Letters to the Editor - February 15, 2000 - American Academy of Family Physicians

Letters to the Editor

Recommended Air Travel Delay in Patients with Otitis Media

TO THE EDITOR: The article by Drs. Bettes and McKenas¹ was a useful overview of air travel preparation. However, the section on ear conditions did not address what is probably the most common scenario encountered by primary care physicians. I am not aware of any study that has shown what to recommend to patients who are planning to travel and who present with acute otitis media. Generally, I have been taught to recommend a delay of commercial air travel for two weeks. Are the authors aware of any evidence-based recommendations in this case?

MARK H. HYMAN, M.D.
University of California, Los Angeles
Los Angeles, CA 90025

REFERENCE

Bettes TN, McKenas DK. Medical advice for commercial air travelers. Am Fam Physician 1999;60: 801-8.

IN REPLY: The letter from Dr. Hyman highlights two areas that can be addressed. The first is the small number of good evidence-based studies on which to make recommendations for patients who travel by air. Studies by Kramer¹ and Cox² referenced in our article³ are good examples of the type of research that would be useful but is generally lacking for most conditions commonly encountered when physicians are answering specific questions from patients.

The second point we hoped to make in the article was the need to individually assess each patient whenever possible. Recent disability legislation (i.e., the Air Carrier Access Act of 1986⁴) discourages making blanket assessments involving passenger acceptance unless good evidence is available to back it up. In the case of a patient with acute otitis media, it may be useful to perform follow-up tympanometry or simply a repeat examination documenting resolution of symptoms and having the patient demonstrate the ability to perform an adequate Valsalva maneuver before providing the clearance to fly. This, of course, is not always possible with managed care and reimbursement constraints.

I agree with Dr. Hyman that a general recommendation of waiting two weeks after a patient presents with acute otitis media to give the condition time to resolve would be reasonable, notwithstanding the above two caveats.

THOMAS BETTES, M.D., M.P.H.
American Airlines
Dallas/Fort Worth Airport, TX 75261-9616

REFERENCES

Kramer MR, Jakobson DJ, Springer C, Donchin Y. The safety of air transportation of patients with advanced lung disease. Experience with 21 patients requiring lung transplantation or pulmonary thromboendarterectomy. Chest 1995;108: 1992-6.

Cox GR, Peterson J, Bouchel L, Delmas JJ. Safety of commercial air travel following myocardial infarction. Aviat Space Environ Med 1996;67:976-82.

Bettes TN, McKenas DK. Medical advice for commercial air travelers. Am Fam Physician 1999;60: 801-8.

An act to amend the Federal Aviation Act of 1958 to provide that prohibitions of discrimination against handicapped individuals shall apply to air carriers. Washington, D.C.: U.S. Government Printing Office, 1986.

Sun Protection for Children

TO THE EDITOR: We recently reported the results of a community-based intervention that increased the sun protection of children.¹ The intervention involved schools and day care centers, primary care practices and recreation areas. Outcomes of the intervention were determined by observing actual sun protection of children at the beach. At baseline in intervention towns, 53 percent of the children were fully protected from the sun by clothing, sunscreen or shade. At follow-up, this proportion increased to 74 percent while the rates in control towns did not change substantially between baseline and follow-up.

The school program and the primary care office intervention have been described elsewhere.^2,3 In addition, intervention materials relevant to schools through grade 4, day care centers and primary care offices are now available at the following Web site: http://nccc.hitchcock.org/sunsafe.htm.

ALLEN J. DIETRICH, M.D.
Department of Community and Family Medicine
Dartmouth Medical School
Hanover, NH 03755

REFERENCES

Dietrich AJ, Olson AL, Sox CH, Stevens M, Tosteson TD, Ahles T, et al. A community-based randomized trial encouraging sun protection for children. Pediatrics 1998;102:E64. Article can be found online at: http://www.pediatrics.org/cgi/content/full/102/6/e64.

Grant-Petersson J, Dietrich AJ, Sox CH, Winchell CW, Stevens MM. Promoting sun protection in elementary schools and child care settings: the SunSafe Project. J Sch Health 1999;69:100-6.

Dietrich AJ, Olson AL, Sox CH, Winchell CW, Grant-Petersson J, Collison CW. Sun protection counseling for children: primary care practice patterns and impact of an intervention on clinicians. Arch Fam Med (In press).

Osteoporosis and Fractures

TO THE EDITOR: I enjoyed the excellent article by Dr. Ullom-Minnich on the prevention of osteoporosis and fractures.¹ For practicing physicians, the preventive aspects of managing osteoporosis can have a significant impact on the lives of patients.

The article¹ contained little mention, however, of the nutritional methods of preventing osteoporosis that specifically relate to soy proteins. Dr. Ullom-Minnich correctly identified women of Asian descent as being at higher risk for fracture secondary to osteoporosis but failed to clarify that these are westernized women now eating a western diet. Asian women residing in their home countries actually have a significantly lower risk of osteoporosis and subsequent fractures that seem to be related to large amounts of soy in their diets.^2,3 A growing body of data show that the isoflavones found in soy protein produce a stabilizing effect on the bone matrix.^4-6 Animal and human studies increasingly show that a diet rich in soy proteins has some of the positive effects of estrogen replacement therapy without the risky side effects.^4-6 Further studies are ongoing and will no doubt continue to support the nutritional value of soy proteins for osteoporosis prevention.

KEITH B. VAN ZANDT, M.D.
Maplewood Family Practice/Novant Health
Winston-Salem, NC 27106

REFERENCES

Ullom-Minnich P. Prevention of osteoporosis and fractures. Am Fam Physician. 1999;60:194-202.

Knight DC, Eden JA. A review of the clinical effects of phytoestrogens. Obstet Gynecol 1996;87(5 Pt 2):897-904.

Tham DM, Gardner CD, Haskell WL. Clinical review 97: potential health benefits of dietary phytoestrogens. J Clin Endocrinol Metab 1998;83:2223-35.

Potter SM, Baum JA, Teng H, Stillman RJ, Shay NF, Erdman JW Jr. Soy protein and isoflavones: their effects on blood lipids and bone density in postmenopausal women. Am J Clin Nutr 1998;68(6 suppl):1375S-9S.

Ishimi Y, Miyaura C, Ohmura M, Onoe Y, Sato T, Uchiyama Y, et al. Selective effects of genistein, a soybean isoflavone, on B-lymphopoiesis and bone loss caused by estrogen deficiency. Endocrinology 1999;140:1893-900.

Harrison E, Adjei A, Ameho C, Yamamoto S, Kono S. The effect of soybean protein on bone loss in a rat model of postmenopausal osteoporosis. J Nutr Sci Vitaminol (Tokyo) 1998;44:257-68.

Dr. Van Zandt is a practicing family physician and the family medicine director of Physician Laboratories, makers of a nutritional soy supplement.

EDITOR'S NOTE: This letter was sent to the author of "Prevention of Osteoporosis and Fractures," who declined to reply.

Correction

The patient information handout accompanying the article "Patellofemoral Pain Syndrome: A Review and Guidelines for Treatment" (November 1, 1999, page 2012) contained a drawing that was incorrectly oriented. The hamstring stretch depicted in the fifth exercise should show the person lying on her back and straightening one leg in the air.

*These corrections have been made to the online version of AFP. The links above will take you to the corrected items, which remain part of the online issues in which they were originally published.

Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672; fax:913-906-6080; e-mail: afplet@aafp.org. Please include your complete address, telephone number and fax number. Letters should be double-spaced, fewer than 500 words and limited to one table or figure and six references. Please submit a word count. Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter constitutes transfer of copyright to the American Academy of Family Physicians. The editors may edit letters to meet style and space requirements.

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