p < 0.001) when D-dimer <10.0 mg/L, in RM group (OR 1.3, 95% CI 1.1–1.5, p < 0.001) when D-dimer >0.4 mg/L, in the non-RM group (OR 6.4, 95% CI 1.7–23.9, p = 0.005) when D-dimer <1.3 mg/L and D-dimer did not increase the incidence of AKI in the non-RM group when D-dimer >1.3 mg/L. AKI is a life-threatening complication of RM following EHS. D-dimer is associated with AKI in critically ill patients with EHS. The relationship between D-dimer and AKI depends on whether RM is present or not.

Impact of successive exertional heat injuries on thermoregulatory and systemic inflammatory responses in mice

The purpose of the study was to determine if repeated exertional heat injuries (EHIs) worsen the inflammatory response. We assessed the impact of a single EHI bout (EHI0) or two separate EHI episodes separated by 1 (EHI1), 3 (EHI3), and 7 (EHI7) days in male C57BL/6J mice (n = 236). To induce EHI, mice underwent a forced running protocol until loss of consciousness or core temperature reached ≥ 42.7°C. Blood and tissue samples were obtained 30 min, 3 h, 1 day, or 7 days after the EHI. We observed that mice undergoing repeated EHI (EHI1, EHI3, and EHI7) had longer running distances before collapse (∼528 m), tolerated higher core temperatures (∼0.18°C higher) before collapse, and had higher minimum core temperature (indicative of injury severity) during recovery relative to EHI0 group (∼2.18°C higher; all P < 0.05). Heat resilience was most pronounced when latency was shortest between EHI episodes (i.e., thermal load and running duration highest in EHI1), suggesting the response diminishes with longer recoveries between EHI events. Furthermore, mice experiencing a second EHI exhibited increased serum and liver HSP70, and lower corticosterone, FABP2, MIP-1β, MIP-2, and IP-10 relative to mice experiencing a single EHI typically at 30 min to 3 h after EHI. Our findings indicate that an EHI event may initiate some adaptive processes that provide acute heat resilience to subsequent EHI conditions. NEW & NOTEWORTHY Mice undergoing repeated exertional heat injuries, within 1 wk of an initial heat injury, appear to have some protective adaptations. During the second exertional heat injury, mice were able to run longer and sustain higher body temperatures before collapse. Despite this, the mice undergoing a second exertional heat injury were more resilient to the heat as evidenced by attenuated minimum body temperature, higher HPS70 (serum and liver), lower corticosterone, and lower FABP2.

Exercise heat acclimation causes human responses and safety performance improvements

Heat acclimation (HA) is a widely recognized physiological phenomenon of human body in hot environments. HA has many benefits, such aspreventing hyperthermia responses, and is an efficient way to improve human responses to hyperthermal environments. However, it is not known whether HA is dependent on the environmental conditions. Moreover, its mechanism and effect on the safety performance remain unexplored. In this study, we created a climate chamber to simulate a hyperthermal environment. Thirty healthy males were recruited for this study, who were then trained under the same ambient conditions (temperature of 38 °C and relative humidity (RH) of 40%). The training involved running on treadmills (at 5 km/h) to simulate heavy manual labor, and performing heat stress tests (HST) under six different conditions (32 °C/40% RH, 35 °C/40%, 38 °C/40%, 32 °C/70%, 35 °C/70%, and 38 °C/70%). Their physiological indices (rectal temperature, heart rate, sweat loss and skin temperature) and one psychological index (thermal sensation) were measured. Furthermore, a hazard avoidance test device (HATD) was designed to evaluate the individual safety performance by detecting human errors. The results show that training and environmental conditions have different effects on HA. After HA, the physiological and psychological strain were significantly improved. More importantly, HA also helped improve the participants' awareness of the dangers and required emergency responses to face potential hazards. Overall, a reasonable HA training under proper conditions is helpful to ensure the safety of human beings. More research is needed to study the role of HA on safety performance.

The relationship between small heat shock proteins and redox homeostasis during acute heat stress in chickens

As heat stress is a major emerging issue in poultry farming, investigations on the molecular mechanisms of the heat-triggered cellular response in chickens are of special importance. In the present study, 32-day-old Ross 308 broiler chickens were subjected to 37 °C environmental temperature combined with 50% relative humidity for 4 or 8 h respectively. Following sampling, redox parameters such as malondialdehyde (MDA), reduced glutathione (GSH), protein carbonyl levels as well as glutathione peroxidase activity were assessed in liver, spleen, and kidney homogenates. The concentrations of small heat shock proteins (sHSP-s) HSP27, αA- and αB-crystallins were also investigated. Among these organs, the liver was found the most susceptible to heat-provoked oxidative stress, indicated by enhanced lipid peroxidation and rapid activation of protective pathways, including the definite increase of glutathione peroxidase activity and the excessive utilization of αA- and αB-crystallin proteins. Heat-associated decline of protein carbonylation and GSH content was observed in the liver in correlation with the increased involvement of αA- and αB-crystallins in cellular defense, resulting supposedly in an overcompensation mechanism. These data highlight the hepatic sensitivity to acute heat shock, potential adaptation mechanisms, and the specific role of sHSP-s in the restoration of physiologic cell function.

A 3-D virtual human thermoregulatory model to predict whole-body and organ-specific heat-stress responses

OBJECTIVE

This study aimed at assessing the risks associated with human exposure to heat-stress conditions by predicting organ- and tissue-level heat-stress responses under different exertional activities, environmental conditions, and clothing.

METHODS

In this study, we developed an anatomically detailed three-dimensional thermoregulatory finite element model of a 50th percentile U.S. male, to predict the spatiotemporal temperature distribution throughout the body. The model accounts for the major heat transfer and thermoregulatory mechanisms, and circadian-rhythm effects. We validated our model by comparing its temperature predictions of various organs (brain, liver, stomach, bladder, and esophagus), and muscles (vastus medialis and triceps brachii) under normal resting conditions (errors between 0.0 and 0.5 °C), and of rectum under different heat-stress conditions (errors between 0.1 and 0.3 °C), with experimental measurements from multiple studies.

RESULTS

Our simulations showed that the rise in the rectal temperature was primarily driven by the activity level (~ 94%) and, to a much lesser extent, environmental conditions or clothing considered in our study. The peak temperature in the heart, liver, and kidney were consistently higher than in the rectum (by ~ 0.6 °C), and the entire heart and liver recorded higher temperatures than in the rectum, indicating that these organs may be more susceptible to heat injury.

CONCLUSION

Our model can help assess the impact of exertional and environmental heat stressors at the organ level and, in the future, evaluate the efficacy of different whole-body or localized cooling strategies in preserving organ integrity.

Molecular and morphometric changes in the small intestine during hot and cold exposure in thermally manipulated broiler chickens

Background and Aim:

Thermal stress (hot or cold) is one of many environmental stressors that severely affects the health of broiler chickens. One negative effect of thermal stress is the disruption of the intestinal barrier function in broiler chickens. This study aimed to evaluate the effect of thermal manipulation (TM) on the small intestine in terms of histomorphometry as well as junctional, heat-shock, and immune response gene expression during post-hatch exposure to thermal stress.

Materials and Methods:

The experiment was conducted by dividing 928 fertile Ross eggs into three incubation groups: The control (C) group (incubated at 37.8°C and 56% relative humidity [RH] for the whole incubation period), the TM using low temperature TML group (incubated at 36°C and 56% RH for 18 h/day from embryonic days 7 to 16), and the TM using high temperature (TMH) group (incubated at 39°C and 65% RH for 18 h/day from embryonic days 7 to 16). On post-hatch day 21, 90 chicks were randomly selected from each incubation group and were equally subdivided into three subgroups for the post-hatch thermal stress experiment: The TN subgroup (room temperature maintained at 24°C), the heat stress (HS) subgroup (room temperature maintained at 35°C), and the cold stress (CS) subgroup (room temperature maintained at 16°C). After 1 day of thermal stress exposure (age 22 days), five birds from each subgroup were euthanized and ileum samples were collected to evaluate the transcription of the Claudin (CLDN1), CLDN-5, Occludin, Cadherin-1, heat shock factors (HSF1), HSF3, 70 kilodalton heat shock protein, 90 kilodalton heat shock protein, Interleukin6 (IL6), IL8, toll-like receptors-2 (TLR2), and TLR4 genes by Real-Time Quantitative Reverse Transcription polymerase chain reaction analysis. Finally, after 4 and 7 days of thermal stress (age 25 and 28 days, respectively), nine chicks were euthanized, and their jejunum and ileum were collected for histomorphometric analysis.

Results:

After exposure to 1 day of thermal stress, the C subgroups exposed to thermal stress (HS and CS) possessed significantly increased expression of junctional, heat-shock, and immune response genes compared to the C-TN subgroup, and similar results were observed for the TMH. In contrast, thermally stressed TMH subgroups had significantly lower expression of the studied genes compared to C subgroups exposed to thermal stress. Furthermore, no significant changes were detected between the TML subgroups exposed to thermal stress and TML-TN. Moreover, significant alterations in villus height (VH), villus surface area, crypt depth (CD), and VH to CD ratio were observed between the TML, TMH, and C subgroups exposed to CS.

Conclusion:

It might be suggested that TM may have a protective impact on the small intestine histomorphometry and epithelial integrity of broilers during post-hatch exposure to thermal stress.

Preventive Effects of Bacillus licheniformis on Heat Stroke in Rats by Sustaining Intestinal Barrier Function and Modulating Gut Microbiota

Heat stroke (HS) models in rats are associated with severe intestinal injury, which is often considered as the key event at the onset of HS. Probiotics can regulate the gut microbiota by inhibiting the colonization of harmful bacteria and promoting the proliferation of beneficial bacteria. Here, we investigated the preventive effects of a probiotic Bacillus licheniformis strain (BL, CMCC 63516) on HS rats as well as its effects on intestinal barrier function and gut microbiota. All rats were randomly divided into four groups: control (Con) + PBS (pre-administration with 1 ml PBS twice a day for 7 days, without HS induction), Con + BL group (pre-administration with 1 ml 1 × 10⁸ CFU/ml BL twice a day for 7 days, without HS induction), HS + PBS (PBS, with HS induction), and HS + BL (BL, with HS induction). Before the study, the BL strain was identified by genomic DNA analysis. Experimental HS was induced by placing rats in a hot and humid chamber for 60 min until meeting the diagnostic criterion of HS onset. Body weight, core body temperature, survival rate, biochemical markers, inflammatory cytokines, and histopathology were investigated to evaluate the preventive effects of BL on HS. D-Lactate, I-FABP, endotoxin, and tight-junction proteins were investigated, and the fluorescein isothiocyanate-dextran (FD-4) test administered, to assess the degree of intestinal injury and integrity. Gut microbiota of rats in each group were analyzed by 16S rRNA sequencing. The results showed that pre-administration with BL significantly attenuated hyperthermia, reduced HS-induced death, alleviated multiple-organ injury, and decreased the levels of serum inflammatory cytokines. Furthermore, BL sustained the intestinal barrier integrity of HS rats by alleviating intestinal injury and improving tight junctions. We also found that BL significantly increased the ratios of two probiotic bacteria, Lactobacillus and Lactococcus. In addition, Romboutsia, a candidate biomarker for HS diagnosis, was unexpectedly detected. In summary, BL pre-administration for 7 days has preventative effects on HS that may be mediated by sustaining intestinal barrier function and modulating gut microbiota.

Expression profiles of genes associated with inflammatory responses and oxidative stress in lung after heat stroke

BACKGROUND

Heat stroke (HS) is a physically dysfunctional illness caused by hyperthermia. Lung, as the important place for gas-exchange and heat-dissipation organ, is often first to be injured. Lung injury caused by HS impairs the ventilation function of lung, which will subsequently cause damage to other tissues and organs. Nevertheless, the specific mechanism of lung injury in heat stroke is still unknown.

METHODS

Rat lung tissues from controls or HS models were harvested. The gene expression profile was identified by high-throughput sequencing. DEGs were calculated using R and validated by qRT-PCR. Gene Ontology (GO), Kyoto Encyclopedia of Genes and Genomes (KEGG), and cell-enrichment were performed using differential expression genes (DEGs). Finally, lung histopathology was accessed by H&E staining.

RESULTS

About 471 genes were identified to be DEGs, of which 257 genes were up-regulated, and 214 genes were down-regulated. The most up-regulated and down-regulated DEGs were validated by qRT-PCR, which confirmed the tendency of expression. GO, KEGG, and protein-protein interaction (PPI)-network analyses disclosed DEGs were significantly enriched in leukocyte migration, response to lipopolysaccharide, NIK/NF-kappaB signaling, response to reactive oxygen species, response to heat, and the hub genes were Tnf, Il1b, Cxcl2, Ccl2, Mmp9, Timp1, Hmox1, Serpine1, Mmp8 and Csf1, most of which were closely related to inflammagenesis and oxidative stress. Finally, cell-enrichment analysis and histopathologic analysis showed Monocytes, Megakaryotyes, and Macrophages were enriched in response to heat stress.

CONCLUSIONS

The present study identified key genes, signal pathways and infiltrated-cell types in lung after heat stress, which will deepen our understanding of transcriptional response to heat stress, and might provide new ideas for the treatment of HS.

Cooling Capacity of Transpulmonary Cooling and Cold-Water Immersion After Exercise-Induced Hyperthermia

CONTEXT

Cold-water immersion (CWI) may not be feasible in some remote settings, prompting the identification of alternative cooling methods as adjunct treatment modalities for exertional heat stroke (EHS).

OBJECTIVE

To determine the differences in cooling capacities between CWI and the inspiration of cooled air.

DESIGN

Randomized controlled clinical trial.

SETTING

Laboratory.

PATIENTS OR OTHER PARTICIPANTS

A total of 12 recreationally active participants (7 men, 5 women; age = 26 ± 4 years, height = 170.6 ± 10.1 cm, mass = 76.0 ± 18.0 kg, body fat = 18.5% ± 9.7%, peak oxygen uptake = 42.7 ± 8.9 mL·kg-1·min-1).

INTERVENTION(S)

After exercise in a hot environment (40°C and 40% relative humidity), participants were randomized to 3 cooling conditions: cooling during passive rest (PASS; control), CWI, and the Polar Breeze thermal rehabilitation machine (PB) with which participants inspired cooled air (22.2°C ± 1.0°C).

MAIN OUTCOME MEASURE(S)

Rectal temperature (TREC) and heart rate were continuously measured throughout cooling until TREC reached 38.25°C.

RESULTS

Cooling rates during CWI (0.18°C·min-1 ± 0.06°C·min-1) were greater than those during PASS (mean difference [95% confidence interval] of 0.16°C·min-1 [0.13°C·min-1, 0.19°C·min-1]; P < .001) and PB (0.15°C·min-1 [0.12°C·min-1, 0.16°C·min-1]; P < .001). Elapsed time to reach a TREC of 38.25°C was also faster with CWI (9.71 ± 3.30 minutes) than PASS (-58.1 minutes [-77.1, -39.9 minutes]; P < .001) and PB (-46.8 minutes [-65.5, -28.2 minutes]; P < .001). Differences in cooling rates and time to reach a TREC of 38.25°C between PASS and PB were not different (P > .05).

CONCLUSIONS

Transpulmonary cooling via cooled-air inhalation did not promote an optimal cooling rate (>0.15°C·min-1) for the successful treatment of EHS. In remote settings where EHS is a risk, access and use of treatment methods via CWI or cold-water dousing are imperative to ensuring survival.

TRIAL REGISTRY

ClinicalTrials.gov (NCT0419026).

The Potential Role of Exercise-Induced Muscle Damage in Exertional Heat Stroke

Exertional heat stroke (EHS) is a life-threatening condition that affects mainly athletes, military personnel, firefighters, and occupational workers. EHS is frequently observed in non-compensable conditions (where the body is unable to maintain a steady thermal balance) as a result of heavy heat stress and muscle contraction associated with prolonged and strenuous physical and occupational activities, resulting in central nervous system dysfunction followed by multi-organ damage and failure. Since the pathophysiology of EHS is complex and involves multiple organs and systems, any condition that changes the interrelated systems may increase the risk for EHS. It has been suggested that exercise-induced muscle damage (EIMD) can lead to thermoregulatory impairment and systemic inflammation, which could be a potential predisposing factor for EHS. In this review article, we aim to (1) address the evidence of EIMD as a predisposing factor for EHS and (2) propose a possible mechanism of how performing muscle-damaging exercise in the heat may aggravate muscle damage and subsequent risk of EHS and acute kidney injury (AKI). Such an understanding could be meaningful to minimize the risks of EHS and AKI for individuals with muscle damage due to engaging in physical work in hot environments.

Heat precondition is a potential strategy to combat hepatic injury triggered by severe heat stress

AIM

Environmental heat stress alters physiological and biochemical functions which leads to multiorgan dysfunction including severe hepatic injury in animals. We hypothesize that heat preconditioning can be potential intervention in combating heat illnesses.

MAIN METHODS

Sprague Dawley rats were exposed to moderate heat stress, severe heat stress and heat preconditioning in heat simulation chamber. Mean arterial pressure, heart rate, skin and core temperature were monitored in pre and post heat exposed animals. After stress exposure, blood for hemodynamic and liver tissue for liver function tests, oxidative stress, inflammatory variables and structural studies were collected from rats. Hepatic mitochondria were isolated to study the key structural alterations and functional changes by transmission electron microscopy.

KEY FINDINGS

The effect of heat precondition shows improvement in time to attain the core temperature, weight loss, blood pressure and heart rate in rats. Results exhibited decreased levels of liver function tests, elevated levels of free radicals and inflammatory cytokines in heat exposed liver as compared with heat preconditioned animals. Expression levels of mitochondrial heat shock protein 60, superoxide dismutase 1 and uncoupling protein 1 along with activity of electron transport chain complexes I-V were examined and found to be increased in heat preconditioned as compared to heat stressed animals. Morphological studies of liver parenchyma demonstrated reduction in structural deterioration of hepatic lobules and restoration of mitochondrial structural integrity in heat preconditioned rats.

SIGNIFICANCE

Present study suggests that heat preconditioning intervention plays a crucial role in protection against heat induced hepatic injury in animals.

Independent effects of rapid eye movement sleep deprivation and exposure to environmental heat stress on aerobic performance and thermoregulatory responses in exercising rats

Evidence indicates that aerobic performance is degraded either by environmental heat stress or sleep deprivation. However, whether these conditions interact to produce more significant performance impairment deserves further investigation. Therefore, this study investigated the effects of experimental sleep deprivation (24 h or 96 h) on aerobic performance and thermoregulatory responses in rats exercised on a treadmill at different environmental conditions. Adult male Wistar rats were subjected to rapid eye movement sleep deprivation (RSD) using the modified multiple platform method and were then subjected to an incremental-speed exercise until they were fatigued. Treadmill running was performed in a temperate (24°C) or warm (31°C) environment, and the colonic temperature (an index of core body temperature; T_CORE) and the tail-skin temperature (T_SKIN; an index of cutaneous heat loss) were recorded. 24-h and 96-h RSD produced small magnitude reductions in aerobic performance (Cohen's d = 0.47-0.58) and minor changes in thermoregulation. Relative to control rats, sleep-deprived rats showed a higher T_CORE at the exercise initiation and a higher threshold for activating cutaneous heat loss, but unchanged T_CORE and T_SKIN at fatigue. Exercise at 31°C induced large reductions in performance (d = 0.82-1.29) and marked changes in thermoregulation, as evidenced by higher T_CORE and T_SKIN at fatigue, compared to exercise at 24°C. Interestingly, none of the effects induced by RSD were exacerbated by environmental heat stress and vice-versa, indicating that both conditions did not interact. We conclude that RSD and heat stress modulate aerobic performance and thermoregulatory responses by acting independently.

Development of an IoT-Based Construction Worker Physiological Data Monitoring Platform at High Temperatures

This study presents an IoT-based construction worker physiological data monitoring platform using an off-the-shelf wearable smart band. The developed platform is designed for construction workers performing under high temperatures, and the platform is composed of two parts: an overall heat assessment (OHS) and a personal management system (PMS). OHS manages the breaktimes for groups of workers based using a thermal comfort index (TCI), as provided by the Korea Meteorological Administration (KMA), while PMS assesses the individual health risk level based on fuzzy theory using data acquired from a commercially available smart band. The device contains three sensors (PPG, Acc, and skin temperature), two modules (LoRa and GPS), and a power supply, which are embedded into a microcontroller (MCU). Thus, approved personnel can monitor the status as well as the current position of a construction worker via a PC or smartphone, and can make necessary decisions remotely. The platform was tested in both indoor and outdoor environment for reliability, achieved less than 1% of error, and received satisfactory feedback from on-site users.

Global warming, heat-related illnesses, and the dermatologist

Global warming, provoked by the greenhouse effect of high levels of atmospheric gases (most notably carbon dioxide and methane), directly threatens human health and survival. Individuals vary in their capacity to tolerate episodes of extreme heat. Because skin is the organ tasked with heat dissipation, it is important for dermatologists to be versed in the physiology of cutaneous heat dissipation and cognizant of clinical settings in which the skin’s thermoregulatory responses may be impaired. When the external temperature is lower than that of the skin, the skin releases internal heat through direct thermal exchange with the environment, a process that is aided by an expansion of cutaneous blood flow and eccrine sweating. Cooling through the evaporation of sweat is effective even when the external temperature exceeds that of skin. Many factors, including environmental and physiological (e.g., age and sex), and pathological (e.g., preexisting illnesses, disorders of eccrine function, and medications) considerations, affect the skin’s capacity to thermoregulate. Identification of individuals at increased risk for heat-related morbidity and mortality will become increasingly important in the care of patients.

Towards smart personalized perspiration analysis: An IoT-integrated cellulose-based microfluidic wearable patch for smartphone fluorimetric multi-sensing of sweat biomarkers

Practical obstacles, such as intricate designs and expensive equipment/materials, in the fabrication of wearable sweat sensors, have limited their feasibility as a personalized healthcare device. Herein, we have fabricated a cellulose-based wearable patch, which further paired with a smartphone-based fluorescence imaging module and a self-developed smartphone app for non-invasive and in situ multi-sensing of sweat biomarkers including glucose, lactate, pH, chloride, and volume. The developed Smart Wearable Sweat Patch (SWSP) sensor comprises highly fluorescent sensing probes embedded in paper substrates, and microfluidic channels consisted of cotton threads to harvest sweat from the skin surface and to transport it to the paper-based sensing probes. The imaging module was fabricated by a 3D printer, equipped with UV-LED lamps and an optical filter to provide the in situ capability of capturing digital images of the sensors via a smartphone. A smartphone app was also designed to quantify the concentration of the biomarkers via a detection algorithm. Additionally, we have recommended an Internet of Things (IoT)-based model for our developed SWSP sensor to promote its potential application for the future. The field studies on human subjects were also conducted to investigate the feasibility of our developed SWSP sensor for the analysis of sweat biomarkers. Our findings convincingly demonstrated the applicability of our developed SWSP sensor as a smart, user-friendly, ultra-low-cost (~0.03 $ per sweat patch), portable, selective, rapid, and non-invasive healthcare monitoring device for immense applications in health personalization, sports performance monitoring, and medical diagnostics.

Skin-interfaced microfluidic devices with one-opening chambers and hydrophobic valves for sweat collection and analysis

Soft, skin-interfaced microfluidic platforms are capable of capturing, storing, and assessing sweat chemistry and total sweat loss, which provides essential insight into human physiological health. However, sweat loss from the outlet of the microfluidic devices often leads to deviation of the measured concentration of the biomarker or electrolyte from the actual value. Here, we introduce hydrophobic valves at the junction of the chamber and the microfluidic channel as a new chamber design to reduce sweat evaporation. Because the advancing front of the liquid in the hydrophilic microchannel is blocked by the hydrophobic valve, the fluid flows into the chambers, forms the initial meniscus, and completely fills the chambers along the initial meniscus. Fluid dynamic modeling and numerical simulations provide critical insights into the sweat sampling mechanism into the chambers. With significantly reduced evaporation and contamination, the sweat sample can be easily stored for a long time for later analysis when in situ analysis is limited. Additionally, the design with multiple chambers can allow sequential generation of sweat collection at different times for long-term analysis. The in situ real-time measurements of the sweat loss and pH value analysis from the human subject demonstrate the practical utility of the devices in collecting, storing, and analyzing the sweat generated from sweat glands on the skin.

Heat related illnesses. Review of an ongoing challenge

Climate change is the most challenging natural calamity of chronic nature that presents intense episodes of heat waves, and events. Effects of heat waves and increasing average temperature on heat-related illnesses (HRIs) demand a review of existing preventive and treatment strategies to direct future research. Heat-related illnesses are presented as minor to severe life-threatening conditions. Despite the understanding of the pathophysiology of HRI, pharmacological interventions are limited. Prevention is the best strategy against HRI. There is a dearth of epidemiological studies that reviewed the effect of pharmacological interventions on mortality, and there remains a need to identify critical key components other than inflammatory modulators, which can be targeted to decrease HRI.

The magnitude of physical exercise-induced hyperthermia is associated with changes in the intestinal permeability and expression of tight junction genes in rats

We investigated whether the magnitude of exercise-induced hyperthermia influences intestinal permeability and tight junction gene expression. Twenty-nine male Wistar rats were divided into four groups: rest at 24 °C and exercise at 13 °C, 24 °C or 31 °C. The exercise consisted of a 90-min treadmill run at 15 m/min, and different ambient temperatures were used to produce distinct levels of exercise-induced hyperthermia. Before the experimental trials, the rats were treated by gavage with diethylenetriaminepentaacetic acid labeled with technetium-99 metastable as a radioactive probe. The rats' core body temperature (T_CORE) was measured by telemetry. Immediately after the trials, the rats were euthanized, and the intestinal permeability was assessed by measuring the radioactivity of blood samples. The mRNA levels of occludin and zonula occludens-1 (ZO-1) genes were determined in duodenum samples. Exercise at 24 °C increased T_CORE to values close to 39 °C, without changing permeability compared with the resting trial at the same environment. Meanwhile, rats' T_CORE exceeded 40 °C during exercise at 31 °C, leading to greater permeability relative to those observed after exercise in the other ambient temperatures (e.g., 0.0037%/g at 31 °C vs. 0.0005%/g at 13 °C; data expressed as medians; p < 0.05). Likewise, the rats exercised at 31 °C exhibited higher mRNA levels of ZO-1 and occludin genes than the rats exercised at 24 °C or 13 °C. The changes in permeability and gene expression were positively and significantly associated with the magnitude of hyperthermia. We conclude that marked hyperthermia caused by exercise in the warmer environment increases intestinal permeability and mRNA levels of tight junction genes.

Caffeine and heat have additive but not interactive effects on physiologic strain: A factorial experiment

This study tested the interactive effects of heat and caffeine on exercise-induced physiological strain by using a 2x2 within-subjects factorial design. Thirty-five physically fit Caucasians underwent a bout of exercise under four conditions wherein ambient conditions (heat vs no heat) and caffeine (placebo vs caffeine; double-blinded) were manipulated. Exercise consisted of a 60-min walk and 5-min step/squat test while wearing weighted backpack. Primary outcomes include measures of physiologic strain (Core temperature [T_r] and heart rate [HR]). Secondary measures included blood pressure, markers of sweat loss, and creatine kinase (CK). Repeated measures models were created to evaluate the individual and combined effects of heat and caffeine. Key results indicated that heat and caffeine significantly increased T_r and HR after walking and stair-stepping. No significant heat by caffeine interactions were detected, and caffeine's main effects were relatively low (≤0.17 °C for T_r and ≤6.6 bpm for HR). Of note, heat and caffeine exhibited opposite effects on blood pressure: caffeine increased both systolic and diastolic blood pressure (by 6-7 mmHg) and heat decreased them (by 4-6 mm Hg; ps < 0.05). In summary, heat and caffeine affected physiologic strain during exercise but exhibited no synergistic effects. In contrast, neither factor affected muscle damage. Clinical implications for heat illness risk in the military are discussed.

Astaxanthin supplementation impacts the cellular HSP expression profile during passive heating

Astaxanthin is a powerful carotenoid antioxidant prevalent in marine organisms and approved as a food supplement. Recent studies have demonstrated Astaxanthin's beneficial attributes in various health states. Following initial reports of potential heat protective properties in Astaxanthin supplemented rats, we present here results of a novel study examining the effect of Astaxanthin supplementation on the heat shock response in rats in relation to core temperature (Tc) and the ensuing physiological strain. Two hours of heat stress at 41 °C during which rats developed their thermoregulatory hyperthermic plateau resulted in progressive increases in HSP72 and HSP27 in the Astaxanthin (Oleoresin)-treated group but not in the control (Olive oil) group. Enhanced elevation in HSPs suggests that Astaxanthin supplementation may augment the cellular stress protective response to heat stress.

Beyond Heat Stress: Intestinal Integrity Disruption and Mechanism-Based Intervention Strategies

The current climate changes have increased the prevalence and intensity of heat stress (HS) conditions. One of the initial consequences of HS is the impairment of the intestinal epithelial barrier integrity due to hyperthermia and hypoxia following blood repartition, which often results in a leaky gut followed by penetration and transfer of luminal antigens, endotoxins, and pathogenic bacteria. Under extreme conditions, HS may culminate in the onset of “heat stroke”, a potential lethal condition if remaining untreated. HS-induced alterations of the gastrointestinal epithelium, which is associated with a leaky gut, are due to cellular oxidative stress, disruption of intestinal integrity, and increased production of pro-inflammatory cytokines. This review summarizes the possible resilience mechanisms based on in vitro and in vivo data and the potential interventions with a group of nutritional supplements, which may increase the resilience to HS-induced intestinal integrity disruption and maintain intestinal homeostasis.

Printed Organic Transistor-based Biosensors for Non-invasive Sweat Analysis

This review describes recent advances in biosensors for non-invasive human healthcare applications, especially focusing on sweat analysis, along with approaches for fabricating these biosensors based on printed electronics technology. Human sweat contains various kinds of biomarkers. The relationship between a trace amount of sweat biomarkers partially partitioned from blood and diseases has been investigated by omic analysis. Recent progress in wearable or portable biosensors has enabled periodic or continuous monitoring of some sweat biomarkers while supporting the results of the omic analysis. In this review, we particularly focused on a transistor-based biosensor that is highly sensitive in quantitatively detecting the low level of sweat biomarkers. Furthermore, we showed a new approach of flexible hybrid electronics that has been applied to advanced sweat biosensors to realize fully integrated biosensing systems wirelessly connected to a networked IoT system. These technologies are based on uniquely advanced printing techniques that will facilitate mass fabrication of high-performance biosensors at low cost for future smart healthcare.

Intestinal Injury in Heat Stroke

BACKGROUND

Heat stroke is a life-threatening syndrome that is characterized by its severe clinical symptoms, rapid progression, and high rate of mortality. Recently, research has indicated that a dysfunctional intestinal epithelia barrier plays an important role in the pathophysiology of heat stroke. Protecting the intestines from heat stress had been identified as a potentially effective treatment for patients with heat stroke and may reduce the innate immune response caused by endotoxins in circulation.

OBJECTIVES

The aim of this review is to discuss this key event in heat stroke and to describe the mechanism during progression.

DISCUSSION

Direct injuries and secondary impairments of the intestine induced by heat stress are discussed; recent studies that refer to intestine-specific prevention and treatment in heat stroke and heat stress-induced injuries are also summarized.

CONCLUSIONS

A more detailed pathogenesis of heat stroke needs to be elucidated so that potentially effective means of treatment and prevention of heat stroke can be developed and studied.

MTOR Variation Related to Heat Resistance of Chinese Cattle

With the inexorable rise of global temperature, heat stress deserves more and more attention in livestock agriculture. Previous studies have shown that the mechanistic target of rapamycin (MTOR) (NC_037343.1:c.2062G>C) gene contributes to the repair of DNA damage repair and is associated with the adaptation of camels in dry and hot environments. However, it is unknown whether this mutation is related to the heat tolerance of Chinese cattle. In this study, PCR and sequencing were used to type the mutation locus in 1030 individuals of 37 cattle breeds. The analysis results showed that the frequency of G allele of the locus gradually diminished from the northern group to the southern group of native Chinese cattle, whereas the frequency of the C allele showed an opposite pattern, displaying a significant geographical difference across native Chinese cattle breeds. Additionally, an analysis of the locus in Chinese indigenous cattle revealed that this SNP was significantly associated with mean annual temperature (T), relative humidity (RH) and temperature humidity index (THI) (p < 0.01), suggesting that cattle with C allele was distributed in regions with higher T, RH and THI. In conclusion, this study proved that the mutation of MTOR gene in Chinese cattle could be associated with the heat tolerance.

Deaths in Australia from Work-Related Heat Stress, 2000-2015

The infrequency of deaths from work-related heat stress may be due to self-pacing, whereby workers adjust their work rate in response to thermal discomfort. Thirteen cases attributed after coronial investigation to work-related heat stress were studied to evaluate the causal contribution of environmental and personal risk factors. Meteorological records and coronial records were examined to estimate environmental and metabolic heat loads and to identify any personal risk factors likely to have contributed to death. Seven deaths occurred in workers within one week of hiring, demonstrating not only the importance of acclimatisation but also the likelihood of compromised self-pacing in recently-hired workers. Personal risk factors identified included intercurrent illness, cardiovascular disease and obesity. Four deaths occurred following indoor work, where the probable critical risk parameter was low air velocity. Cerebral and pulmonary oedema were reported in some autopsy reports, and uncal herniation was found in one case. Modified work rates and close supervision are essential in recently-hired workers. The risk of death from raised intracranial pressure suggests the need for specific remediation of cerebral oedema in hyperthermic individuals.

Impacts of previous heatstroke history on physiological parameters eHSP72 and biomarkers of oxidative stress in military working dogs

Heatstroke (HS) is an acute, progressive life-threatening emergency. Animals, including military working dogs (IDFMWD), rapidly activate cytoprotective processes, e.g., heat shock proteins (HSPs) and antioxidative molecules, in response to heat stress. We hypothesized that serum HSPs (eHSP72) and oxidative stress markers would differ in IDFMWD with a history of HS compared with controls and thus could be used to detect susceptibility to recurrent HS. eHSPs concentration, oxidative stress markers, and systemic physiological parameters were studied in dogs with and without histories of HS, undergoing indoor or outdoor training. Treadmill physical performance tests (PPTs) were conducted indoors at 22 °C (groups C-I and HS-I) or outdoors under heat stress conditions of 36 °C; 60% humidity (groups C-O and HS-O). Pre-, immediately post-, and 45 min post-PPT heart rate (HR), respiratory rate, and rectal temperature (Tre) were recorded in all dogs. Likewise, blood samples were collected and eHSP72, venous blood gas analysis, and lactate and creatine kinase activity (CK) were assayed. Serum uric acid (sUA) and total serum redox potential (TRP) were measured only in the indoor group. Immediately post-PPT under both environmental conditions, Tre, HR, eHSP, sUA, and TRP (only measured in indoor PPT) significantly (P < 0.05) increased, whereas venous blood pH and bicarbonate decreased significantly (P < 0.05). Between groups comparisons demonstrated significant differences in basal HR and post-PPT Tre immediately after outdoor PPT. eHSP72 induction, CK, sUA, and serum TRP remained significantly higher in the HS group during post-PPT recovery. Taken together, animals with a history of HS have different results, and this signature of previous HS may predict altered heat sensitivity.

Health Risks and Interventions in Exertional Heat Stress

BACKGROUND

With climate change, heat waves are expected to become more frequent in the near future. Already, on average more than 25 000 "heat deaths" are estimated to occur in Europe every year. However, heat stress and heat illnesses arise not just when ambient temperatures are high. Physical exertion increases heat production within the organism many times over; if not enough heat is lost, there is a risk of exertional heat stress. This review article discusses contributing factors, at-risk groups, and the diagnosis and treatment of heat illnesses.

METHODS

A selective literature search was carried out on PubMed. Current guidelines and expert recommendations were also included.

RESULTS

Apart from muscular heat production (>70% of converted energy), there are other factors that singly or in combination can give rise to heat stress: clothing, climate/acclimatization, and individual factors. Through its insulating properties, clothing reduces the evaporation of sweat (the most effective physiological cooling mechanism). A sudden heat wave, or changing the climate zone (as with air travel), increases the risk of a heat-related health event. Overweight, low fitness level, acute infections, illness, dehydration, and other factors also reduce heat tolerance. In addition to children, older people are particularly at risk because of their reduced physiological adaptability, (multi-)morbidity, and intake of prescription drugs. A heat illness can progress suddenly to life-threatening heat stroke. Successful treatment depends on rapid diagnosis and cooling the body down as quickly as possible. The aim is to reduce core body temperature to <40 °C within 30 minutes.

CONCLUSION

Immediately effective cooling interventions are the only causal treatment for heat stroke. Time once lost cannot be made up. Prevention (acclimatization, reduced exposure, etc.) and terminating the heat stress in good time (e.g., stopping work) are better than any cure.

Heart rate variability dynamics during treatment for exertional heat strain when immediate response is not possible

NEW FINDINGS

What is the central question of this study? Does a delay in cold water immersion treatment affect the cardiac autonomic control of exertionally heat-strained individuals? What is the main finding and its importance? Cold water immersion is effective for treating exertionally heat-strained individuals even when treatment is commenced with a significant delay. However, that treatment delay leads to only partial/transient restoration of cardiac autonomic control. Therefore, we recommend that exertional heatstroke patients are continuously monitored for several hours even after core temperature has returned to normal values.

ABSTRACT

Immediate cold water immersion (CWI) is the gold-standard treatment for exertional heatstroke. In the field, however, treatment is often delayed, primarily owing to a delayed paramedic response and/or inaccurate diagnosis. We examined the effect of treatment (reduction of rectal temperature to 37.5°C) delays of 5 (short), 20 (moderate) and 40 (prolonged) min on cardiac autonomic control [as assessed via heart rate variability (HRV)] in eight exertionally heat-strained (40.0°C rectal temperature) individuals. Eleven HRV indices were computed that have been described commonly in the literature and characterize almost all known domains of the variability and complexity of the cardiopulmonary system. We found that the cardiac autonomic control (as assessed via HRV) of exertionally heat-strained individuals was significantly affected by the amount of time it took for the CWI treatment to be applied. Six out of 11 HRV indices studied, from all variability domains, displayed strong (P ≤ 0.005) time × delay interaction effects. Moreover, the number of significantly (P ≤ 0.005) abnormal (i.e. different from the short delay) HRV indices more than doubled (seven versus 15) from the moderate delay to the prolonged delay. Finally, our results demonstrated that a CWI treatment applied with delays of 20 and, primarily, 40 min did not lead to a full restoration of cardiac autonomic control of exertionally heat-strained individuals. In conclusion, this study supports CWI for treating exertionally heat-strained individuals even when applied with prolonged delay, but it highlights the importance of continued cardiac monitoring of patients who have suffered exertional heatstroke for several hours after restoration of core temperature to normal.