The Fungus that Can Kill You—Candida Auris Spreading and Very Hard to Decontaminate

Candida Auris is about as scary a threat as one might imagine: a fungus that is multidrug resistant, hard to identify, and very had to clean/kill from hospital settings.

Be afraid, be very afraid because assuming hospitals are going to make patients aware of an outbreak is something only those born yesterday will find credible. State governments are suppressing information about it, a Low State that will surely lead to unnecessary deaths going forward.

From NYT: How a Chicago Woman Fell Victim to Candida Auris, a Drug-Resistant Fungus:

Nearly 600 cases of C. auris have been reported in the United States, the majority of them in New York, New Jersey and Illinois. According to the Centers for Disease Control and Prevention, nearly half of people who contract the illness die within 90 days. But the true death rate is difficult to quantify because most patients have other medical conditions and their deaths may be attributed to other causes.

...on Tuesday, the C.D.C. confirmed that it has learned in the last month of the first known cases in the United States of so-called “pan-resistant” C. auris — a strain resistant to all major antifungals.

It often has been hard to gather details about the path of C. auris because hospitals and nursing homes have been unwilling to publicly disclose outbreaks or discuss cases, creating a culture of secrecy around the infection. States have kept confidential the locations of hospitals where outbreaks have occurred, citing patient confidentiality and a risk of unnecessarily scaring the public.

It’s not just fungus, there was a new deadly bacteria outbreak in Mexico that the CDC noted in January 2019 in Drug-Resistant Infections in Patients Who Had Weight-Loss Surgery in Mexico.

Comments on Bicycling.com: 'Pro Cyclists Open Up About Depression'

I commented on the death by suicide of 23-year-old is Stanford graduate student and Olympic cyclist Kelly Catlin earlier this month.

Reader Robert VB pointed me at an article in Bicycling.com: Pro Cyclists Open Up About Depression. There is of course nothing “pro” about anxiety and depression*, but pro cyclists presumably are going to get more attention than my concussion log —I applaud their sharing of their experiences and that Bicycling.com thought to publish the article.

* I suffered from depression for many years, but being the “strong silent type” (my high-school guidance counselor’s words), I suffered through it in college and beyond. At first I did not understand it, then I was ashamed to admit to it. Needless years of drained life. Only later in life have I mastered the skills to beat it off when (highs require lows but not too low!), but it requires energy.

Carmen Small’s experience

The account that resonated powerfully for me was that of zzzzzzzzz. It mirrors my experience (an OMG moment when I read it), differing only in that her trauma was more severe than mine and more than I care to contemplate, and the impacts on her have lasted longer, with less good resolution of symptoms.

And I’m different now. I have anxiety about everything, I cannot deal with stress, I am overly emotional, I am sad all the time, I am irritable, I have trouble with noise, driving makes all this worse (not the best in my profession), and the part that is the hardest is I have a fucking headache every day.

I'm screaming on the inside and looking fine on the outside. I get comments all the time, “Oh, you look great. How are you?” I just normally say, “Yeah, doing well thanks. You?” mostly because I am sick of explaining two years later that I still have problems with this damn concussion. I am frustrated, I get depressed, and I hate my life most days, but I put on a smile and head out to do my job and act "normal." I

My sense is that few people (not even trained psychiatrists) can begin to understand the complex set of feelings she has expressed in any 'gut' way—but having gone through it myself, I feel qualified to say her description is spot-on as far as words can go. I am glad to see it in print since just knowing one is not alone in the world is some comfort, and it might at least help non-victims to have some degree of understanding when no physical issue is visible. That last point cannot be emphasized strongly enough: brain injuries are invisible and yet most everyone sees only the physical body. No blame to them, but my own family could not understand, so how would any stranger?

No one can foresee the benefits of trying to help (for either party), but that can’t happen without communication, so in spite of being a very private person, I feel compelled to reach out: readers are welcome to contact me if they have had a concussion along these lines that they would like to discuss.

My experience, particularly after my concussion, is that out there for the finding exists a precious thing: minds that can operate on the same wavelength effortlessly, be it a shared experience like a concussion, or otherwise. If you’ve had a concussion, reach out and don’t give up because if you find the right person, it could be a breakthrough. Ditto for regular life. I meant that both intellectually and romantically and for the lucky few, both.

I consider my concussion very lucky in multiple ways. All of my symptoms have receded into the background, though I have some impairment in terms of workload, sleep needs and similar a year later, and maybe forever. The benefits have lingered: not a day goes by in which a positive perspective on life is not of some use, sometimes things of minor importance, sometimes more. Still, there are days (or series of days) where fighting the Anxiety Beast consumes nearly all my energy, problematic for a self-employed person. Yet that weakness has made me stronger and wiser and I am not sure I would trade it back for an “undo”. I have little idea how my own experience tracks, hence my interest in talking with others.

With full respect for medical professionals: I don’t think that doctors of any kind are really of much service post-concussion beyond some basics, and only in the most primitive sense (how to recover quickly and well is a empty book for the medical profession). Plus, not having any skin in the game (with rare exceptions not having experienced a concussion), what doctor of any kind can really relate, particularly those pressed to spend 5.87 minutes per patient on a rigorous schedule? Thus a dry clinical approach as with the physical body. Which is not to say that counseling* is without merit; it surely is in terms of tools and guidance in dealing with challenges. But it is cold comfort compared to a shared experience and very hard to access mental health services*, which are rendered in medical setting that is clinical and formalized and thus itself a source of stress—and stress is intolerable after a concussion, or it was for me—nature/outdoors was and is free and was my solution.

* A scandalous health care problem these days is claimed availability of mental health services that are not actually available due to excessive cost and/or distance and/or months-long waiting periods (in my experience with myelf and my family, all of those). Insurance company executives ought to be held criminally responsible for fraudulent claims about benefits.

Commentary on Sodium Supplementation during Prolonged Exercise

Sodium (na) and salt (NaCl) are two different things in terms of weight (milligrams). Sodium is 39.3% by weight of NaCl. Hence 1000 mg (1 gram) of table salt contains 393 mg of sodium. Other electrolytes matter also and need to be in balance, such as potassium (K), Calcium (Ca), and Magnesium (Mg).

See prior posts such as Sodium and Electrolyte Losses During Prolonged Exertion — an Experiment.

This posts comments on selected excerpts from Sodium supplementation is not required to maintain serum sodium concentrations during an Ironman triathlon. I chose that paper because all the others I’ve found seem to have no relation to my reality over a decade of ultra endurance riding, whereas this paper seems to dovetail with my self-observation conclusions while avoiding any contradictions with my own self-observations.

Emphasis added in places.

Core summary

I would say with confidence that *no* supplementation is unwise, particularly under very hot conditions where fluid losses exceed 2L/hour and hyponatremia becomes a risk with too much fluid ingestion. Plus, pure water is absorbed more slowly than something approaching an isotonic solution. For years I used Hammer HEED as my sports drink, and it is very low in sodium (only 40mg per 100-calorie serving, which is 303mg per serving)*. I had no evidence of sodium deficiency when using HEED (e.g., cravings for salt).

* I stopped using Hammer HEED because I am pretty sure that its Xylitol and/or Stevia additives might be responsible for gastric distress, particularly at mile 140 and beyond.

Results

Subjects in the sodium supplementation group ingested an additional 3.6 (2.0) g (156 (88) mmol) sodium during the race (all values are mean (SD)). There were no significant differences between the sodium, placebo, and no supplementation groups with regard to age, finishing time, serum sodium concentration before and after the race, weight before the race, weight change during the race, and rectal temperature, systolic and diastolic blood pressure after the race. The sodium supplementation group consumed 14.7 (8.3) tablets, and the placebo group took 15.8 (10.1) tablets (p  =  0.55; NS).

Conclusions

Ad libitum sodium supplementation was not necessary to preserve serum sodium concentrations in athletes competing for about 12 hours in an Ironman triathlon. The Institute of Medicine's recommended daily adequate intake of sodium (1.5 g/65 mmol) seems sufficient for a healthy person without further need to supplement during athletic activity.

As I read it, the study is not saying that zero intake is advisable, only that additional supplementation over and above sports drinks is unnecessary.

Sodium stasis

What the study is saying here dovetails with my own finding using the simple “lick test”: there is just not that much salt on my skin after finishing a double century. There is notably more if it was very hot (very high sweat/fluid losses), but I don’t look like a floured dumpling that 9 grams of sodium X 12 hours would imply (the idea that over 100 grams of NaCl would be excreted is absurd).

Moreover, highly trained athletes surely well be mal-adapted if after years of training the body did not adapt its electrolyte balance to ultra endurance events.

Triathletes competing in the 2001 South African Ironman triathlon maintained their serum [Na+] within the normal range whether they drank the Na+‐poor drinks (water or a sports drink with [Na+]  =  18 mmol/l) or supplemented with ∼156 mmol Na+.

... Athletes in the placebo, sodium supplementation, and “no” supplementation groups did not differ in their finishing time nor in subjective measures of exercise intensity and mental wellbeing, nor in the prevalence of medical diagnoses after the race.

Clinical measures of fluid status, rectal temperature, blood pressure, absolute and percentage weight loss were also not different between groups

Therefore predictions of the expected consequences of “large” Na+ losses during prolonged exercise are inaccurate either because athletes sweat less or have lower sweat [Na+] than are currently believed. Alternatively, during acute states of Na+ loss, additional Na+ may be released either from intracellular body stores—for example, bone, skin—or by contraction of the extracellular fluid volume, in order to buffer acute Na+ losses until these are replenished by Na+ ingestion during the next meal.

Bottom line: extra sodium is of zero benefit.

Flawed studies

Other studies are clearly flawed and I don’t need this study to tell me that: glycogenolysis has long been part of my own planning for fluid-replacement. During the first five hours of a double century, considerable water is released as glycogen stores are largely burned off.

Not losing weight in my experience has always been associated with over-hydration and performance problems: I expect to be about 8 pounds lighter (e.g. 175 lb => 168 lb) after a double due to the loss of fuel and its associated water, and a moderation dehydration. I have seen such losses even on only 4 hour rides when ingesting 3L of water!

...two studies are often quoted to support the notion that Na+ ingestion during exercise is essential if a progressive fall in serum [Na+] is to be prevented. Both studies contain important logical flaws, not least because they encouraged trial subjects to drink to excess during exercise.

The goal of the study of Vrijens and Rehrer24 was for athletes to drink sufficiently to ensure that they did not lose weight during two hours of laboratory exercise. Normal fluid balance during exercise requires that some weight must be lost due to (a) the release of stored water consequent to glycogenolysis, and (b) irreversible loss of fuel through substrate oxidation.... athletes in any trial who do not lose weight during exercise must complete the trial in a mild state of over-hydration. That study therefore evaluated the effect of Na+ supplementation on serum [Na+] in subjects encouraged to overdrink during prolonged exercise. The data show that the response of the serum [Na+] to overdrinking was determined by the renal response to exercise, so that those athletes who passed the most urine during exercise were best able to maintain their serum [Na+].

This is compatible with the conclusion that serum [Na+] is far more sensitive to changes in total body water than to Na+ balance during prolonged exercise28 and with the explanation that acute hyponatraemia is always due to altered renal function in which the rate of free water clearance fails to match the rate of free water ingestion, whether at rest or during exercise.29 Finally only four of 10 subjects completed all trials in that study, further limiting the validity of these findings.

Similarly Twerenbold et al1 studied athletes who drank to excess while running ∼40 km in four hours. As sweat rates were only ∼500 ml/h whereas rates of fluid ingestion were ∼1000 ml/h, subjects gained an average of 2 kg weight during the run. In the presence of this large weight gain, the ingestion of additional [Na+] predictably lessened the fall in serum [Na+] by about 2–3 mmol/l. Yet, despite the ingestion of an additional 118 mmol Na+, the group that ingested the most Na+ still developed hyponatraemia during exercise (mean serum [Na+] after the run  =  134 mmol/l). The authors' suggestion that their data prove that all athletes should ingest additional Na+ during exercise is incorrect, as fully argued elsewhere.12 Rather the correct conclusion is that, as the single best predictor of post‐exercise serum Na+ is the change in body mass during exercise (fig 1​1),), avoidance of overhydration is the most important intervention necessary to prevent the development of symptomatic exercise associated hyponatraemia.14,30,31,32

Conclusion

My take away here is that the rate of ingestion of water should target finishing in a mild to moderate state of dehydration. A goal of mild to moderate dehydration seems best, because overhydrating is associated with stomach issues (bloating, very uncomfortable) and an increased risk of hyponatremia whether or not there is supplemental sodium/electrolytes, as per the comments above. I know that my very best performances have *always* left me depleted by at least 2 liters of body fluid, as determined by my fluid intake over the following 3-4 hours.

Put another way: the body has an easier time maintaining statis in a state of mild dehydration than it does trying to correct an electrolyte balance from excess fluid and/or excess sodium intake. Excess sodium intake is particularly problematic.

Tentative plan of attack

I conclude that I need to focus on the rate of fluid intake along with the caloric content. Typically I end up ingesting less than 1L/hour of fluid, as my stomach cannot handle it.

Possibilities:

• Ingest small amounts of fluid for the first two hours (assuming going out fully hydrated and with fluid in stomach). This implies a higher concentration of calories in the fluid in order to take in adequate calories (so as not to prematurely burn off body stores), e.g., 4 scoops of Tailwind per liter of fluid.
• Being ingesting 1L/hour of fluid by the end of hour 3, depending on intensity and beginning hydration status. Reduce caloric content of the fluid to 300 calories per liter.
• At hour 4 and beyond, shoot for 1L of fluid intake per hour, 200 to 300 calories per liter. Experiment with 200 vs 300.

Sodium and Electrolyte Losses During Prolonged Exertion — an Experiment

Sodium (na) and salt (NaCl) are two different things in terms of weight (milligrams). Sodium is 39.3% by weight of NaCl. Hence 1000 mg (1 gram) of table salt contains 393 mg of sodium. Other electrolytes matter also and need to be in balance, such as potassium (K), Calcium (Ca), and Magnesium (Mg).

Referring to Sodium and Electrolyte Losses During Prolonged Exertion, and with the intent of diagnosing the power “drop outs” I too often experience during double centuries, I decided to do an experiment to test out whether increased sodium intake helped or hurt.

The working scientific theory in some papers (which looks to have been debunked) is that when losing a liter or more of fluid an hour* that sodium losses are about 3500 mg, equivalent to about 9000mg of salt (sodium’s molecular weight is only fraction that of NaCl aka table salt). I maintain, based on a decade of riding experience, that the claim of losing 3500mg or even half that figure per hour is wildly inaccurate.

My tentative proposition is that most all scientific findings for sodium losses during exercise are BOGUS for athletes like me. The one exception in scientific papers that I found dovetails with my own experience and experiential results, that is, the findings for Ironman athletes found that sodium supplementation did not matter for 10-hour Ironman effort.

Ad libitum sodium supplementation was not necessary to preserve serum sodium concentrations in athletes competing for about 12 hours in an Ironman triathlon. The Institute of Medicine's recommended daily adequate intake of sodium (1.5 g/65 mmol) seems sufficient for a healthy person without further need to supplement during athletic activity.

My simple test below shows that sodium supplementation is not only not needed, but has a substantial negative effect (pronounced thirst) even replacing just half of theoretical sodium losses. Nothing matters except what actually works to improve performance.

* Losing 1L/hour of fluid is about the minimum for me riding at ~200 watt, even in cool weather, increasing to 2L or more in very hot weather on climbs. The stomach can absorb at most about 1L/hour fluid under optimal conditions.

Testing sodium supplementation

I wondered if increasing sodium (atomic symbol Na) intake in the form of Himalaya sea salt would improve or degrade performance. Of course, sea salt contains many things besides NaCl (table salt), presumably all good for blood electrolyte balance, e.g., Potassium (K), Magnesium (Mg), Calcium (Ca) and other trace elements.

Test conditions:

• Three-hour 2200-calorie ride of 57 miles, averaging 203 watts (216 watts normalized power). Ambient temperature of ~68°F, sunny (additional heat load vs being cloudy).
• 2 liters fluid intake: one bottle with 400 calories of Tailwind, the other 300 calories of Tailwind, 7 servings, caffeine-free.
• Supplementary sodium and other minerals: 1/2 teaspoon Himalayan sea salt in each bottle weighing 6 grams for an implied sodium content of 0.393 * 6000 = 2358 mg sodium. It has other elements/minerals as well of course.

Total theoretical sodium losses: 3500*3 = 10500 mg of sodium.

Total sodium intake: 7 * 303 = 2100 + 2358 = 4458 mg.

If scientific claims in some papers are valid, then I replaced less than half the sodium losses.

Results of replacing *half* theoretical sodium losses: awful thirst!

• At about the 2 hour mark, I was more thirsty when done that I have been for years, thirsty to the point of nagging discomfort/annoyance. Yet there is no chance that there was significant dehydration any more than similar workouts I have done for years—I was probably 'down' about 1.5L total fluid, which is an acceptable loss for a 3 hour workout.
• Licking my arm (heavy sweating area which dries quickly) I tasted only a trace of salt. Also, no white residue anywhere on my body (arms, legs, face).
• I had absolutely no craving for salt when done. I craved only pure water, promptly drinking about a liter. This cut the thirst within 5 minutes back to normal.

I repeated this experiment on a 4-hour 70-mile ride, but added an additional liter of pure water. I had better results with that but was still slightly thirsty. Even on that ride, not much salt accumulated on my skin, as per the taste test and visual inspection. While that extra liter seems to have added enough fluid to cut out most of the thirst problem, the core problem seems to be too much sodium relative to fluid intake.

Interpreting the results.

There are a few possible avenues of thought from the results.

• The thirst clearly seems to be the result of too much sodium, creating an imbalance in the body, or at the least too much sodium and not enough water. But it is not plausible that by replacing half the theoretical sodium losses that such a pressing thirst should result.
• Drinking 2 liters in 3 hours is ample and has never been an issue before in years of workouts. Moreover it can be difficult to stomach 3 liters of fluid in the first three hours.
• I lose far less sodium than scientific studies claim, perhaps because of years of training.
• Given that it is often difficult to fully hydrate, it seems very unwise to supplement with additional sodium.
• No evidence I can discern that sodium supplementation improved performance.
• No evidence that I was short on sodium when done, despite in theory having a 5000 mg deficit.
• Sodium supplementation in line with the (bogus) scientific findings in some studies might be a good way to damage the kidneys, judging by the very uncomfortable thirst; it’s the body’s way of signaling distress.

Bottom line: I will not be adding more sodium to my exercise drinks. I will focus instead on more consistent fluid intake.

Sodium and Electrolyte Losses During Prolonged Exertion

This page is a followup to my comments on the 2019 Joshua Tree Double Century. It is an attempt to understand what I term “drop outs” of power and focus during a double century.

Franklin K writes:

I have a few suggestion tracks regarding your double centuries. I’m not very familiar with sport medicine, - you know I’m a nephrologist and having worked very long in ICU - I feel involved in understanding precise and subtle mechanisms in physiology.

I point first you didn’t drink for the first two hours. OK, but what about sweat losses, I mean H2O and above all Na losses. You noticed temperature was as low as 34°F, but it won’t keep you to loose more than a liter per hour, which means more than 9g of NaCl per sweat loss, roughly 3.5g of sodium (Na). 66 miles, which means 2,5-3 hours without drinking, mean nearly 3 liters of H2O and 10.6 g sodium !!

And when you’re late about H2O and Na, as you quote, it is a long time to catch up. About this point , and for a better understanding go and read Na+/K+-ATPase OK I noticed you had four 1-liter bottles but as I told you, in this era when you’re late.

Our life system is organized to maintain constant body composition and the only organs to regulate this are the kidneys, yes… BUT… if you’re Na/H2O short, the kidneys are not able to manage this regulation. Do you know that the 2 kidneys are « using » 1,2l of blood per minute ? You understand what it means in terms of hypovolemia. By the end, I propose an explanation - I wrote « propose » ?, that your « slack » was H2O/Na dependant.

WIND: first a set-aside: given my relative lack of fatigue and very rapid recovery, it seems clear-cut that the issues I experienced were not a fitness issue. Indeed, my heart rate and breathing rate were relatively low. It surely has to be body statis of some kind, so I take the sodium (electrolyte) theory seriously as a key point to research.

This was about my 45th double on top of 90K miles of riding over the past decade and I’ve yet to crack this nut. Maybe it all comes down to some numbers game of increasing sodium+electrolytes until the problem goes away? Solving it would vault me into the top tier of riders consistently (maintaining 210 watts vs 180 for 10 to 12 hours is a HUGE difference), so I have a lot of incentive.

While I suspect it is a brain/neurological effect and not muscular/kidneys one, electrolytes could still be involved.

Quantifying sodium and electrolytes and energy

During the 2019 Joshua Tree Double Century, I took in about 2500 calories total (15 scoops Tailwind, 3 100-calorie Panda black licorice, 7 servings GU). That's plenty (36% of burn) for an event burning 6900 calories—much more than I typically consume by as much as double (usually it is 20% to 25% of total caloric expenditure). So I am going to rule out energy intake as a factor.

I use Tailwind for energy and electrolytes, 2.5 scoops per 1L bottle (see nutritional info for Tailwind). A one-liter bottle thus contains:

760mg Na + 220mg K + 65mg Ca + 35mg Mg + 250 calories

Since I consumed 6 such bottles during Joshua Tree, I took in from Tailwind alone:

4560mg Na + 1320g K + 390g Ca + 210mg Mg + 1500 calories

PLUS another bottle of some unknown drink (low in whatever it had) and 3 Panda 100-calorie black licorice sticks.. Plus about 7 servings of GU energy gel containing:

875mg Na + 280mg K + n/a Ca

= absolute minimum intake (not counting the licorice and that other unknown drink):

5430g Na + 1600g K + 390g Ca + 210mg Mg <=== accurate minimum taken in during JT

When done, my skin is salty, but not overly so unless it is very hot (in which case a lot drips off and fluid loss doubles). After Joshua Tree, I did not crave salt or anything like that, though I have done so after very hot double centuries.

If I were losing 3500g of sodium (Na) per liter of sweat, then my total intake for the day would replace only the first 1.5 hours worth, which seems dubious. Still, if the losses are 3500 mg/hour then the total loss is 35000mg or so, for a deficit of about 30000 mg. That does not seem believable: if it affected me at hour 5, then why did I feel no worse at hour 11?

Thus I remain a bit skeptical that I am losing 3500 mg/hour of sodium.

How to test it

Update: see my simple test of increasing sodium content.

I intend to change my dilution from 2.5 scoops of Tailwind per liter to 4 scoops in order to test that theory in the next double century. That matches up better for my cool weather (70°F or cooler) fluid intake needs balanced with caloric needs. In hot weather, I’d need more fluid and that concentration would need to be cut it back.

What science says

Science seems to have few good answers. Sodium and electrolyte losses can be high, yet one study of ironman participants concludes that no supplementation is needed!

Franklin K’s comments on 9000mg of sodium (Na) loss per liter of fluid are in line with the high end of what is suggested in studies. However, it is also true the acclimatized individuals might lose much less than that. I have no way of knowing my own sodium and electrolyte losses BUT I can say that in cool weather my skin is not particularly salty‚ nor does my clothing stain white under those conditions. During very hot weather my skin does get very salty and my clothing stiff with salts, but the sweating rate is at least double.

NIH: Sweat rate and sodium loss during work in the heat suggests 480 to 600mg sodium loss per hour for workers under hot conditions for workers, depending on acclimatization.

People working in moderately hot conditions for 10 hours on average will lose between 4.8 and 6 g of sodium (Na) equivalent to 12–15 g of salt (NaCl) depending on acclimatisation.

However due to the substantial interindividual variation in sweat rate and sodium concentration individual losses may be much higher. This essential electrolyte must be replaced in order to avoid fluid imbalances, thus eating during the shift is a must.

One work session in the heat, for an acclimatised person is sufficient to activate sodium-conserving mechanisms. However in the unacclimatised worker longer exposure is required. A worker starting work in harsh conditions should be given 10 days or more to acclimatise before performing heavy manual work in the heat.

Since I am highly trained and highly acclimatized, I take the 480mg/hour figure as most likely. However, riding at ~200 wattsfor 10+ hours continuallu is surely far more energy intensive than virtually all workers. Thus that should be considered a bare minimum.

NIH: Sweat Rates, Sweat Sodium Concentrations, and Sodium Losses in 3 Groups of Professional Football Players notes that overconsumption of fluid can be not only uncomfortable but dangerous—my rule of thumb has always been 1L/hour, as that is about all the stomach can handle, regardless of conditions.

Ironman study of sodium

An ironman effort is pretty darn close to a double century effort, both taking 10+ hour.

Sodium supplementation is not required to maintain serum sodium concentrations during an Ironman triathlon

Main outcome measures

Sodium supplementation was not necessary to maintain serum sodium concentrations in athletes completing an Ironman triathlon nor required to prevent hyponatraemia from occurring in athletes who did not ingest supplemental sodium during the race.

Results

Subjects in the sodium supplementation group ingested an additional 3.6 (2.0) g (156 (88) mmol) sodium during the race (all values are mean (SD)). There were no significant differences between the sodium, placebo, and no supplementation groups with regard to age, finishing time, serum sodium concentration before and after the race, weight before the race, weight change during the race, and rectal temperature, systolic and diastolic blood pressure after the race. The sodium supplementation group consumed 14.7 (8.3) tablets, and the placebo group took 15.8 (10.1) tablets (p  =  0.55; NS).

Conclusions

Ad libitum sodium supplementation was not necessary to preserve serum sodium concentrations in athletes competing for about 12 hours in an Ironman triathlon. The Institute of Medicine's recommended daily adequate intake of sodium (1.5 g/65 mmol) seems sufficient for a healthy person without further need to supplement during athletic activity.

Experience Report: 2019 Joshua Tree Double Century

Joshua Tree Double Century was run out of the usual motel in Twenty Nine Palms, CA. This year the course was permitted to run through Joshua Tree National Park, including the climb to Keys Road lookout.z

Going out, it was very cold at 5:40 to 7 AM, reading 34°F / 1°C for 20 miles or so, rising to a balmy 39° at the top of the Keys Road lookout.

As usual I soloed (no drafting), leaving alone at 5:40 AM. By the top of Keys View, I had caught 56 riders, most of whom had left 70 minutes ealier or more. By Chiriaco (mile ~90), I had ovetaken all but 3 riders (according to the rest stop folks at Desert Center). And there things stayed until the end, but at mile ~95 I lose 25% of my power, suddenly.

Fear of fast

With the Southern Inyo Double Century done the Saturday prior, I had a lot more confidence in my fitness (excellent, 2-day recovery) but I remained concerned as to whether I could do any fast descents (the post-crash fear/anxiety at speed that I had to Southern Inyo Double.

As it turned out, I was fine descending from Keys View Road at ~35 mph, though that is only a ~3% grade and no cliffs to install fear, and with excellent smooth bump-free pavement. I had mentally worked on the speed-fear for the week prior and made progress, but I still cannot manage high-speed steep descents without visualizing myself in a mangled heap. Hopefully that will fade.

Strategy, issues, etc

I was concerned about having to pee too frequently as at SIDC, so I did not drink much for the first 2 hours or so, but had nearly 2L of fluid by mile 66, where I resupplied with four 1-liter ottles each with 250 calories of Tailwind. I had also consumed some GU energy gel by then, perhaps 300 calories worth.

Still, by mile 90 (five hours or so in) and with a 3200 calorie “burn”, I had taken in only ~700 calories. That should have been enough by the numbers (22% of expenditure is spot-on), but in the space of 2-3 minutes at mile ~95, I went from rocketing past Chiriaco Summit at ~230 watts to a major loss of energy/power to piddle along at ~180 watts. Something just shut off in a very short time period. When this sort of thing happens (many times in many doubles), it takes hours to recover regardless of nutrition. Not until mile 180 or so did I finally get back to ~200 watts and feel sort or right again, but I had been dealing with knee (patella) pain for 50 miles, and could no longer utilize my strength.

Here’s the thing: my muscles were not at all tired when done, as proven by a 2300 calorie hard workout with the highest power (watts) of the year only 36 hours later. Clearly there was no muscle fatigue issue involved at all during the double (I had no sense of fatigue nor soreness), and muscles don’t just get tired over a few minutes after working great for 5 hours. And recovery was almost literally overnight. Just not a fitness issue at all, and that hard workout was with the lowest HR of the year and a sense of ease, indicating excellent recovery.

So what the hell happened during JT?

As I was totally loaded with glycogen prior (I have a dietary routine to do so over 2 days), I did not expect so early an energy dip/loss. But averaging 225 watts for about 5 hours apparently took its toll, perhaps draining my body of glycogen? Still, I did not feel tired at all, in fact I felt robustly strong up through Chiriaco summit.

How could I average ~225 watts for five hours(a blistering pace for double) then have it all go to hell in the space of a few minutes? Maybe it is/was a fueling issue. And maybe not.

I cannot rule out central fatigue (intracortical excitability causing decreased neural drive from the motor cortex to the muscles), e.g., a brain fatigue.

I really need to sort out the cause—if I can, I should expect to finish an hour faster on such a ride, which would put me into the top 2 or 3.

See Sodium and Electrolute Losses During Prolonged Exertion.

Experience Report: 2019 Southern Inyo Double Century

Southern Inyo Double Century was run out of Ridgecrest, CA this year. I presume it will stay there in futureu years; I am not a fan as I prefer the Lone Pine start location and route.

Going out, it was raining steadily. My feet swam in water for nearly all the day, and I was soaked by the rain and dried out again at least three times. The upside was that by mid-day, it was spectacularly beautiful seeing rainclouds over the mountains while riding in the sun and getting soaked, what with strong winds pushing the rain for a mile or more.

Strategy, issues, etc

As the first double of the year and unsure of whether I would do the double the next day, I paced myself pretty slowly, averaging ~200 watts for the first five hours or so.

At mile 60 or so, I started to feel thirsty, so I started drinking (Tailwind mix)... only to have to pee frequently for the rest of the day, a very frustrating and not a very fast process each time.

In total, I stopped numerous times to shed or don clothing (rain jacket), and to take some pictures. I just did not know what to expect on my first double, so I just rode at a measured asy pace.

A key factor is that I still was suffering an unreasoning fear of crashing, triggered by my Dec 30 crash. Any downhill more than 25 mph made me very nervous, or even 10mph with high wind (which we had a lot of, to the point of hazardous). This psychology caused me to go out more slowly, not to use my ideal riding position, and to slow to a crawl on downhills where there was any wind buffeting me. I did not master that fear that day or even the next few, but by Joshua Tree Double Century I was able to descend (on dry roads with no wind) at up to 38 mph or so with only a little anxiety.

I’m not sure of the finish, but no one passed me except a 3-man team drafting each other. I started at 05:00 and finished at 16:11 — 11:11 or so. Riding time (rolling time) was 10:21, so I spent 50 minutes stopping, etc.

Images

Unlke most doubles, I took a few pictures since I had to stop to remove or don my rainjacket and/or to drink safely (high wind).

Heading north, near Olancha

f1.8 @ 1/2400 sec, ISO 20; 2019-03-02 09:07:28
[location “Near Olancha”, altitude 3564 ft / 1086 m, 60°F / 15°C, panorama]
iPhone 7 Plus + iPhone 7 Plus 4.0 mm f/1.8

[low-res image for bot]

Heading north, the rain has ceased for a while

f1.8 @ 1/950 sec, ISO 20; 2019-03-02 10:28:58 [altitude 3707 ft / 1130 m]
iPhone 7 Plus + iPhone 7 Plus 4.0 mm f/1.8

[low-res image for bot]

Uh oh... getting close to the turnaround point near Lone Pine. North wind is picking up.

f1.8 @ 1/2500 sec, ISO 20; 2019-03-02 10:29:23
[altitude 3709 ft / 1131 m, "riding straight into the rainstorm"]
iPhone 7 Plus + iPhone 7 Plus 4.0 mm f/1.8

[low-res image for bot]

South of Lone Pine, wet again

f1.8 @ 1/2300 sec, ISO 20; 2019-03-02 12:36:24
[location “South of Lone Pine”, altitude 3698 ft / 1127 m]
iPhone 7 Plus + iPhone 7 Plus 4.0 mm f/1.8

[low-res image for bot]

Stunningly beautifu but getting rained on with blue skuy above!

f1.8 @ 1/4400 sec, ISO 20; 2019-03-02 14:15:43
[altitude 3928 ft / 1197 m, 60°F / 15°C]
iPhone 7 Plus + iPhone 7 Plus 4.0 mm f/1.8

[low-res image for bot]

Heading towards Coso Junction. Cross-wind get smore and more violent to the point of hazardous

f1.8 @ 1/4000 sec, ISO 20; 2019-03-02 14:15:54
[location “Heading towards Coso Junction”, altitude 3923 ft / 1196 m, 60°F / 15°C, panorama]
iPhone 7 Plus + iPhone 7 Plus 4.0 mm f/1.8

[low-res image for bot]

Stanford graduate student and Olympic cyclist Kelly Catlin Commits Suicide Following Concussion

See also: Comments on “Pro Cyclists Open Up About Depression”.

Update: see also Olympic Cyclist Kelly Catlin Seemed Destined for Glory. Then She Killed Herself.

The death by suicide of 23-year-old is Stanford graduate student and Olympic cyclist Kelly Catlin is a sad story I’d rather not have read. I couldn’t piece it together until I read the following story:

According to the family, Kelly’s mental health struggles began in December after she suffered a concussion during a cycling race. She began having vision problems, severe headaches and was unable to complete workouts with her team, Kelly’s father, Mark Catlin, tells PEOPLE.

“She wrote that she had been having racing thoughts and her mind wasn’t working the way it used to,” Christine says, adding that she believed Kelly was describing symptoms of the concussion. “She described being tortured mentally by not being able to do what she used to do.”

The story resonated with me for three reasons: I’m a cyclist, I had a concussion last year with sinilar issues, and I’m a Stanford alum.

I wish there had been some way I could have reached out and helped her. I’ve been pondering starting a concussion support group actually—I am still considering it.

Not being able to do what was possible prior to the concussion is to be expected. It’s awful that someone did not or was not able to communicate that to her, to counsel her to give it time and rest. Presumably she was driven to excel, which means that accepting that kind of setback must have been extremely difficult, leading to highly negative thoughts.

I also had vision problems and headaches and was unable to train normally during 3 weeks or so after. Indeed, a very short workout 5 days after my crash apparently did further damage, sending sent me to the ER a second time where it took me 30 to 60 seconds to answer simple questions, and where I did not realize it was my wife holding my hand (I thought it was a kindly nurse).

I suspect that Catlin made the tragic mistake of trying to train without even having gotten over the acute phase—what the hell were the coaches thinking?! But I don’t really blame them, as my experience is that doctors and even most neurologists really don’t have a clue about concussions—blind people feeling up an elephant. If you haven’t experienced it, you really cannot understand how it works inside the head, IMO.

I had not been assessed for a concussion after my crash, even though I had clear signs of one (crying, walking like an old man, inability to speak for half an hour, etc). Not that assessment is worth a whole lot necessarily depending on the when and how: I had a almost complete inability to speak for 30 minutes or so after the crash, followed by volubility, followed by emotional breakdown and physical impairment.

After a concussion

To all those cyclists (or others) out there who have had a concussion or know somehow who has, please read my concussion log for perspective—I did not hold much back. If it only helps a handful of people, then I am content.

Attitude and expectations are everything to recovery.

A reality check: it would be crazy to train on a broken leg, but it’s not so easy to understand training with an injured brain because it is not visible! Yet it is potentially far more dangerous during the acute phase. Later, training is the best way to return to normality (increased blood flow to the brain is critical IMO), at least it was for me. Work and study have to wait.

Emotional breakdowns are a classic sign of a concussion, so family and friends should be vigilant. They don’t necessarily resolve in a few weeks! For perhaps 6 months I was emotionally fragile—easily triggered into crying. One gut-wrenching crying fit lasted 14 hours or so, about 3 months after the crash. Another one 5 months after, lasting about 3 hours. Various less severe ones. A year later, I do not feel as strong that way as before, but it has been months without any serious trouble.

Staying in a low stress environment is really important—rent an RV or Sprinter van if you have to, and get far away from life stressors (camp out and listen to the winds and birds)—your recovery and the rest of your life might depend on it. Take 1 month or three and understand that it is not a luxury, but a necessity.

Anon writes:

Amen to that. People have no idea about the lasting effects a head injury can have.

My injury was over 5 1/2 years ago and the perceived physical effects (numbness, loss of fine motor control, etc etc etc) caused by the brain injury are *still* evolving (mental effects too of course). People think that because you can stand up andga

eat a cheeseburger you must be completely well, but the truth is very far from that.

Your points about what happens later are too true also, e.g. part of what happened to me lying in ICU was a stroke to the thalamus, which I believe to be the source of a lot of my lasting brain issues. you can’t make this deal of course, but if I could exchange the loss of a leg for having my brain back I’d do it. Fortunately I’ve avoided falling into the trap of that kind of hypothetical bargaining. Of course it could be worse, I came within minutes of death and there are a lot of survivors of head injuries out there who have it a lot worse than I do, for instance I don’t have neuropathy expressed as unrelievable pain, I don’t have long episodes of uncontrollable rage and I can live with my difficulty spelling.

I’ve never really gone into the effects with you because these injuries are unique to the individual and I see no reason to scare people who are on a different path.

WIND: the areas of the brain affected can be different, and the brain is extremely complex. Anyone with a concussion might should take it very seriously. My concusssion log might offer some guidance as to how things progressed for me.

Southern Inyo Double Double Century

I’ve trained hard and lost 10 pounds of body fat, feel great, and I’m ready for my first double century. So while I’m registered for the Southern Inyo Double Double Century (double century on Saturday and another double century on Sunday), I have my doubts as to that 2nd double on Sunday... I feel almost nauseated thinking about it. And yet...

The litmus test for me will be literally whether I can eat on Saturday night: I’ve finished doubles where my stomach is so upset that 3 AM sardines were all I could manage. I can’t fathom doing a 2nd double on Sunday without my stomach accepting a steady supply of nutrients from Saturday evening until 4 AM on Sunday morning.

The projected 30 mph SW winds on Saturday along with my soloist approach (no drafting) means that Saturday could be a sore trial for my first double of the year.

The Best Performance Enhancer for Cycling: Drafting

How is Drafting in a Paceline Different from an Electric Motor?

Science News: With its burning grip, shingles can do lasting damage (varicella zoster)

I’ve been meaning to get the vaccine for shingles (adult-onset attack of latent chicken pox virus). Science News report that the effects of shingles can be very bad, and I’m at an age where it could be hit by it (I had full-on chicken pox as a kid).

While my immunue system has been exceptionally strong, I could see for example, being temporarily weakned by a double century, giving the virus a leg up. I’m not keen on even a small risk of blindness or burning pain or dementia.

The vaccine to get is Shingrix, which looks much superior to the predecessor vaccine. It requires two doses, spaced some months apart, and is in short supply at present.

With its burning grip, shingles can do lasting damage

When varicella zoster reawakens, it wreaks a surprising amount of havoc in the body

Decades after its first assault, varicella zoster virus can mount a second attack from its hiding place within nerve cells, bringing pain, burning, numbness or itchiness to the skin, after which a blistery rash often blooms...

The torso is the most common site of this eruption; the belt of pain and rash wraps from front to back on half of the body. Indeed, the words zoster and shingles, from Greek and Latin, mean girdle or belt. As to the pain, the Norwegian word for shingles, helvetesild, means “hell’s fire.”

Less common, but just as painful, shingles can originate on one side of the face, in an ear or in and around an eye. And researchers now know that shingles can occur in the gut, which comes with no rash tip-off.

Age discriminator Shingles can strike anyone infected with varicella zoster virus, but the risk really begins to climb with each year after age 50.

The list of nasty complications from the infection has also grown beyond the debilitating pain that persists in some people for months or years. Recently, scientists have learned more about the virus’s ability to infect arteries, increasing the risk of stroke or causing headaches and vision problems. There are even hints of a connection between shingles in the eye and dementia.

...

In 2017, the U.S. Food and Drug Administration approved Shingrix, a vaccine to prevent shingles in people 50 and older that outperforms an earlier vaccine, Zostavax.

What a Cracked Bike Crash Helmet Looks Like

The crash that gave me my concussion in March 2018 hardly seemed to have affected the brand-snew helmet. But exerting force would open up a crack in this area as shown below.

In my December 30 2018 bike crash, a very obvious crack is seen. The sunglasses were also damaged, which presumably means my eyes and nose area got a little protection—I always wear protective glasses, night or day.

Giro has discontinued the Giro Aero model I like, but I was able to scavenge a new one on closeout. The new models are too heavy for my taste—it matters with the head extended out for 200 miles, plus the new system cuts into my scalp in back when I tilt my head up.

Cracked Helmet

The apparent impact site.

Impact site on helmet

Most of the helmet looks OK; the impact was in front.

Cracked helmet

It’s hard to say what would have happened to my eyes without sunglasses: something could have wedged into an eye socket, for example.

Nearly new sunglasses staved off damage to eye area

Resting Heart Rate — Bradycardia

I went in for some routine medical stuff today, and the blood pressure machine would not shut up—it lit up yellow and bonged because of my low resting heart rate (41 beats per minute). This went on steadily until the triple readings were all done. I suppose my resting heart rate would have been 38 or 39 if I had been lying down (it was 39 a few years ago in a physical when I was in peak condition). The nurse had to shut off the noise.

A low resting heart rate in the AM is a good sign while training hard: this was at 8 AM, and the grueling training load of 107 miles over the prior two days (4100 calories burned) put a load on my system which I could feel as fatigure by evening—and this reading was only about 14 hours later.

For my HR to be at 41 in the morning means good overall recovery/response to the workout, though my legs were clearly short on glycogen today—very hard to replace glycogen stores overnight when also doing a 3000 calorie deficit for those two days, and far more over several weeks*. If I am not well rested, I’ll see my HR in the 48 to 55 range, 60 to 80 if getting sick.

When fit, a very low heart rate is totally normal for me. One year (when younger), I measured it at 31 for over a minute. Recording it for a minute or so while lying down in bed before getting out of bed in the morning is a great way to keep tabs on recovery—patterns will emerge that tell a story about how physical status—recovery, illness, etc.

Medical science doesn’t know much of anything about outliers like me. I’ve had at least 3 experiences in the last year where medical personnel look concerned with my HR in the 41-45 range. They are so used to seeing grotesquely overweight patients I guess (why am I lumped in with such people for health insurance? Grossly unfair). What is “normal” anyway?

So being an outlier, I have a deep skepticism of medical “knowledge”—so much of what was “established science” seems to have been debunked in recent years (in nutrition and health in particular). Then there is the intellectual incompetence and laziness of using BMI, which placed me quite close to “overweight” with 8% body fat for a BMI of 23.8. Applying population statistics to individuals is medical incompetence, except perhaps (and only) as a crude initial screen. But for a doctor seeing someone in person, I say unequivocally that it is incompetence or at least laziness.

* The frequent and extended periods of very cold rain have really “holed” my training schedule but I have still managed to drop 5 pounds of fat in 4 weeks. This is way below my goal, but losing 10 days or so of training makes it tough, especially when I enounctered a box of See’s Candy one day. The box was empty all too soon.

Nutritional Science Studies Start to Look very Non-Sciency

As I understand it, visceral (android) fat acts like an organ all its own with negative health consequences. Only a few weeks into my season, I am already losing fat out of my abdomen, as my ribs/stomach now have a nice drop-off while lying down versus being level prior. A DEXA scan is the best way to see the android/gynoid breakdown.

Emphasis added in places.

Any way you slice it, there’s a lot to say about nutrition studies

For every study that warns against the health perils of coffee, there's another that points to java as the key to longevity.

Really, if you pick any trendy food — wine, kale, chocolate — and search for its health effects, you're bound to find mixed messages.

So what's the deal? Why are nutrition studies so complicated?

The question was debated in a scholarly squabble this past month by nutrition specialist Christopher Gardner, PhD, and John Ioannidis, MD, DSc, who focuses on the accuracy and reliability of scientific studies. The two met to debate a controversial statement: Most studies on the effect of nutrition and diet are false.

...

WIND: sounds about right, and relates to the replication crisis in science.

Still, I’d bet that a BigMac a day is not good for your, or even the fries alone and ditto for sugary drinks. I don’t eat that kind of garbage and most Americans just don’t care anyway.

More Evidence That Nutrition Studies Don’t Always Add Up

A Cornell food scientist’s downfall could reveal a bigger problem in nutrition research.

...

But as news of the scandal reverberated through academic circles, some experts said they feared it was symptomatic of a broader problem in food and health research. While very few scientists are accused of misconduct or misreporting data, critics have long contended that nutrition research is plagued by a credibility problem. They argue that an alarming number of food studies are misleading, unscientific or manipulated to draw dubious conclusions.

...

WIND: don’t even get started on “sin” things like alcohol. With big bucks at stake in the food industry and a government mucking around and subject to influence, one has to wonder what studies if any can be trusted.

What’s Wrong with American Health Care System (everything, but here’s one thing)

One serious but relatively minor crash in terms of total bodily damage = $90468 bill. And that’s not the whole bill—it’s something like another $20K more.

This sort of thing can break someone (most people) financially without insurance. So we all pay far more, since they cannot.

$101.15 for Tylenol, for starters. An MRI for $7900 that is about $400 at Insight Imaging. $13760 for an overnight stay in a secondary facility bed, where the nurse could not manage to produce god-damned Tylenol for two hours while I was in pain, in spite of asking 3 or 4 times. Etcetera.

I’m not sure that this is all of it (the $5500 surgeons’s bill is not listed yet, at the least)—my insurance has stated that I owe $11000 or so, which is a cost for me that displaces all sorts of things, none of which involve niceties.

For many, medical care is an ongoing trauma for a year or so as the bills roll in and what with dueling with the insurance company. In the past, Stanford has billed me up to a year after the fact, so I wonder how this one will roll out.

Update: I called the insurance company. This is ONLY the hospital portion, for which (this is not a typo!) the insurance company paid out about US$64,800 to Stanford Hospital. It does NOT include other expenses (like surgery), for which I am on the hook for over $11,000, pending appeal. I was late on my monthly premium—had I not gurgled out instructions to my wife to pay it the next day (Dec 31), I’d have lost most of my life savings. This is sheer insanity—criminal IMO.

Update 2: I appealed the other charges (for which I was stated to owe about $11500). This is called a “grievance”. To Blue Shield’s credit, the appeal was granted “as a one-time exception”. I still have to wait 30 to 45 days to see what I owe, which will be at least the deductible ($5000) and co-pays (inscrutable as yet).

One visit to the Stanford Hospital Emergency Room

How to Deal with Biodiesel with the Mercedes Sprinter

Biodiesel is the kiss of death for a Sprinter diesel, notwithstanding the biodiesel industry-produced propaganda spread all over the internet, and internalized and repeated by every nitwit who reads it.

Mercedes Sprinter Maintenance: Dealing with Biodiesel

Excerpt from 2018 Mercedes Sprinter operating manual