Letters to the Editor - March 15, 2001 - American Family Physician

Letters to the Editor

Restless Legs Syndrome

TO THE EDITOR: Restless legs syndrome (RLS) is an often unrecognized but common disorder encountered in family practice. It is more common than diabetes mellitus, with significant symptoms occurring in 5 to 15 percent of the population and 25 percent of patients older than 65 years.¹ In the 1999 Omnibus Sleep in America Poll,² only a small percentage of persons with significant symptoms of RLS were diagnosed by their primary care physician.

A major reason for this is that, although RLS was definitively described in neurology literature in 1945,³ it has not been prominently published in family practice journals. That's why I was pleased to see the article and editorial about RLS in American Family Physician.^4,5 With more information such as this, family physicians can be in a better position to recognize this frequently disagreeable and rest-robbing disorder. However, our patients are equally uninformed about RLS, and the vast majority suffer in silence during the evening hours and in bed, not realizing they have an actual medical disorder that can be readily treated. They do not share their problem with their family physician for years or until it is truly agonizing. Patient education in the office is the primary tool we have to change undertreatment of this syndrome.

A simple RLS questionnaire and a one-page brochure have been very useful in my practice to discover which of my patients have RLS; moreover, they help toward a shared decision regarding medical treatment. In addition, an RLS patient log can help track our patient over the years. Because RLS occurs in approximately 50 percent of first-degree relatives,⁶ the education brochure is sent home with the patient to give to their family members. Frequently, it is discovered that a parent has had RLS symptoms for many years. Once treated, both patients and parents are grateful for our efforts.

The Restless Legs Syndrome Foundation serves as support and an educational source for patients. In addition, it is an up-to-date information source for physicians. On request, the Foundation will furnish a complimentary annual medical bulletin, bibliography and brochures.

ROBERT WERRA, M.D.
P.O. Box 2739
Ukiah, CA 95482

Restless Legs Syndrome Foundation, Inc.
819 Second St., SW
Rochester, MN 55902-2985
Telephone: 1-507-287-6465
Fax: 1-507-287-6312
E-mail: rlsfoundation@rls.org
Web address: http://www.rls.org.
For a free patient brochure, call toll-free: 1-877-463-6757.

REFERENCES

Lavigne GJ, Montplaisir JY. Restless legs syndrome and sleep bruxism: prevalence and association among Canadians. Sleep 1994;17:739-43.

Johnson E. 1999 Omnibus sleep in America poll. Washington: National Sleep Foundation. Retrieved October 2000, from: http://www.sleepfoundation.org/publications/1999poll.html.

Ekbom KA. Restless legs: a clinical study. Acta Medication Scand 1945;158(suppl):1-123.

Restless Legs Syndrome: Detection and management in primary care. National Heart, Lung, and Blood Institute Working Group on Restless Legs Syndrome. Am Fam Physician 2000;62:108-14.

Wellbery CE. Getting the facts on restless legs [Editorial]. Am Fam Physician 2000;62:51-2.

Trenkwalder C, Seidel VC, Gasser T, Oertel WH. Clinical symptoms and possible anticipation in a large kindred of familial restless legs syndrome. Mov Disord 1996;11:389-94.

Role of Papanicolaou Tests

TO THE EDITOR: Why does the American Academy of Family Physicians (AAFP) advocate performing Papanicolaou (Pap) tests in all women at age 18 regardless of their sexual activity status? The young woman who presents without a history of previous sexual activity does not need to undergo a Pap test. The Pap test is a screening test for cervical cancer and precancerous conditions. Human papillomavirus (HPV) is virtually the sole cause of cervical cancer and is sexually transmitted. The woman who has had no sexual experience is at extremely low or no risk for cervical cancer. Why advocate screening in this group?

Another area that puzzles me is Pap screening in women who have undergone total hysterectomy. I see this testing being done in clinics and observe physicians who say, "Just do it" to residents in training, but I do not see the point. These women have no cervices. What is the purpose of a screening test when the organ is not present? I am aware that, occasionally, vaginal abnormalities are discovered; a high degree of suspicion may be present from the physical examination and/or history in these cases. The Pap test then becomes a test to confirm an abnormality found on physical examination--not a screening test.

Finally, why continue Pap test screening in women older than 65 years who have no sexual contact or who have had the same partner and many previous Pap tests that were within normal limits?

I stress that in all these situations, I speak of performing screening Pap tests as probably being performed unnecessarily, and do not refer to those persons where the medical history and physical examination prompts the physician to conduct appropriate testing.

MARIA D. RODRIGUEZ, M.D.
Richmond HIll, NY 11418

EDITOR'S NOTE: The American Academy of Family Physicians (AAFP) recommends Pap test screening for all women who are sexually active or who have a cervix, but the recommendations do not specify a lower or upper age limit. The U.S. Preventive Services Task Force 1996 Guidelines¹ make a similar recommendation, but include that adolescents who are thought to be unreliable should be presumed to be sexually active at the age of 18.

As for the issue of Pap screening in women who have undergone total hysterectomies, the U.S. Preventive Services Task Force 1996 Guidelines¹ further state that post-hysterectomy Pap screening is of no benefit--unless the hysterectomy was performed for cervical cancer. Post-hysterectomy Pap tests may detect vaginal cancer, but the yield and predictive value are low, and the test was never designed for this purpose.

Finally, the U.S. Preventive Task Force 1996 Guidelines¹ state that there is insufficient evidence to recommend an upper age limit for Pap screening. However, they acknowledge that a recommendation can be made to discontinue Pap tests in women older than 65 years who have had regular previous Pap tests that were within normal limits. Continued Pap testing in women at the age of 65 reduces their risk of death from cervical cancer by only 0.18 percent, and by the age of 74, the risk reduction is only 0.06 percent.

The AAFP recommendations for Pap screening are currently under review.

REFERENCE

Guidelines from Guide to Clinical Preventive Services. 2d ed. U.S. Report of the Preventive Services Task Force. Baltimore: Williams & Wilkins, 1996.

Counseling to Reduce Noise-Induced Hearing Loss

TO THE EDITOR: The article "Noise-Induced Hearing Loss"¹ contained an inaccurate sentence. On page 2753, the final sentence of the first paragraph in the left-hand column states that no evidence has shown that counseling is effective in changing behaviors related to noise exposure. It would be more accurate to say that there is no evidence regarding the effectiveness of physician counseling about noise exposure. In the occupational setting, there is encouraging evidence that counseling by nonphysicians can increase the use of hearing protection.²

PETER M. RABINOWITZ, M.D., M.P.H.
Yale School of Medicine
Occupational and Environmental Medicine Program
135 College St.
New Haven, CT 06510-2483

REFERENCES

Rabinowitz PM. Noise-induced hearing loss. Am Fam Physician 2000;61:2749-56.

Lusk S, Hong OS, Ronis DL, Eakin BL, Kerr MJ, Early MR. Effectiveness of an intervention to increase construction workers' use of hearing protection. Hum Factors 1999;41:487-94.

Noise-Induced Hearing Loss in Shooters of Shoulder Firearms

TO THE EDITOR: With regard to Dr. Rabinowitz's fine article¹ on noise-induced hearing loss, I wanted to add a telltale sign of hearing damage that occurs in shooters of shoulder firearms.

Shooters, as do most persons exposed to high sound levels, have a characteristic "notch" of greatest hearing loss at 4,000 or 6,000 Hz; however, shooters of shoulder arms have an asymmetric hearing loss with a greater deficit in the ear opposite the shoulder from which the gun is fired. Because most people are right-handed and fire from the right shoulder, the majority of shoulder firearm shooters show a deeper "4,000 Hz notch" in the left ear. This may seem counter intuitive, but the ipsilateral ear is somewhat protected by the angle of the head when shooting. The contralateral ear is more exposed to the sound of the muzzle blast.

Counseling hunters presents a considerable challenge. As Dr. Rabinowitz¹ points out, the best way to prevent hearing damage is avoiding high-level sounds or using some barrier-like protection (plugs or muffs). Hunters are averse to wearing ear protection, claiming that they need to hear the movement of game they are hunting. I advise them to cover their ears when another person is shooting, to wear ear protection when the success of hunting depends more on vision than on hearing (watching for ducks to fly in rather than listening for the rustling of deer), not to fire unnecessarily and to wear ear protection during practice or sighting in.

I tell hunters that the choice is theirs: either practice hearing conservation or lose more hearing. I point out that communication difficulty will increase, social enjoyment and domestic tranquility will decrease, tinnitus may begin or worsen, and that a hearing aid may become necessary, although hearing aids are less successful with the notch patterns of noise-induced hearing loss than with most other patterns. I wonder if people would take the same risk with their vision?

JAMES E. PECK, PH.D., CCC-A
University of Mississippi Medical Center
2500 N. State St.
Jackson, MS 39216-4506

REFERENCE

Rabinowitz PM. Noise-induced hearing loss. Am Fam Physician 2000;61:2749-56.

IN REPLY: I appreciate Dr. Peck's comments regarding the problem of recreational firearm use and noise-induced hearing loss. Results from a recent study¹ revealed an increased risk of marked high-frequency hearing loss among persons who had used recreational firearms. In addition to Dr. Peck's practical suggestions for counseling hunters about the use of hearing protection, physicians discussing the prevention of hearing loss with hunters should be aware of the existence of devices offering "leveldependent hearing protection."² These devices can permit hearing of low-intensity sounds such as speech or animal movement, while attenuating louder sounds such as gunfire. These devices may be appropriate for use in certain hunting or shooting situations.²

PETER RABINOWITZ
Yale University
Occupational and Environmental Medicine Program
135 College St.
New Haven, CT 06510-2483

REFERENCES

Nondahl DM, Cruickshanks KJ, Wiley TL, Klein R, Klein BE, Tweed TS. Recreational firearm use and hearing loss. Arch Fam Med 2000;9:352-7.

Lindley GA 4th, Palmer CV, Goldstein H, Pratt S. Environmental awareness and level-dependent hearing protection devices. Ear Hear 1997;18:73-82.

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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