Chief of Critical Care Services, United Memorial Medical Center Past Chief of Staff, University General Hospital
Professor of Acute and Continuing Care, The University of Texas Health Science Center
Clinical Professor of Medicine, The University of Texas Medical Branch at Galveston
Professor of Medicine and Surgery – UAT, UDEM, UABC, UPAEP, USON, UNE, Anahuac
President, Dorrington Medical Associates, PA Houston, Texas, USA
Endurance sports, such as marathons, every year capture the interest of more participants. Most of these contestants are not professional athletes but recreational runners. In some marathons, many runners collapse, stimulating investigation into physiologic changes and possible health complications during these events. Losses of water and electrolytes have historically been assumed to be the dominant cause of collapse in marathon runners. In recent years, medical attention has focused on the incidence and mechanism of hyponatremia with its attendant pulmonary and neurologic implications in the affected runners. In 1999, a cluster of seven life-threatening hyponatremia cases were seen by Varon and Ayus and reported a year later. All of these were critically ill patients that developed hyponatremic encephalopathy after running the Houston marathon. They were all admitted to the hospital and were suported with
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World Nutrition Journal is biannual, open-access journal, which addresses to all who are interested in and require references of community, clinical, and critical care nutrition. It is also a media for authors to share science of nutrition and publish their researches.
It is my pleasure to invite you to submit a manuscript to be publish in the 4th edition of World Nutrition Journal Volume 2 Issue 2 scheduled to be Publish on January 2019.
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Dr. dr. Saptawati Bardosono, MSc Editor-in-Chief of World Nutrition Journal
Official website : http://www.worldnutrijournal.org World Nutrition Journal
World Nutrition Journal Editorial Of ice Wisma Nugraha Building, Suite 501, 5thFloor Jl. Raden Saleh No. 6 Jakarta Pusat Phone: +622131905330
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World Nutrition Journal Editorial Of ice Wisma Nugraha Building, Suite 501, 5thFloor Jl. Raden Saleh No. 6 Jakarta Pusat Phone: +622131905330 Email : [email protected]
Editorial Original Paper Clinical Nutrition : Critical Care Nutrition Nitrogen balance and its relation with energy and protein intake in critically ill elderly patients The relationship between hyperglycemia status and high gastric residual volume status in adult critically ill patients Clinical Nutrition : Nutrition and Metabolism The effect of specific oral nutritional supplements compared to tea with sugar on gastric emptying time, blood sugar level and hunger response in healthy adults Association of serum adiponectin levels with metabolic syndrome risk factors in Malay adult Effect of green tea ingestion on postprandial triglyceride levels in young women The effect of vitamin C and E combination on sperm quality and cement 8-OHdG level of smoke exposed rats Correlation between serum zinc level and erythrocyte superoxide dismutase (SOD) activity in non-frail and frail geriatric patients Community Nutrition: Nutrition Through Life Cycle Bonding development between parents and children through playing together to improve family happiness) Food and Nutrition/Functional Food Effect of rice bran oil on the lipid profile of mild -moderate hypercholesterolemic male age 19-55 years old
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Volume 1:
Number : 01, Juli 2017 Official website : http:/ /www.worldnutrijournal.org
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Hyponatremia in Marathon Runners:
The Varon-Ayus Syndrome
Joseph VaronChief of Critical Care Services, United Memorial Medical Center Past Chief of Staff, University General Hospital
Professor of Acute and Continuing Care, The University of Texas Health Science Center
Clinical Professor of Medicine, The University of Texas Medical Branch at Galveston
Professor of Medicine and Surgery – UAT, UDEM, UABC, UPAEP, USON, UNE, Anahuac
President, Dorrington Medical Associates, PA Houston, Texas, USA
Endurance sports, such as marathons, every year capture the interest of more participants. Most of these contestants are not professional athletes but recreational runners. In some marathons, many runners collapse, stimulating investigation into physiologic changes and possible health complications during these events. Losses of water and electrolytes have historically been assumed to be the dominant cause of collapse in marathon runners. In recent years, medical attention has focused on the incidence and mechanism of hyponatremia with its attendant pulmonary and neurologic implications in the affected runners. In 1999, a cluster of seven life-threatening hyponatremia cases were seen by Varon and Ayus and reported a year later. All of these were critically ill patients that developed hyponatremic encephalopathy after running the Houston marathon. They were all admitted to the hospital and were suported with
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assisted mechanical ventilation due to severe hypoxemic respiratory failure. Magnetic resonance imaging was performed in six of them showing cerebral edema. This condition was years later recognized as the Varon-Ayus syndrome (VAS).
The management of hyponatremia and the VAS is dictated by the severity of the condition. Cases of patients with asymptomatic hyponatremia usually require no treatment, mostly because these patients do not seek medical attention. In the case an athlete presents with symptomatic hyponatremia, without signs or symptoms of cerebral or pulmonary edema, the management will require several hours of observation and monitoring of serum sodium. There is no clear indication for intravenous luids administration in these patients, as they are already luid overloaded. Patients with symptomatic VAS can present with a variety of symptoms that can go from nausea, emesis and weakness to be as dramatic such as respiratory failure with non- cardiogenic pulmonary edema and seizures. These patients must be considered critical and need to be emergently treated and monitored in an intensive care unit. Treatment with hypertonic saline creates an osmolar gradient of 10–20 mOsm/L to mobilize brain water. Due to the possible danger of brain damage, serum sodium should never be acutely elevated. Brain damage has also been associated with acute excessive changes in serum sodium. In author's experience, serum sodium should never be in normal or above normal levels. The elevation in serum sodium should not be more than 25 mmol/L in 24 hours. The main concern when sodium is corrected too fast, is the development of central pontine myelinolysis (CMP), that is rare neurological condition that is more common in patients with chronic hyponatremia. The mainstay preventive measure is to adopt an adequate luid replacement regimen during ultra-distance racing in order to avoid overdrinking with a subsequent over luid state. In the original VAS description, athletes were drinking hypotonic
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luid. Isotonic luid ingestion is recommended.
Biography
Dr. Varon is the Chief of Critical Care at United Memorial Medical Center in Houston. In addition, he is the Former Chief of Critical Care Services and Past Chief of Staff at University General Hospital. He is a Professor of Acute and Continuing Care at the University of Texas Health Science Center in Houston, Texas and Clinical Professor of Medicine at the University of Texas Medical Branch in Galveston. He is also Professor of Medicine, Surgery and Professor of Emergency Medicine at several universities in Mexico, the Middle East and Europe. After completing medical training in Mexico City, Mexico, Dr. Varon served residency in internal medicine at Stanford University School of Medicine in Stanford, California. This was followed by fellowships in critical care medicine and pulmonary diseases at Baylor College of Medicine in Houston. An avid researcher, Dr, Varon has contributed more than 750 peer-reviewed journal articles, 10 full textbooks, and 14 dozen book chapters to the medical literature. He is Editor-in-Chief of Critical Care and Shock and Current Respiratory Medicine Reviews. Dr. Varon has won many prestigious awards and is considered among one of the top physicians in the United States. Dr. Varon is also known for his groundbreaking contributions to Critical Care Medicine in the ields of cardiopulmonary resuscitation and therapeutic hypothermia. He has developed and studied technology for selective brain cooling. He is also a well-known expert in the area of hypertensive crises management. With Dr. Carlos Ayus, he co-described the hyponatremia associated to extreme exercise syndrome also known as the “Varon-Ayus syndrome”. Dr. Varon has lectured in over 56 different countries around the globe. Along with Professor Luc Montagnier (Nobel Prize Winner for Medicine in 2008), Dr.
Varon created the Medical Prevention and Research Institute in Houston, Texas, where they conduct work on basic sciences
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assisted mechanical ventilation due to severe hypoxemic respiratory failure. Magnetic resonance imaging was performed in six of them showing cerebral edema. This condition was years later recognized as the Varon-Ayus syndrome (VAS).
The management of hyponatremia and the VAS is dictated by the severity of the condition. Cases of patients with asymptomatic hyponatremia usually require no treatment, mostly because these patients do not seek medical attention. In the case an athlete presents with symptomatic hyponatremia, without signs or symptoms of cerebral or pulmonary edema, the management will require several hours of observation and monitoring of serum sodium. There is no clear indication for intravenous luids administration in these patients, as they are already luid overloaded. Patients with symptomatic VAS can present with a variety of symptoms that can go from nausea, emesis and weakness to be as dramatic such as respiratory failure with non- cardiogenic pulmonary edema and seizures. These patients must be considered critical and need to be emergently treated and monitored in an intensive care unit. Treatment with hypertonic saline creates an osmolar gradient of 10–20 mOsm/L to mobilize brain water. Due to the possible danger of brain damage, serum sodium should never be acutely elevated. Brain damage has also been associated with acute excessive changes in serum sodium. In author's experience, serum sodium should never be in normal or above normal levels. The elevation in serum sodium should not be more than 25 mmol/L in 24 hours. The main concern when sodium is corrected too fast, is the development of central pontine myelinolysis (CMP), that is rare neurological condition that is more common in patients with chronic hyponatremia. The mainstay preventive measure is to adopt an adequate luid replacement regimen during ultra-distance racing in order to avoid overdrinking with a subsequent over luid state. In the original VAS description, athletes were drinking hypotonic
51
‘
‘
luid. Isotonic luid ingestion is recommended.
Biography
Dr. Varon is the Chief of Critical Care at United Memorial Medical Center in Houston. In addition, he is the Former Chief of Critical Care Services and Past Chief of Staff at University General Hospital. He is a Professor of Acute and Continuing Care at the University of Texas Health Science Center in Houston, Texas and Clinical Professor of Medicine at the University of Texas Medical Branch in Galveston. He is also Professor of Medicine, Surgery and Professor of Emergency Medicine at several universities in Mexico, the Middle East and Europe. After completing medical training in Mexico City, Mexico, Dr. Varon served residency in internal medicine at Stanford University School of Medicine in Stanford, California. This was followed by fellowships in critical care medicine and pulmonary diseases at Baylor College of Medicine in Houston. An avid researcher, Dr, Varon has contributed more than 750 peer-reviewed journal articles, 10 full textbooks, and 14 dozen book chapters to the medical literature. He is Editor-in-Chief of Critical Care and Shock and Current Respiratory Medicine Reviews. Dr. Varon has won many prestigious awards and is considered among one of the top physicians in the United States. Dr. Varon is also known for his groundbreaking contributions to Critical Care Medicine in the ields of cardiopulmonary resuscitation and therapeutic hypothermia. He has developed and studied technology for selective brain cooling. He is also a well-known expert in the area of hypertensive crises management. With Dr. Carlos Ayus, he co-described the hyponatremia associated to extreme exercise syndrome also known as the “Varon-Ayus syndrome”. Dr. Varon has lectured in over 56 different countries around the globe. Along with Professor Luc Montagnier (Nobel Prize Winner for Medicine in 2008), Dr.
Varon created the Medical Prevention and Research Institute in Houston, Texas, where they conduct work on basic sciences
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projects. Dr. Varon has appeared in National and International television and radio shows with his techniques and care of patients. Dr. Varon is well known for his academic and clinical work in the management of acute hypertension and has published extensively on this subject. In addition, Dr.
Varon has worked on studies related to ethical issues in acute care medicine and has several peer-reviewed publications on this controversial subject.
Presenting author details
Full name: Joseph Varon, MD, FACP, FCCP, FCCM, FRSM Contact number / Email : +1-713-669-1671
[email protected] Twitter account: joevaron Linked In account: joevaron
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