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Subtle signs

BMJ 2007; 335 doi: (Published 18 October 2007) Cite this as: BMJ 2007;335:0
  1. Rajendra Kale, senior clinical editor
  1. rkale{at}

    I was never a part of the boxing debate—at least not in the ring. This was mostly because I like my brain, eyes, and ego, and I believe boxing can damage all of these. The debate, however, is making a comeback in the BMJ. This time it is about amateur boxing and the risk of chronic traumatic brain injury. This week, Mike Loosemore and colleagues report their systematic review of observational studies, which finds no strong evidence of a link (doi: 10.1136/bmj.39342.690220.55). Given the quality of published reports, it is hardly surprising that the evidence is inconclusive, says Paul McCrory in his editorial (doi: 10.1136/bmj.39352.454792.80). He also says that today's amateur boxers are unlikely to sustain the injuries of boxers of a bygone era, because they have relatively shorter careers. And boxing is more regulated today than it ever was.

    Today's and tomorrow's boxers could of course have more sensitive tests such as high quality magnetic resonance imaging to detect subtle brain injury. Neuroimaging is on a technological high and climbing higher. For example, a paper in an imaging journal (Journal of Magnetic Resonance Imaging 2006;24:537-42, doi: 10.1002/jmri.20656) reports microstructural abnormalities in the brains of professional boxers with no history of moderate or severe head trauma, which were detected with diffusion tensor imaging. Another study reports non-specific white matter disease in 7 of 42 professional boxers and other significant changes in all the boxers compared with controls (American Journal of Neuroradiology 2006;27:2000-4, We don't yet know the significance of these tiny abnormalities, but the debate about the risks of boxing may advance more quickly through research using high quality neuroimaging to detect subtle signs of injury than through discussions around poor quality evidence.

    An increase in shoe size from 9 to 11 would not be considered a subtle sign, but the best of clinicians could miss it (doi: 10.1136/bmj.39253.602141.AD). Stephen Cohen, a general practitioner, with whom I sympathise, missed the subtle changes of acromegaly in his patient, Jon Danzig, because he saw him so regularly that he failed to notice the changes in Jon's appearance. Other doctors missed the diagnosis too. Jon's friend, who saw him after a long gap, said, “You've rearranged your face,” and his sister thought he had been in a fight. Fortunately the story has a happy ending. After two operations Jon's face started going back to normal, the acne disappeared, his sleep improved, and testosterone levels increased. He is friends with Stephen Cohen, whom he considers his strongest ally. Both have learnt lessons and Cohen says: “Any doctor who's not prepared to learn may as well retire.”

    Tonny Bakhoven, a 74 year old general practitioner from Driebergen near Utrecht, has no intentions of retiring and is happy to work every night and weekend (doi: 10.1136/bmj.39367.610058.DB). Deputising is her profession's downfall, says Tonny: “When something serious happens [to my patient] I want to be there.” So why has her certification been withdrawn? Is it about age? No, it is because she hasn't joined the deputising services—a necessity in the Netherlands.

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