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Hintz CN, Butler CR. Wearable and ingestible technology to evaluate and prevent exertional heat illness: A narrative review. PM R 2024; 16:398-403. [PMID: 38501700 DOI: 10.1002/pmrj.13155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 01/21/2024] [Accepted: 01/23/2024] [Indexed: 03/20/2024]
Abstract
Exertional heat illness remains a constant threat to the athlete, military service member, and laborer. Recent increases in the number and intensity of environmental heat waves places these populations at an ever increasing risk and can be deadly if not recognized and treated rapidly. For this reason, it is extremely important for medical providers to guide athletes, service members, and laborers in the implementation of awareness, education, and measures to reduce or mitigate the risk of exertional heat illness. Within the past 2 decades, a variety of wearable technology options have become commercially available to track an estimation of core temperature, yet questions continue to emerge as to its use, effectiveness, and practicality in athletics, the military, and the workforce. There is a paucity of data on the accuracy of many of these newer devices in the setting of true heat stroke physiology, and it is important to avoid overreliance on new wearable technology. Further research and improvement of this technology are critical to identify accuracy in the diagnosis and prevention of EHI.
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Affiliation(s)
- Courtney N Hintz
- Special Warfare Human Performance Support Group, USAF, San Antonio, Texas, USA
| | - Cody R Butler
- Special Warfare Human Performance Support Group, USAF, San Antonio, Texas, USA
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Hintz C, Presley DM, Butler CR. Heat stroke burden and validity of wearable-derived core temperature estimation during elite military training. PHYSICIAN SPORTSMED 2024; 52:154-159. [PMID: 36919415 DOI: 10.1080/00913847.2023.2190729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 03/09/2023] [Indexed: 03/16/2023]
Abstract
OBJECTIVES Exertional heat stroke (EHS) remains a significant health concern while training in hot environments, prompting the development of noninvasive wearable technology for monitoring estimated core temperature (ECT). The objective of this study was to review the effectiveness of an ECT device during elite military training by providing a case series of individuals who developed EHS. METHODS This is a retrospective study of EHS cases during high-intensity training while wearing the ECT device, Zephyr BioharnessTM. Data was collected from January 2021 through September 2021 at the Air Force Special Warfare Training pipeline in San Antonio, TX. Rectal temperatures of EHS diagnoses, defined by central nervous system (CNS) dysfunction and rectal temperature approaching or >40°C (104°F), were compared to ECT reading via Zephyr BioharnessTM. Incidence rates and psychometric properties were calculated using R package. RESULTS A total of 47,058 daily peak ECT measurements were collected among 1,364 trainees. A total of 499 trainees flagged as potential EHS by Zephyr BioharnessTM reading >39.7°C (103.5°F). The incidence of confirmed EHS was 0.8/1000 person-months. Of the 10 confirmed EHS cases (9 males, 1 female; age = 23.4 ± 2.7 yrs; BMI = 25 ± 2; body fat = 13 ± 5%), 8 trainees had a peak ECT reading below 39.7°C which resulted in a sensitivity of 20%, specificity of 98.9%, positive likelihood ratio (LR) of 18.93 (95% Confidence Interval [CI] 5.5-65.6), and a negative LR of 0.81 (95% CI 0.6-1.1). CONCLUSION ECT had substantial false positive and negative rates. Further studies are needed to validate this technology in other populations, and the algorithm used in this device needs to be refined to better capture the environmental and physical requirements in the special operations population.
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Affiliation(s)
- Courtney Hintz
- Special Warfare Human Performance Support Group, USAF, Lackland AFB, San Antonio, TX, USA
| | | | - Cody R Butler
- Special Warfare Human Performance Support Group, USAF, Lackland AFB, San Antonio, TX, USA
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Kruijt N, van den Bersselaar LR, Hopman MTE, Snoeck MMJ, van Rijswick M, Wiggers TGH, Jungbluth H, Bongers CCWG, Voermans NC. Exertional Heat Stroke and Rhabdomyolysis: A Medical Record Review and Patient Perspective on Management and Long-Term Symptoms. SPORTS MEDICINE - OPEN 2023; 9:33. [PMID: 37204519 DOI: 10.1186/s40798-023-00570-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 04/19/2023] [Indexed: 05/20/2023]
Abstract
INTRODUCTION Exertional heat stroke (EHS) is a medical emergency, occurring when the body generates more heat than it can dissipate, and frequently associated with exertional rhabdomyolysis (ERM). In the present study we aimed to (I) identify clinical features and risk factors, (II) describe current prehospital management, (III) investigate long-term outcomes including the impact on mental health, and review the guidance received during restarting activities. We hope that our approach will improve individual and organizational heat illness preparedness, and improve follow-up care. METHODS We performed a prospective online survey and retrospective medical record review among athletes and military personnel with an episode of EHS/ERM in the Netherlands between 2010 and 2020. We evaluated prehospital management, risk factors, clinical features and long-term outcomes at 6 and 12 months after the event, including mental health symptoms. Furthermore, we investigated what guidance participants received during follow-up, and assessed the patients' perspective on these outcomes. RESULTS Sixty participants were included, 42 male (70%) and 18 female (30%), of which 47 presented with EHS (78%) and 13 with ERM (22%). Prehospital management was inconsistent and in the majority of participants not conducted according to available guidelines. Self-reported risk factors included not feeling well-acclimatized to environmental heat (55%) and peer pressure (28%). Self-reported long-term symptoms included muscle symptoms at rest (26%) or during exercise (28%), and neurological sequelae (11%). Validated questionnaires (CIS, HADS and SF-36) were indicative of severe fatigue (30%) or mood/anxiety disorders (11%). Moreover, 90% expressed a lack of follow-up care and that a more frequent and intensive follow-up would have been beneficial for their recovery process. CONCLUSION Our findings indicate major inconsistencies in the management of patients with EHS/ERM, emphasizing the compelling need for implementing standardized protocols. Based on the results of long-term outcome measures, we recommend to counsel and evaluate every patient not only immediately after the event, but also in the long-term.
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Affiliation(s)
- Nick Kruijt
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Geert Grooteplein 10 (Route 652), 6525 GA, Nijmegen, The Netherlands.
- Department of Primary and Community Care, Radboudumc, Nijmegen, The Netherlands.
| | - L R van den Bersselaar
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Geert Grooteplein 10 (Route 652), 6525 GA, Nijmegen, The Netherlands
- Malignant Hyperthermia Investigation Unit, Department of Anesthesiology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - M T E Hopman
- Department of Physiology, Radboudumc, Nijmegen, The Netherlands
| | - M M J Snoeck
- Malignant Hyperthermia Investigation Unit, Department of Anesthesiology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - M van Rijswick
- Department of Exercise Medicine and Exercise Physiology, Royal Dutch Army, Utrecht, The Netherlands
| | - T G H Wiggers
- Department of Sports Medicine, Anna Hospital, Geldrop, The Netherlands
| | - H Jungbluth
- Randall Centre for Cell and Molecular Biophysics, Muscle Signalling Section, Faculty of Life Sciences and Medicine (FoLSM), King's College London, London, UK
- Department of Paediatric Neurology, Neuromuscular Service, Evelina Children's Hospital, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
| | - C C W G Bongers
- Department of Physiology, Radboudumc, Nijmegen, The Netherlands
| | - N C Voermans
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Geert Grooteplein 10 (Route 652), 6525 GA, Nijmegen, The Netherlands
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Chao CM, Wang LY, Huang CC, Chang WT, Tang LY, Lin MT, Chang CP. Myocardial structure and functional alterations in a preclinical model of exertional heat stroke. Life Sci 2023; 323:121640. [PMID: 37004732 DOI: 10.1016/j.lfs.2023.121640] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 03/17/2023] [Accepted: 03/24/2023] [Indexed: 04/03/2023]
Abstract
AIM Relatively little information is available about the effect of an acute exertional heat stroke (EHS) on myocardium structure and function. Herein, we used a survival male rat model of EHS to answer the question. MAIN METHODS Adult male Wistar rats underwent forced treadmill running at a 36 °C room temperature and 50 % relative humidity until EHS onset, characterized by hyperthermia and collapse. All rats that were followed for 14 days survived. Injury severity scores of both gastrocnemius and myocardium were determined histologically. Following an EHS event, pathological echocardiography, skeletal muscle and myocardial damage scores and indicators, myocardial fibrosis, hypertrophy, and autophagy were elucidated. KEY FINDINGS Rats with EHS onset displayed skeletal muscle damage, elevated serum levels of skeletal muscle indicators (e.g., creatinine kinase, myoglobin, and potassium) and myocardial injury indicators (e.g., cardiac troponin I, creatinine kinase, and lactate dehydrogenase) returning to homeostasis within 3 days post-EHS. However, EHS-induced myocardial damage, pathological echocardiography, myocardial fibrosis, hypertrophy, and deposited misfolded proteins lasted up to 14 days post-EHS at least. SIGNIFICANCE First, we provide evidence to confirm that despite the apparent return to homeostasis, underlying processes may still be ongoing after EHS onset. Second, we provide several key findings emphasizing the pathophysiology and risk factors of EHS, highlighting gaps in knowledge with the aim of stimulating future studies.
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Dolson CM, Harlow ER, Phelan DM, Gabbett TJ, Gaal B, McMellen C, Geletka BJ, Calcei JG, Voos JE, Seshadri DR. Wearable Sensor Technology to Predict Core Body Temperature: A Systematic Review. SENSORS (BASEL, SWITZERLAND) 2022; 22:s22197639. [PMID: 36236737 PMCID: PMC9572283 DOI: 10.3390/s22197639] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 09/30/2022] [Accepted: 10/01/2022] [Indexed: 05/28/2023]
Abstract
Heat-related illnesses, which range from heat exhaustion to heatstroke, affect thousands of individuals worldwide every year and are characterized by extreme hyperthermia with the core body temperature (CBT) usually > 40 °C, decline in physical and athletic performance, CNS dysfunction, and, eventually, multiorgan failure. The measurement of CBT has been shown to predict heat-related illness and its severity, but the current measurement methods are not practical for use in high acuity and high motion settings due to their invasive and obstructive nature or excessive costs. Noninvasive predictions of CBT using wearable technology and predictive algorithms offer the potential for continuous CBT monitoring and early intervention to prevent HRI in athletic, military, and intense work environments. Thus far, there has been a lack of peer-reviewed literature assessing the efficacy of wearable devices and predictive analytics to predict CBT to mitigate heat-related illness. This systematic review identified 20 studies representing a total of 25 distinct algorithms to predict the core body temperature using wearable technology. While a high accuracy in prediction was noted, with 17 out of 18 algorithms meeting the clinical validity standards. few algorithms incorporated individual and environmental data into their core body temperature prediction algorithms, despite the known impact of individual health and situational and environmental factors on CBT. Robust machine learning methods offer the ability to develop more accurate, reliable, and personalized CBT prediction algorithms using wearable devices by including additional data on user characteristics, workout intensity, and the surrounding environment. The integration and interoperability of CBT prediction algorithms with existing heat-related illness prevention and treatment tools, including heat indices such as the WBGT, athlete management systems, and electronic medical records, will further prevent HRI and increase the availability and speed of data access during critical heat events, improving the clinical decision-making process for athletic trainers and physicians, sports scientists, employers, and military officers.
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Affiliation(s)
- Conor M. Dolson
- School of Medicine, Case Western Reserve University, Cleveland, OH 44106, USA
| | - Ethan R. Harlow
- Sports Medicine Institute, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| | - Dermot M. Phelan
- Sanger Heart and Vascular Institute, Atrium Health, Charlotte, NC 28204, USA
| | - Tim J. Gabbett
- Gabbett Performance Solutions, Brisbane, QLD 4000, Australia
- Centre for Health Research, University of Southern Queensland, Ipswich, QLD 4305, Australia
- Institute of Health and Wellbeing, Federation University, Ballarat, VIC 3350, Australia
| | - Benjamin Gaal
- School of Medicine, Case Western Reserve University, Cleveland, OH 44106, USA
| | - Christopher McMellen
- Sports Medicine Institute, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| | - Benjamin J. Geletka
- School of Medicine, Case Western Reserve University, Cleveland, OH 44106, USA
- Sports Medicine Institute, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
- University Hospitals Rehabilitation Services and Sports Medicine, Cleveland, OH 44106, USA
| | - Jacob G. Calcei
- Sports Medicine Institute, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| | - James E. Voos
- Sports Medicine Institute, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| | - Dhruv R. Seshadri
- Sports Medicine Institute, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
- Department of Biomedical Engineering, School of Engineering, Case Western Reserve University, Cleveland, OH 44106, USA
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Navalta JW, Bodell NG, Tanner EA, Aguilar CD, Radzak KN. Effect of exercise in a desert environment on physiological and subjective measures. INTERNATIONAL JOURNAL OF ENVIRONMENTAL HEALTH RESEARCH 2021; 31:121-131. [PMID: 31240953 DOI: 10.1080/09603123.2019.1631961] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 06/10/2019] [Indexed: 06/09/2023]
Abstract
Green exercise is beneficial to emotional and physiological measures, however, the US has large desert areas. We aimed to determine if exercise in a desert (brown) environment extends similar benefits to green. Participants (N = 10) completed baseline measures (PRE), 30-min seated rest (SIT), and 30-min self-paced walking (WALK) in: indoor, outdoor urban, green, and two brown environments. Heart rate (HR), blood pressure (BP), and measures of stress, comfort, and calm were obtained. After SIT, HR was elevated in urban vs green (p = 0.05). Systolic BP was lower after SIT compared to PRE and WALK (p = 0.05). Brown and green returned greater comfort and calm scores (p = 0.001). Stress was lower following WALK than PRE and SIT (p < 0.01). Comfort and calm were greatest in natural environments, and exercise significantly reduced perceived stress. Taken together, these data provide evidence that exercise in a desert environment is just a beneficial as the exercise performed in a green environment. Abbreviations: ANCOVA: analysis of covariance; ANOVA: analysis of variance; AU: arbitrary units; BP: blood pressure; BSL: below sea level; DBP: diastolic blood pressure; HR: heart rate; PRE: baseline measurement; PS: perceived stress; SBP: systolic blood pressure; SIT: measurement following 30-min seated rest; WALK: measurement following 30-min self-paced walking.
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Affiliation(s)
- James W Navalta
- Department of Kinesiology and Nutrition Sciences, University of Nevada , Las Vegas, NV, USA
| | - Nathaniel G Bodell
- Department of Kinesiology and Nutrition Sciences, University of Nevada , Las Vegas, NV, USA
| | - Elizabeth A Tanner
- Department of Kinesiology and Nutrition Sciences, University of Nevada , Las Vegas, NV, USA
| | - Charli D Aguilar
- Department of Kinesiology and Nutrition Sciences, University of Nevada , Las Vegas, NV, USA
| | - Kara N Radzak
- Department of Kinesiology and Nutrition Sciences, University of Nevada , Las Vegas, NV, USA
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Alele FO, Malau-Aduli BS, Malau-Aduli AEO, J. Crowe M. Epidemiology of Exertional Heat Illness in the Military: A Systematic Review of Observational Studies. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E7037. [PMID: 32993024 PMCID: PMC7579124 DOI: 10.3390/ijerph17197037] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 09/22/2020] [Accepted: 09/23/2020] [Indexed: 12/13/2022]
Abstract
Exertional heat illness (EHI) is an occupational hazard among military personnel. This systematic review describes the incidence, risk factors, clinical manifestations, and biomarkers of EHI in the military. Six databases from inception to 28 May 2020 were systematically reviewed using the PRISMA guidelines. Forty-one articles met the inclusion criteria and the incidence of EHI ranged from 0.2 to 10.5 per 1000 person years, while the prevalence rates ranged from 0.3% to 9.3%. Intrinsic risk factors influencing EHI were gender, physical fitness, obesity, previous history of heat illness, and motivation, while the extrinsic factors included hot environmental conditions and service unit. Evidence suggests that loss of consciousness, absence of sweating and confusion were the common clinical features of exertional heat stroke (EHS). The mean core temperature ranged from 40 to 41.6 °C, while elevated levels of creatine phosphokinase, liver enzymes, and creatinine were common biochemical markers of EHS. The findings of the review suggest a variation in the incidence of EHI among military populations possibly due to the varying definitions used. Although some risk factors of EHI were identified, more analytical studies are needed to investigate the association between EHI and other important factors such as acclimatisation and occlusive clothing.
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Affiliation(s)
- Faith O. Alele
- College of Healthcare Sciences, James Cook University, Townsville QLD 4811, Australia
| | - Bunmi S. Malau-Aduli
- College of Medicine and Dentistry, James Cook University, Townsville QLD 4811, Australia;
| | - Aduli E. O. Malau-Aduli
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville QLD 4811, Australia;
| | - Melissa J. Crowe
- Division of Tropical Health and Medicine, James Cook University, Townsville QLD 4811, Australia;
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Nzvere FP, Tariq E, Nishanth K, Arshid A, Cancarevic I. Long-Term Cardiovascular Diseases of Heatstroke: A Delayed Pathophysiology Outcome. Cureus 2020; 12:e9595. [PMID: 32789098 PMCID: PMC7416985 DOI: 10.7759/cureus.9595] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Heatstroke, defined as an elevated core body temperature above 40°C accompanied by altered mental status (e.g., confusion, disorientation, seizure and coma), is the most severe and life-threatening condition in the spectrum of heat-related illnesses. Heatstroke patients may present with multi-organ dysfunction, but with rapid cooling and organ failure management, a full recovery often occurs within weeks. Long-term impairment is rare, with neurological impairment occurring most frequently. Despite an abundance of research on the persistent neurological and hepatic impairments, our knowledge of the long-term cardiovascular events in patients with heatstroke history is poor. We wondered whether heatstroke leads to cardiovascular diseases long after full recovery. Using Pubmed, Web of Science and Scopus, we gathered cohort studies looking at cardiovascular disease incidence or mortality as an outcome, including heatstroke animal studies. Based on the available literature, we found that a history of heatstroke is associated with an increased risk of cardiovascular diseases, including ischemic heart disease, heart failure and atrial fibrillation. Delayed metabolic disturbances occurring in exertional heatstroke mice are linked to the formation of atherosclerosis and the development of heart failure. These processes provide potential pathophysiological pathways leading to ischemic heart disease and heart failure in heatstroke patients. Our findings may massively impact our understanding of heatstroke recovery and the follow up of heatstroke patients. Therefore larger, more adequately powered cohort studies with cardiovascular disease as an outcome, in tandem with animal studies examining the underlying pathophysiology, are required to confirm or reject these findings and answer the proposed questions.
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Affiliation(s)
- Farirai P Nzvere
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Ezza Tariq
- Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA.,Medicine, Nishtar Medical College, Multan, PAK
| | - Katukuri Nishanth
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Assam Arshid
- Surgery, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Ivan Cancarevic
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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Chun JK, Choi S, Kim HH, Yang HW, Kim CS. Predictors of poor prognosis in patients with heat stroke. Clin Exp Emerg Med 2020; 6:345-350. [PMID: 31910506 PMCID: PMC6952628 DOI: 10.15441/ceem.18.081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 11/23/2018] [Indexed: 11/23/2022] Open
Abstract
Objective The predictors of poor prognosis in heat stroke (HS) remain unknown. This study investigated the predictive factors of poor prognosis in patients with HS. Methods Data were obtained and analyzed from the health records of patients diagnosed with heat illness at Ajou university hospital between January 2008 and December 2017. Univariate and multivariate analyses were performed to identify the independent predictors of poor prognosis. Results Thirty-six patients (median age, 54.5 years; 33 men) were included in the study. Poor prognosis was identified in 27.8% of the study population (10 patients). The levels of S100B protein, troponin I, creatinine, alanine aminotransferase, and serum lactate were statistically significant in the univariate analysis. Multiple regression analysis revealed that poor prognosis was significantly associated with an increased S100B protein level (odds ratio, 177.37; 95% confidence interval, 2.59 to 12,143.80; P=0.016). The S100B protein cut-off level for predicting poor prognosis was 0.610 μg/L (area under the curve, 0.906; 95% confidence interval, 0.00 to 1.00), with 86% sensitivity and 86% specificity. Conclusion An increased S100B protein level on emergency department admission is an independent prognostic factor of poor prognosis in patients with HS. Elevation of the S100B protein level represents a potential target for specific and prompt therapies in these patients.
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Affiliation(s)
- Jae-Kwon Chun
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Sangchun Choi
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Hyuk-Hoon Kim
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Hee Won Yang
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea
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Management of exertional heat stroke. Br J Gen Pract 2018; 68:415-416. [DOI: 10.3399/bjgp18x698477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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