311 e-Letters

  • Are we tilting at cardiac Windmills?

    Zorrzi et al. (1) have recently compared the sensitivity and specificity of the European Society of Cardiology (2010) and the International (2017) ECG criteria for the diagnosis of hypertrophic cardiomyopathy (HCM), concluding that the International criteria have a greater specificity and a slightly lesser sensitivity in making a differential diagnosis from the normal hypertrophy of an endurance athlete's heart.

    However, such an analysis presupposes a clear identification of normal from pathological cases, and this appears to be lacking. The sole criterion for the diagnosis of HCM is "the presence of a hypertrophied and non-dilated left ventricle in the absence of other diseases that could produce the same magnitude of hypertrophy," based on an echocardiographic wall thickness equal to or greater than 15 mm in adult index patients and equal or greater to 13 mm in adult relatives.

    Given the exclusion of patients with symptoms or evidence with systolic dysfunction, there seems little to exclude the possibility that the individuals identified are not simply exceptionally well-trained endurance athletes, and that what is being examined is simply the ability of the 2 sets of ECG criteria to identify a person who has developed a large heart. It is particularly disturbing that the supposed diagnostic criteria seems to make no allowance for age, body size and sex, all of which undoubtedly influence the range of normal cardiac dimensions.


    Show More
  • Author response to Boynton et al. [Response to: We need to talk about manels: the problem of implicit gender bias in sport and exercise medicine, 11 April 2018]

    We want to thank Boynton et al. for writing a letter to the editor (LTE) in response to our recent editorial on gender disparities in the sport and exercise medicine (SEM) community [1]. As the title of our editorial indicates [We need to talk about manels: the problem of implicit gender bias in sport and exercise medicine], we were primarily motivated to stimulate a conversation about the issues we raised, and an LTE contributes to this conversation [2].

    We were also motivated by a desire to assert that i) the SEM community does indeed manifest many examples of gender disparity; ii) social media has provided a space where this issue is being debated, notably (but not exclusively) under the hashtag #manels; iii) implicit bias is a significant contributor to these disparities, and iv) there exist well-established resources where interested readers might explore their own implicit biases [3].

    It is in these goals, then, that we fundamentally disagree with most of the assertions the LTE authors have made about our work and the conclusions they draw.

    We noted with interest that the authors of the LTE did not take direct issue with our assertion that there exist substantial gender imbalances within the field of SEM. Rather, they took issue with our assertion that implicit gender bias underpins these imbalances.

    We posit in our editorial that implicit bias is a factor contributing to the gender disparities we see in SEM. Discussing implicit bias in t...

    Show More
  • Zinc lozenges and vitamin C for high-performance athletes

    In their International Olympic Committee consensus statement, Maughan et al. reviewed the evidence for dietary supplements for high-performance athletes [1].

    They wrote in regard to zinc that “Cochrane review shows benefit of [using] zinc acetate lozenges (75 mg) to decrease duration of URS [upper respiratory symptoms]” [1, Table 4]. This statement was based on their reading of the Cochrane review (2013) by Singh and Das [2], which was withdrawn in 2015 because of plagiarism [3]. In addition, the same Cochrane review had a large number of other severe problems [4]. In the above statement, Maughan et al. imply that only zinc acetate lozenges are effective; however, a recent meta-analysis showed that, up until 2017 at least, there was no evidence that zinc gluconate lozenges are less effective than zinc acetate lozenges [5].

    When discussing treatment effects, the size of the effect and its confidence interval should be considered [6]. Thereby a critically-minded reader can form his or her own opinion about whether the treatment effect is relevant. The data of 7 placebo-controlled double-blind RCTs showed that zinc acetate and zinc gluconate lozenges shortened common cold duration on average by 33% (95% CI 21% to 45%) [5]. Individual-patient data were available for 3 zinc acetate lozenge trials and on the basis of these findings, zinc lozenges shortened the duration of colds by 2.7 days (95% CI 1.8 to 3.3 days) [7], and increased the rate of recovery by RR = 3....

    Show More
  • Do Foot Orthoses Benefit the Symptoms of Plantar Heel Pain and How Might they Work? Further Considerations in Designing Research Protocols for Foot Orthoses.

    I would like to raise some comments regarding the paper ‘Foot orthoses for plantar heel pain: a systematic review and meta-analysis.’ Whittaker et al, 2018, Br J Sports Med. 52(6): 322-328, and the editorial ‘Foot orthoses research: identifying limitations to improve translation to clinical knowledge and practice’, Griffiths & Spooner 52(6) in the same edition.

    I would like to applaud the intention of the paper by Whittaker et al, to try and establish a conclusion to the question of foot orthoses efficiency in treating heel pain symptoms. This same praise I also give to the editorial in bring into the discussion the potential issue of the validity of random control trials as a research method to test foot orthoses efficiency. However, some key issues with the paper need exploring beyond the issues raised in the editorial in regarding how orthoses may work.

    There are several key issues with the paper by Whittaker et al, which overall is a noble attempt to make sense of the present research on using orthoses for plantar heel pain. The issues are; plantar heel pain is a symptom not a diagnosis (therefore some of these studies may include multiple conditions); the studies are subject to potential bias (addresses by the authors); the studies do not compare like with like studies and seemed to have been shoe horned together to achieve a conclusion; and finally, foot orthoses do not logically conform to randomised control trials. Despite the best efforts of th...

    Show More
  • Response to: We need to talk about manels: the problem of implicit gender bias in sport and exercise medicine

    Response to: We need to talk about manels: the problem of implicit gender bias in sport and exercise medicine

    A recent editorial in the British Journal of Sports Medicine asserted that the presence of implicit bias in Sport and Exercise Medicine (SEM) is negatively affecting women in the field.1 We are concerned with the editorial’s lack of scientific approach, poor standard of evidence, and exclusion of important facts.

    The editorial argued implicit bias results in pronounced real-world effects in the form of gendered differences in SEM and society as a whole. However, no substantial scientific evidence of the magnitude of implicit bias’s real-world consequences on gender differences was presented. Instead, circular reasoning was utilized as implicit bias was assumed to manifest the gendered differences present in the SEM field and society.

    Implicit bias has been criticised within its field of psychology. A recent meta-analysis found little evidence that measurements of implicit bias are associated with any real-world manifestations of explicit bias or behaviour.2 Indeed, Patrick Forscher, one of the study’s authors implied in an interview that implicit bias’ use in policy making could be wasteful and even harmful.3

    Research suggests gender has an influence on personality, career preferences, and priorities.4 Indeed, where more freedom is allowed, the greater the disparity in traditionally gendered sectors.5 Extrapolation of thes...

    Show More
  • typing error

    Table 3: First supplement "Beta Alanine". This should read "Caffeine" as described in the text.

  • Maybe an error occured in IMG 2 caption.

    First, I'd like to thank you for your precious work, as I'm doing a research about kitesurfing injuries statistics.

    As kitesurfing instructor, I'd like to tell that in picture n°2, I think the guy is intentionally doing a trick. The kite is flying high, pulling him up. As far as the kite pulls the rider above the center of gravity, put the upper body below that point (as in the picture) requires strength, control and intentionality.
    In really dangerous situation (those that need the rider to use quick release safety system), you usually can see the kite low in the air in front of the rider (power zone) pulling hard and the rider's legs behind.
    I don't want to say that the situation described in the picture couldn't be dangerous at all, but in this case it depends on factors you can't see in the picture (obstacles, beach, other people, maximum height of the jump...).

    Again, thanks for your research work and thanks to people working on safety on the beaches and in kitesurfing.


  • An alternative term to Plantar Heel Pain

    Whilst plantar heel pain be a more appropriate term than plantar fasciitis the later is more diagnostic than plantar heel pain which is more symptomatic. It is suggested that the attachments to the os calcis ought to be termed plantar enthesopathy for instance plantar enthesitis

  • Enjoyable form of exercise

    Dear Editor,

    I thank Dr. Batacan et al. for their excellent meta-analysis “Effects of high-intensity interval training on cardiometabolic health” in the March 2017 issue of the British Journal of Sports Medicine [1]. Even if the effects of high-intensity interval training (HIIT) on inflammation are still unclear, research in the coming years will hopefully prove more positive benefits. For example, two recent studies showed effects through a long-term HIIT (12 weeks or more) in the inflammatory profile of overweight/obese adults, such as decreased interleukin (IL) 6, and increased IL-10 concentrations [2, 3].

    But regardless of the various health effects of HIIT, I think the following fact is also worth mentioning for consumers. Health is a motivation to start with regular exercise, but mostly no motive to stay in the long term. On a permanent and regular basis, sport is only practiced when factors such as pleasure and enjoyment are added to the movement. Therefore, I am especially pleased that even overweight/obese teenagers and adults feel HIIT for an enjoyable and time-efficient form of exercise, as several recent studies demonstrate [4-8].

    To Dr. Batacan and colleagues: Very well written, correct results, and appropriate references. Congratulations!


    1. Batacan RB Jr, Duncan MJ, Dalbo VJ, Tucker PS, Fenning AS. Effects of high-intensity interval training on cardiometabolic health: a systematic review and meta-analysis of inte...

    Show More
  • Dr James Thompson

    How soon after completion of the exercise regime were the cognitive measures taken, and what was the average length of the followup?