63 e-Letters

published between 2015 and 2018

  • On editorials, access and bias at the BJSM

    In May 2018, the following tweet was posted from the BJSM twitter account:

    '115K views. via brave iconocolast @DrAseemMalhotra. Importantly, no rebuttals. Real food saturated fat does not clog arteries - beware processed food that causes hyperinsulinemia (& hypertension). #Rethink'

    Followed by signposting to a linked editorial(1)

    Several people responded, including Catherine Collins (https://twitter.com/RD_Catherine/status/1001707243828596737), pointing out that a number of rebuttals to the editorial in question had in fact been made, not least a 2017 PubMed Commons/PubPeer commentary (https://pubpeer.com/publications/8741FBE4D9D7A38A7802515B33302E), which form the precursor of our rebuttal here. In response to Catherine, the BJSM Editor in Chief (EIC) Karim Khan contacted the lead author here indicating he had missed his email a year previous regarding our commentary originally offered to the BJSM as a formal rebuttal [see PubPeer post]. The EIC indicated he would be happy to publish our PubPeer rebuttal in the BJSM. The lead author thanked the EIC and, with co-authors Duane Mellor, Nicola Guess, and Ian Lahart, submitted a revised version in July 2018.

    In the interest of fairness and open debate, we made a request to the EIC and BJSM editorial board that our manuscript be made o...

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  • Should a pregnancy test be required before scuba diving?

    In this letter the authors observe "a significant difference ..in the rate of offspring malformations between women who dive (6 children affected), and those who did not dive during their pregnancy (none had malformation, p<0.01). A rate of zero malformations in the non-diving population should immediately have alerted the authors to the fact that their survey was biased. In the UK population there is an approximate rate of malformation of 1 in 80 live births and I would think that the rate is similar in France. Instead of using 0 for the malformations the authors should have used the rate observed in the French population. The conclusion of the paper that pregnancy testing should be undertaken before each scuba diving session is not supported by these data.

  • Rolfing---not. Structural Integration---yes

    The last paragraph cites Rolfing when it should be Structural Integration. There are many schools of Structural Integration of which Rolfing Structural Integration is one, Describe the modality as massage if you must, though I would prefer, "a form of manual therapy" or "a form of manual therapy that is often categorized as massage." I am surprised that this error passed through the editors and peer review.

  • The Ankle Roll Guard is a Tested & Effective Alternative to Braces & Tape for Lateral Ankle Support

    The Ankle Roll Guard (anklerollguard.com) is a patented & independently tested, brace-less ankle support that cushions the ankle from an inversion or “roll”. Unlike conventional ankle braces, it wraps securely around the outside of any shoe type and allows the user to retain full ankle mobility and comfort.
    - Patented outside shoe design allows user to retain ankle mobility & comfort while still having ankle protection (no ankle restriction like a brace)
    - Provides ankle stability & protection for users with chronic lateral ankle instability
    - Clinical, independent testing at Boise State University using a motion analysis system showed equivalent inversion protection plus better range of motion & vertical jump versus a brace or tape
    - Weighs only 2.4 ounces so users do not feel it

    Independent Testing at Boise State University
    White Paper Completed January, 2018:
    “Of all the devices (Ankle Roll Guard, Brace, Tape), only the Ankle Roll Guard appears to allow the user normal ankle motion (i.e. typical anatomical joint motion), while preventing excessive ankle inversion” 
    – Tyler Brown, PhD, CSCS, Director COBR
    ​Conclusion: The Ankle Roll Guard may provide similar prevention of excessive inversion as either the brace or tape, but without the mechanical restriction of the joint that reportedly limits physical performance when wearing ankle prophylactic devices.  With the Ankle Roll Guard, p...

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  • Evidence for RICE in acute sprains?

    I congratulate the authors for such a well-rounded and informative update of this CPG. I was not surprised to see the conclusion in the text that the evidence is 'unclear' in the use of ice on acute ankle injuries. There simply are not enough well-controlled RCTs can support RICE's efficacy when used alone. Clinically, we always combine ice with other interventions such as exercise. Your recommendation in the text was, "There is no evidence that RICE alone, or cryotherapy, or compression therapy ALONE (emphasis added) has any positive influence on pain, swelling or patient function. Therefore, there is no role for RICE ALONE (emphasis added) in the treatment of acute LAS." Based on the evidence, I would agree with that statement. However, Table 8's "Final Recommendations" for RICE states, "RICE is not advised as treatment modality after a LAS." I would argue that the authors should have inserted the word, "ALONE" in this recommendation; otherwise, they are making a blanket conclusion that ice is NOT effective when in fact, the evidence remains unclear (there may be some benefit when used in conjunction with other treatments) and potential harmful effects were not discussed if that was part of the decision-making. Unfortunately, I was unable to find the meta-analysis data upon which these recommendations against RICE were made, as Supplement 3 did not include any analysis on RICE interventions. While I am not a...

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  • No evidence for dehydration

    This is a case of exertional heat stroke in which a young, experienced woman runner exerts herself and develops heat stroke. There is no effort to describe the patient's state of hydration besides indicating that she drank 250 mL prior to running (in what timeframe?) and that she drank 200mL after/during collapse. We are unaware of her weight and thus cannot even roughly calculate what her fluid deficit range may be after 90 minutes of running. We are unaware of her dress, which could lead to heat retention. Per figure 2, it appears that her blood pressure was approximately 110/70 at the time of collapse, which does not support hypovolemia. Values of BUN and creatinine are not presented that would have supported dehydration as a predisposing condition. Certainly in a road race there were other runners that reached her same level of hydration - why did they not suffer heat stroke?
    While this is a classically presented case of exertional heat stroke in a road race, there is insufficient evidence to associate it with dehydration.

  • What an odd piece.

    I was quite surprised to see this piece in a BMJ journal. It is quite odd and doesn't appear to bear much relationship to the data. If any readers are interested I strongly suggest that the read the original peer reviewed lancet PACE trial paper and make up their own minds.

  • 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.


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  • 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...

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  • 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....

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