Blood lactate threshold and type II fibre predominance in patients with exertional heatstroke

Nutritional ketosis improves exercise metabolism in patients with very long-chain acyl-CoA dehydrogenase deficiency

A maladaptive shift from fat to carbohydrate (CHO) oxidation during exercise is thought to underlie myopathy and exercise-induced rhabdomyolysis in patients with fatty acid oxidation (FAO) disorders. We hypothesised that ingestion of a ketone ester (KE) drink prior to exercise could serve as an alternative oxidative substrate supply to boost muscular ATP homeostasis. To establish a rational basis for therapeutic use of KE supplementation in FAO, we tested this hypothesis in patients deficient in Very Long-Chain acyl-CoA Dehydrogenase (VLCAD). Five patients (range 17-45 y; 4 M/1F) patients were included in an investigator-initiated, randomised, blinded, placebo-controlled, 2-way cross-over study. Patients drank either a KE + CHO mix or an isocaloric CHO equivalent and performed 35 minutes upright cycling followed by 10 minutes supine cycling inside a Magnetic Resonance scanner at individual maximal FAO work rate (fatmax; approximately 40% VO₂ max). The protocol was repeated after a 1-week interval with the alternate drink. Primary outcome measures were quadriceps phosphocreatine (PCr), Pi and pH dynamics during exercise and recovery assayed by in vivo ³¹ P-MR spectroscopy. Secondary outcomes included plasma and muscle metabolites and respiratory gas exchange recordings. Ingestion of KE rapidly induced mild ketosis and increased muscle BHB content. During exercise at FATMAX, VLCADD-specific plasma acylcarnitine levels, quadriceps glycolytic intermediate levels and in vivo Pi/PCr ratio were all lower in KE + CHO than CHO. These results provide a rational basis for future clinical trials of synthetic ketone ester supplementation therapy in patients with FAO disorders. Trial registration: ClinicalTrials.gov. Protocol ID: NCT03531554; METC2014.492; ABR51222.042.14.

Individual risk factors associated with exertional heat illness: A systematic review

NEW FINDINGS

What is the topic of this review? Exertional heat illness (EHI) remains a persistent problem for athletes and individuals. This threat remains despite numerous athletic position statements and occupational guidance policies. This review explores primary evidence that demonstrates a direct association between 'known' risk factors and EHI. What advances does it highlight? Primary evidence to support 'known' risk factors associated with EHI is not comprehensive. Furthermore, it is not evident that single individual factors predispose individuals to greater risk. In fact, the evidence indicates that EHI can manifest in non-hostile compensable environments when a combination of risk factors is prevalent.

ABSTRACT

Despite the widespread knowledge of exertional heat illness (EHI) and clear guidance for its prevention, the incidence of EHI remains high. We carried out a systematic review of available literature evaluating the scientific evidence underpinning the risk factors associated with EHI. Medline, PsycINFO, SportDiscus and Embase were searched from inception to January 2019 with no date limitation, with supplementary searches also being performed. Search terms included permutations of risk and heat illness, with only studies in English included. Study selection, data extraction and quality assessment, using the QUALSYST tool, were performed by two independent reviewers. Of 8898 articles identified by the searches, 42 were included in the systematic review as primary evidence demonstrating a link between a risk factor and EHI. The quality scores ranged from 57.50 to 100%, and studies were generally considered to be of strong quality. The majority of risks attributable to EHI were categorized as those associated with lifestyle factors. The findings from the systematic review suggest complex manifestation of EHI through multiple risk factors rather than any one factor in isolation. Further research is needed to explore the accumulation of risk factors to help in development of effective preventative measures.

Physiological, biochemical and histopathological changes associated with heatstroke in the galah (Eolophus roseicapilla) and rock dove (Columba livia)

The pathophysiology of heat illnesses in birds has not been well characterized. In this study, we describe the changes in heart rate, respiratory rate, blood biochemistry and histopathological findings in galahs and rock doves after heat exposure under standardized conditions designed to induce heatstroke. Birds in the heat-exposed group were exposed to environmental heat stress and compared to control birds. Both groups of birds were under general anaesthesia throughout the experiment and serial blood collections were performed for biochemical analyses, while organs were collected at the end of the experiment for histopathology. No electromyography traces consistent with the onset of heat cramps were observed in any of the birds. Biochemical changes suggestive of skeletal muscle and hepatocellular injury, including hyperkalaemia and increased serum muscle and hepatic enzyme activities, were often observed in heat-exposed galahs and rock doves at the onset of heatstroke. Microscopic analyses did not reveal any significant cardiac changes, although some lungs had signs of acute congestion. Some heat-exposed rock doves had microscopic changes indicative of necrosis in the pectoral muscle. There were significant hepatic changes in some heat-exposed galahs, but not in rock doves. This suggests that there may be species differences amongst birds in the organs most affected by heatstroke. The observed species differences in the physiological, biochemical and histopathological changes indicate that bird species should be studied separately for clinical syndromes such as heatstroke. RESEARCH HIGHLIGHTS Biochemical changes suggestive of skeletal muscle and hepatocellular injury in heat-exposed galahs and rock doves at the onset of heatstroke No electromyography traces consistent with the onset of heat cramps were observed Some heat-exposed rock doves had indications of necrosis in the pectoral muscle There were significant hepatic changes in some heat-exposed galahs.

Cold-Water Immersion Cooling Rates in Football Linemen and Cross-Country Runners With Exercise-Induced Hyperthermia

CONTEXT

  Ideal and acceptable cooling rates in hyperthermic athletes have been established in average-sized participants. Football linemen (FBs) have a small body surface area (BSA)-to-mass ratio compared with smaller athletes, which hinders heat dissipation.

OBJECTIVE

  To determine cooling rates using cold-water immersion in hyperthermic FBs and cross-country runners (CCs).

DESIGN

  Cohort study.

SETTING

  Controlled university laboratory.

PATIENTS OR OTHER PARTICIPANTS

  Nine FBs (age = 21.7 ± 1.7 years, height = 188.7 ± 4 cm, mass = 128.1 ± 18 kg, body fat = 28.9% ± 7.1%, lean body mass [LBM] = 86.9 ± 19 kg, BSA = 2.54 ± 0.13 m², BSA/mass = 201 ± 21.3 cm²/kg, and BSA/LBM = 276.4 ± 19.7 cm²/kg) and 7 CCs (age = 20 ± 1.8 years, height = 176 ± 4.1 cm, mass = 68.7 ± 6.5 kg, body fat = 10.2% ± 1.6%, LBM = 61.7 ± 5.3 kg, BSA = 1.84 ± 0.1 m², BSA/mass = 268.3 ± 11.7 cm²/kg, and BSA/LBM = 298.4 ± 11.7 cm²/kg).

INTERVENTION(S)

  Participants ingested an intestinal sensor, exercised in a climatic chamber (39°C, 40% relative humidity) until either target core temperature (T_gi) was 39.5°C or volitional exhaustion was reached, and were immediately immersed in a 10°C circulated bath until T_gi declined to 37.5°C. A general linear model repeated-measures analysis of variance and independent t tests were calculated, with P < .05.

MAIN OUTCOME MEASURE(S)

  Physical characteristics, maximal T_gi, time to reach 37.5°C, and cooling rate.

RESULTS

  Physical characteristics were different between groups. No differences existed in environmental measures or maximal T_gi (FBs = 39.12°C ± 0.39°C, CCs = 39.38°C ± 0.19°C; P = .12). Cooling times required to reach 37.5°C (FBs = 11.4 ± 4 minutes, CCs = 7.7 ± 0.06 minutes; P < .002) and therefore cooling rates (FBs = 0.156°C·min^-1 ± 0.06°C·min^-1, CCs = .255°C·min^-1 ± 0.05°C·min^-1; P < .002) were different. Strong correlations were found between cooling rate and body mass (r = -0.76, P < .001), total BSA (r = -0.74, P < .001), BSA/mass (r = 0.73, P < .001), LBM/mass (r = 0.72, P < .002), and LBM (r = -0.72, P < .002).

CONCLUSIONS

  With cold-water immersion, the cooling rate in CCs (0.255°C·min^-1) was greater than in FBs (0.156°C·min^-1); however, both were considered ideal (≥0.155°C·min^-1). Athletic trainers should realize that it likely takes considerably longer to cool large hyperthermic American-football players (>11 minutes) than smaller, leaner athletes (7.7 minutes). Cooling rates varied widely from 0.332°C·min^-1 in a small runner to only 0.101°C·min^-1 in a lineman, supporting the use of rectal temperature for monitoring during cooling.

Genetic polymorphisms associated with exertional rhabdomyolysis

Exertional rhabdomyolysis (ER) occurs in young, otherwise healthy, individuals principally during strenuous exercise, athletic, and military training. Although many risk factors have been offered, it is unclear why some individuals develop ER when participating in comparable levels of physical exertion under identical environmental conditions and others do not. This study investigated possible genetic polymorphisms that might help explain ER. DNA samples derived from a laboratory-based study of persons who had never experienced an episode of ER (controls) and clinical ER cases referred for testing over the past several years were analyzed for single nucleotide polymorphisms (SNPs) in candidate genes. These included angiotensin I converting enzyme (ACE), α-actinin-3 (ACTN3), creatine kinase muscle isoform (CKMM), heat shock protein A1B (HSPA1B), interleukin 6 (IL6), myosin light chain kinase (MYLK), adenosine monophosphate deaminase 1 (AMPD1), and sickle cell trait (HbS). Population included 134 controls and 47 ER cases. The majority of ER cases were men (n = 42/47, 89.4 %); the five women with ER were Caucasian. Eighteen African Americans (56.3 %) were ER cases. Three SNPs were associated with ER: CKMM Ncol, ACTN3 R577X, and MYLK C37885A. ER cases were 3.1 times more likely to have the GG genotype of CKMM (odds ratio/OR = 3.1, confidence interval/CI 1.33-7.10), 3.0 times for the XX genotype of ACTN3 SNP (OR = 2.97, CI 1.30-3.37), and 5.7 times for an A allele of MYLK (OR = 21.35, CI 2.60-12.30). All persons with HbS were also ER cases. Three distinct polymorphisms were associated with ER. Further work will be required to replicate these findings and determine the mechanism(s) whereby these variants might confer susceptibility.

Exertional rhabdomyolysis: a clinical review with a focus on genetic influences

In this review, the clinical and laboratory features of exertional rhabdomyolysis (ER) are discussed in detail, emphasizing the full clinical spectrum from physiological elevations of serum creatine kinase after exertion to life-threatening rhabdomyolysis with acute kidney injury and associated systemic complications. Laboratory markers used to diagnose both ER and rhabdomyolysis are very sensitive, but not very specific, and imperfectly distinguish "subclinical" or asymptomatic from severe, life-threatening illness. However, genetic factors, both recognized and yet to be discovered, likely influence this diverse clinical spectrum of disease and response to exercise. Genetic mutations causative for McArdle disease, carnitine palmitoyl transferase deficiency 2, myoadenylate deaminase deficiency, and malignant hyperthermia have all been associated with ER. Polymorphic variations in the myosin light chain kinase, α-actin 3, creatine kinase-muscle isoform, angiotensin I-converting enzyme, heat shock protein, and interleukin-6 genes have also been associated with either ER or exercise-induced serum creatine kinase elevations typical of ER. The prognosis for ER is significantly better than that for other etiologies of rhabdomyolysis, but the risk of recurrence after an initial episode is unknown. Guidelines for management are provided.

Framing the research agenda for sickle cell trait: building on the current understanding of clinical events and their potential implications

Sickle Cell Trait (HbAS), the heterozygous state for the sickle hemoglobin beta globin gene is carried by as many as 100 million individuals including up to 25% of the population in some regions of the world (World Health Organization, Provisional agenda item 4.8, EB117/34 (22 December 2005) or World Health Organization, Provisional agenda item 11.4 (24 April 2006)). Persons with HbAS have some resistance to falciparum malaria infection in early childhood (Piel FB, Patil AP, Howes RE, et al., Nat Commun 2010;1104:1-7 and Aidoo M, Terlouw DJ, Kolczak M, et al., Lancet 2002;359:1311-1312) and as a result individuals with HbAS living in malarial endemic regions of Africa have a survival advantage over individuals with HbAA. Reports from the US emphasize possible health risks for individuals with HbAS including increased incidence of renal failure and malignancy, thromboembolic disorders, splenic infarction as a high altitude complication, and exercise-related sudden death. The National Heart, Lung, and Blood Institute, National Institutes of Health convened a workshop in Bethesda, Maryland on June 3-4, 2010, Framing the Research Agenda for Sickle Cell Trait, to review the clinical manifestations of HbAS, discuss the exercise-related sudden death reports in HbAS, and examine the public health, societal, and ethical implications of policies regarding HbAS. The goal of the workshop was to identify potential research questions to address knowledge gaps.

Relationship between serum creatine kinase activity following exercise-induced muscle damage and muscle fibre composition

In this study, we examined the relationship between serum creatine kinase activity following exercise-induced muscle damage and muscle fibre composition. Seventeen untrained males volunteered and underwent a .[Vdot]O2max test, Wingate test, and an exercise-induced muscle damage protocol. Muscle soreness and blood samples were recorded before, immediately after, and 24, 48, 72, and 96 h after exercise. Biopsy samples from the vastus lateralis were collected one week after exercise-induced muscle damage and were assessed for muscle fibre composition. There was no significant relationship (P > 0.05) between muscle fibre composition and creatine kinase activity. A significant positive correlation (P < 0.05) was observed between soreness 48 h after exercise and type II and IIb fibres, and a significant negative correlation (P < 0.05) was observed between soreness 48 h after exercise and type I muscle fibres. Significant positive correlations were observed between soreness 48 h after exercise and the fatigue index, relative average power, and relative anaerobic capacity. Our results suggest that creatine kinase activity following exercise-induced muscle damage may not be related to muscle fibre proportions, and higher post-exercise muscular pain may be related to a predominance of type II muscle fibres and higher anaerobic capabilities.

Successful conservative management of acute hepatic failure following exertional heatstroke

Acute hepatic failure is a rare complication of exertional heatstroke with poor prognosis. We herein report a 24-year-old man presenting with acute hepatic failure and rhabdomyolysis following exertional heatstroke during hard physical work on a construction site. Acute hepatic failure occurred after 2 days and led to massive impairment of coagulation parameters. On day 3 after heatstroke the patient fulfilled standard criteria for emergency liver transplantation (i.e. the 'London criteria' and the 'Clichy criteria') but was not transplanted. Nevertheless liver function improved spontaneously thereafter and the patient recovered completely within 12 days. In contrast, the outcome of emergency liver transplantation was dismal in three cases of exertional heatstroke in the literature. Thus conservative management appears to be justified in heatstroke-associated liver failure even in the presence of accepted criteria for emergency liver transplantation.

Rhabdomyolysis: a review

Rhabdomyolysis, a syndrome of skeletal muscle breakdown with leakage of muscle contents, is frequently accompanied by myoglobinuria, and if sufficiently severe, acute renal failure with potentially life-threatening metabolic derangements may ensue. A diverse spectrum of inherited and acquired disorders affecting muscle membranes, membrane ion channels, and muscle energy supply causes rhabdomyolysis. Common final pathophysiological mechanisms among these causes of rhabdomyolysis include an uncontrolled rise in free intracellular calcium and activation of calcium-dependent proteases, which lead to destruction of myofibrils and lysosomal digestion of muscle fiber contents. Recent advances in molecular genetics and muscle enzyme histochemistry may enable a specific metabolic diagnosis in many patients with idiopathic recurrent rhabdomyolysis.

Heat illness--recent developments

This paper reviews the literature concerning exertional heat illness in soldiers. It focuses on developments since Bricknell's two part paper "Heat Illness--A Review of Military Experience" published in this journal in 1996. Recent advances in the understanding of risk factors, pathophysiology and treatment are discussed with a view to reducing the already low incidence of heat illness within the Armed Forces.

Muscle fibre characteristics and lactate responses to exercise in chronic fatigue syndrome

OBJECTIVES

To examine the proportions of type 1 and type 2 muscle fibres and the degree of muscle fibre atrophy and hypertrophy in patients with chronic fatigue syndrome in relation to lactate responses to exercise, and to determine to what extent any abnormalities found might be due to inactivity.

METHODS

Quadriceps needle muscle biopsies were obtained from 105 patients with chronic fatigue syndrome and the proportions of type 1 and 2 fibres and fibre atrophy and hypertrophy factors were determined from histochemical preparations, using a semiautomated image analysis system. Forty one randomly selected biopsies were also examined by electron microscopy. Lactate responses to exercise were measured in the subanaerobic threshold exercise test (SATET).

RESULTS

Inactivity would be expected to result in a shift to type 2 fibre predominance and fibre atrophy, but type 1 predominance (23%) was more common than type 2 predominance (3%), and fibre atrophy was found in only 10.4% of cases. Patients with increased lactate responses to exercise did have significantly fewer type 1 muscle fibres (p<0.043 males, p<0.0003 females), but there was no evidence that this group was less active than the patients with normal lactate responses. No significant ultrastructural abnormalities were found.

CONCLUSION

Muscle histometry in patients with chronic fatigue syndrome generally did not show the changes expected as a result of inactivity. However, patients with abnormal lactate responses to exercise had a significantly lower proportion of mitochondria rich type 1 muscle fibres.