Dear Editor

I read with interest this work..But from the radiological point of view the in line technique for injection is much effective for attacking the color spots which represent the neovessls. There are two types for this technique.First the long in line technique which enable us to see the entire path of the needle in its way to attack the target. We inject from the medial side in the direction of the long axis of the tendon with a shallow angle to attack several spots. The injection is done during withdrawal of the needle. Here the position of the probe is identical to the figure 1. In short line technique the probe is perpendicular to the short axis of the tendon. And the needle is at a shallow angle to the probe. The injection also is done from the medial side. We see the distal part of the needle attacking the target. The needle in the perpendicular plain to the tendon and to the long axis of the probe will appear as an echogenic dot with posterior artifact. This echogenic dot will appear after a certain distance from the edge of the probe. We cannot accurately know whether it is inside the color spot or, before or after it at the same plain .The immediate disappearance of the color spots may be simply from pressure of our material on the vessels not to it's direct effect on it. . so the in-line technique is more accurate and enables us to directly attack multiple colour spots with one injection.....Thanks

Dear Editor,

We appreciate the electronic letter from Dickinson and McConnell who refer to our review “Inhaled beta 2-agonists and performance in competitive athletes”. They make the point that maintaining the formal requirement to apply for a TUE (therapeutic use exemption) before the start of therapy with inhaled beta 2-agonists in asthmatic athletes in the long term leads to improved medical care and diagnostic techniques. However, this argument leads to the consideration whether such aims are worth the bureaucratic burden brought up by the application process – a view that we challenge. In addition, we do not agree that improvement of medical care and refinement of diagnostic techniques are worthwhile targets for the formulation of prohibited lists within doping control efforts. In contrast, optimal medical care and innovation of diagnostic tools represent natural issues for physicians dealing with elite athletes as well as for sports medical science.

Sincerely, W. Kindermann, T. Meyer

Dear Editor,

We read with great interest the recent review from Kinderman and Meyer in the recent supplement in the BJSM entitled ‘Inhaled ß₂-agonists and performance in competitive athletes’. They raise the issue as to whether it is appropriate for inhaled ß₂-agonists to require an abbreviated TUE before an athlete is allowed to use them in order to attenuate their asthma/EIA. They put forward the suggestion inhaled ß₂-agonists are inappropriately on the WADA prohibited list due to the lack of evidence in the literature suggesting a performance enhancing effect of inhaled ß₂-agonists. Although the process of acquiring a TUE can cause administrative burden we would like to point out that our work in this area has demonstrated marked improvement in the quality of care elite athletes receive regarding respiratory issues. In the build up to the 2004 Athens Olympic Games we reported that 20% of British elite athletes using asthma medication where doing so inappropriately [1]. Furthermore, screening elite athletes for asthma/EIA appears warranted as reports have suggested many athletes fail to recognise the symptoms of asthma and even those athletes who do report symptoms do not necessarily have EIA and may suffer from other conditions such as inspiratory stridor [2;5,4;3]. Therefore diagnosis without specific tests for EIA may result in false positive and false negative diagnosis.

In summary we agree with Kinderman and Meyer that there is no conclusive evidence that inhaled ß₂-agonists improves athletic performance. However, the requirement of abbreviated TUE’s has resulted in improved diagnostic techniques being used on a more regular basis with elite athletes and has lead to an improvement in the quality of care athletes receive. In the future if inhaled ß₂-agonists are removed from the WADA prohibited list we hope this will not result in deterioration of the support athletes have started to receive since the TUE requirement came into effect in 2002

Yours Sincerely,

Dr. John Dickinson

English Institute of Sport

Prof. Alison McConnell

Sports Science, Brunel University

References

1. Dickinson, J., Whyte, G., McConnell, A. et al. The Impact of the IOC- MC changes in asthma criteria: A British Perspective. Thorax 2005; 60: 629 -632

2. Dickinson, J., Whyte, G., McConnell, A. et al. Screening elite winter athletes for exercise-induced asthma: a comparison of three challenge methods. British Journal of Sports Medicine 2006; 40: 179-183

3. Holzer, K. and Brukner, P. Screening of athletes for exercise-induced bronchoconstriction. Clinical Journal of Sports Medicine 2004; 14: 134-8

4. Rundell, K. Im, J. Mayers, L. et al. Self-reported symptoms and exercise-induced asthma in the elite athlete. Medicine and Science in Sports and Exercise 2001; 33: 208-213

5. Rundell, K. and Spiering, B. Inspiratory Stridor in Elite Athletes. Chest 2003; 123: 468-74

Dear Editor,

Noakes and Speedy, in the article, “Case proven: exercise associated hyponatremia is due to overdrinking,” deliver a shot at the 1996 ACSM Exercise and Fluid Replacement Position Stand that is off the mark. Much as the popular 1960’s television cartoon series Rocky and Bullwinckle Show presented Aesop’s Fables in “Fractured Fairy Tales;” a key element of the story is missing.

The ACSM position stand recommends that athletes “consume the maximal amount of fluids during exercise that can be tolerated without gastrointestinal discomfort up to a rate equal to that lost from sweating,” not "drink as much as you can,” as is stated in the text of “Case Proven.” The recommendation is briefly summarized in the abstract of the position stand, which creates a possibility for misunderstanding or misquoting if one reads only the abstract and not the Position Stand itself. Reading the entire document is required to avoid a “fractured” message. Attributing “drink as much as you can” to the 1996 American College of Sports Medicine (ACSM) Exercise and Fluid Replacement Position Stand is a recurring theme in the works of a few authors, but the problem is simply misapplication of the ACSM advice.

I have copied the pertinent section of the ACSM position stand to illustrate the recommendations: “As such, individuals participating in prolonged intense exercise must rely on strategies such as monitoring body weight loss and ingesting volumes of fluid during exercise at a rate equal to that lost from sweating, i.e., body weight reduction, to ensure complete fluid replacement. This can be accomplished by ingesting beverages that enhance drinking at a rate of one pint of fluid per pound of body weight reduction. While gastrointestinal discomfort has been reported by individuals who have attempted to drink at rates equal to their sweat rates, especially in excess of 1 L/h, this response appears to be individual and there is no clear association between the volume of ingested fluid and symptoms of gastrointestinal distress. Further, failure to maintain hydration during exercise by drinking appropriate amounts of fluid may contribute to gastrointestinal symptoms. Therefore, individuals should be encouraged to consume the maximal amount of fluids during exercise that can be tolerated without gastrointestinal discomfort up to a rate equal to that lost from sweating.”

Some confusion may arise from reading only the abstract, which states, “During exercise, athletes should start drinking early and at regular intervals in an attempt to consume fluids at a rate sufficient to replace all the water lost through sweating (i.e., body weight loss), or consume the maximal amount that can be tolerated.” In light of the main text, this statement was intended to mean “replace up to sweat losses.” The abstract summary statement apparently opened the door to misinterpretation. The point is clearly stated and correct in the body of the document and leads to the moral of the tale. First, read the entire document, and second, ACSM has cautioned its Position Stand authors to make absolutely sure their abstracts represent clearly and accurately the main conclusions, since summaries by their nature are incomplete and can lead to confusion or worse. Since Dr. Noakes was a reviewer of the 1996 ACSM fluid position stand, he should be familiar with the entire Position Stand.

While most involved in the care and study of athletes agree that ingesting too much hypotonic fluid, either water or sports drink, predisposes certain athletes to hypervolemic hypernatremic encephalopathy and pulmonary edema, the exercise associated hyponatremia case is not closed. As Dancaster demonstrates in his 1971 publication, hypovolemic hyponatremia did, and from my clinical experience still does, occur in long duration events, probably as a combined result of sweat sodium and water losses. Eight hyponatremic cases with 4-7% decreases in body weight in one race, as Dancaster outlines from a relatively cool Comrades Marathon, would be a rarity today, probably because we have changed the culture of fluid replacement since the 60’s and early 70’s when replacement fluids on the sidelines and at races were non existent. Now fluids are freely available to athletes and there is less severe dehydration than in the past. Fluid availability is good to a point as Noakes and Speedy outline in their paper, but too much of a good thing can be disastrous for a select few.

While the number of hyponatremic cases has increased since 1971, mostly from the hypervolemic class, replace only your sweat losses remains the best advice today. Giving ranges, whether it is 600-1200 ml/h in the ACSM Position Stand or 400-800 ml/hr as suggested by Noakes, the individual variability in sweat rates leave some underhydrated and others overhydrated A prime example is the case presented by Dugas and Noakes of a woman who repeatedly developed hyponatremia during prolonged activities and had a sweat rate of 270 ml/hour. She was destined to overhydrate with any of the published volume recommendations because she has a sweat rate that falls far below the usual sweat rate ranges during exercise. Replacing sweat losses is her safest route to successful participation, because her kidneys do not respond with appropriate diuresis during activity. The wide variation in fluid requirements across the entire athlete population makes it nearly impossible to give a precise recommendation that includes specific fluid volumes. The best advice still remains to “replace the sweat losses” as outlined in the 1996 ACSM Position Stand. We are all interested in athlete safety and a “fractured” misunderstood or misstated message does not advance that goal.

ACSM’s Exercise and Fluid Replacement Position Stand is currently in revision and should be published in the near future with updates that reflect changes in the area since 1996.

William O Roberts MD, MS, FACSM Past President, American College of Sports Medicine (I have no financial or advisory ties to any water or sports drink companies. I did receive an honorarium from the Gatorade Company for appearing on an educational film clip regarding exertional heat stroke in 2003.)

References

Convertino VA, Armstong LE, Coyle EF, et al. American College of Sports Medicine Position Stand: Exercise and Fluid Replacement. Med Sci Sports Exerc 1996; 28: R1-7.

Dancaster CP and Whereat SJ: Fluid and electrolyte balance during the Comrades Marathon. S Afr Med J 45:147-50, 1971.

Dugas JP and Noakes TD. Hyponatremia encephalopathy despite a modest rate of fluid intake during a 109 km cycle race. Brit J Sports Med 2005; 39;e38 [http//bjsportmed.com/cgi/content/ful/39/10/e38].

Noakes TD and Speedy DB. Case proven: exercise associated hyponatremia is due to overdrinking. Brit J Sports Med 2006; 40(7):567- 572.