HEALTH TRIBUNE Wednesday, February 14, 2001, Chandigarh, India

No needless tests, please!
by Dr S.M. Bose
HE title of this health-education article may be found to be a bit amusing as it is presumed that medical investigations are always undertaken on the basis of need alone. This is known in medical terms as "on being indicated". 

The computer and the eye
by P.S. Sandhu
OMPLAINTS of vision-related problems like eye-strain, blurred vision, headache, browache and neckache are multiplying rapidly among computer users. Millions of people from pre-school age to adulthood or even elderly persons who work on computers are suffering needlessly. 

Don't stop rescue operations
E are witnessing the most inhuman act on the part of those who have taken the grim decision to stop rescue operations, both for the earthquake victims in Gujarat, and the entrapped miners in the collieries of Bihar.

Kids’ hospital care
HE average time that a child in America occupies a hospital bed varies considerably from state to state, researchers report in the inaugural issue of the journal Ambulatory Pediatrics. Kids’ length of stay ranges from a low of 2.7 days, on average, in Arizona to a high of four days in New York, they found. 




No needless tests, please!
by Dr S.M. Bose

THE title of this health-education article may be found to be a bit amusing as it is presumed that medical investigations are always undertaken on the basis of need alone. This is known in medical terms as "on being indicated". This impression is correct in most of the cases but, unfortunately, in the present era, medical care in general and investigations in particular, are not always need-based. It is pathetic but true that a number of investigations are done not because they are required for the proper management of the patient but because of extra-academic reasons. Similarly, a number of investigations are not undertaken because either the realisation is not there or the facilities do not exist. Surprisingly, this malady is not only confined to India and other developing countries; it is prevalent all over the world and is rapidly spreading like a wild fire.

Radiological investigations

The biggest "culprits" are radiological investigations, right from a plain x-ray of the chest or the abdomen to sophisticated, high-tech investigations like ultrasonography, CT scan, MRI, mammogram and coronary angiography.

The age-old golden methods of good history-taking and a proper clinical examination are being rapidly forgotten or not practised and their place has been taken by costly investigations.

Hundreds of patients tell us the sad story of a doctor who never examined the patient at all but straightaway sent him for a CTscan or ultrasonography. Most of us forget that until a few years back, when these sophisticated investigation were not there, patients were still being diagnosed, treated and operated upon. The use of the CT scan in head injury will be most appropriate to illustrate my point. A present, practically each and every patient with the history of a head injury (he may not have any symptom or sign of a head injury) is being sent for CTscan to rule out any lesion inside the head.

No doubt, these investigations have come as a boon to clinicians, but these should not be misused. The investigations are not only very costly (one CTscan of the abdomen costs hundreds of rupees and one MRI costs much more. In addition, radiation to the patient can be very harmful. Radiation can cause cancer. It is not commonly realised that the radiation given by a CTscan examination is equal to 40 plain x-rays.

Similarly, coronary angiography and angiography for other blood vessels are good investigations but only as long as they are done on the need based premise. These invasive investigations (where the body system is entered) can give rise to serious, and even fatal, complications not always because of any fault on the part of the investigator but also otherwise as angiography itself has this inherent risk factor.


Endoscopic surveillance of the upper and lower gastro-intestinal tract, the genito-urinary system and the respiratory system are being frequently undertaken by the endoscopists, who have costly equipment with them.

Endoscopy is again an invasive procedure and is liable to produce complications, ranging from infections to bleeding and perforation. The investigation is of tremendous use but only on proper indication.

In government hospitals, where the endoscopist is not paid any share for every endoscopy that is undertaken, the complaint is that even deserving cases are not asked to get the examination done, whereas in private clinics each and every patient even with a mild problem, will be advised to undergo endoscopy. Ruling out cancer is a common indication put forward by the doctor.

Radioactive isotopic studies

These studies are carried out to study a number of organs, the common ones being the heart, the liver, the kidney, the spleen, the thyroid gland, the intestines, the bones, etc.

Blood studies

Hundreds of investigations are being carried out on blood specimens. Some are of proven values and other are being done just like that. Probably, blood tests will top the list of investigations that are being done without establishing the need — for example, ordering the serum electrolyte estimation in a normal young man waiting for a hernia operation is ridiculous but is being frequently done.

Urine culture and sensitivity

Similarly, any patient complaining for a urinary problem will invariably get a requisition for urine culture and sensitivity examination; a routine examination prior to this is not even asked for although most of the time the latter can show the presence of UTI and the other patients can be spared this hassle.

Repetition of investigations

The repetition of investigations is another problem that is being commonly faced by the patients. No doubt, repetition and re-repetition of almost each and every investigation may be indicated and should be undertaken, but I am talking of the repetitions that are not justified. The frequently given reason is the unreliability of the laboratory from where the previous investigation had been done. This is true in a small percentage of the cases, and no doubt, the clinician must be doubly sure before he takes a major decision (like removing a breast or any other organ) but in the majority of the cases, the repetition is because of other reasons. The commonest one is to oblige a particular laboratory. Unfortunately, there has been allegations that investigations are done indiscriminately because doctors are being given sums as commission for ordering investigations.

It has been clearly shown that in a chronic illness, if no new development has taken place, investigations do not require a repetition within a period of six months but only a few of us stick to this principle.

The repetition of an investigation does not only drain the pockets of a patient; it also gives more radiation, increases the workload of the laboratories and delays treatment. The inconvenience to the patient is the "bonus" that he gets in the process.

Medical science has made very rapid progress during the last quarter of the 20th century. The availability of newer and better diagnostic tools has spurred the early detection and complete mapping of the disease process. But we must remember that it is the moral duty of a clinician to ensure that the diagnostic modalities are used judiciously.Medical audit is just round the corner and it is going to come very soon. Then every action that the doctor takes will have to be justified.


The computer and the eye
by P.S. Sandhu

COMPLAINTS of vision-related problems like eye-strain, blurred vision, headache, browache and neckache are multiplying rapidly among computer users. Millions of people from pre-school age to adulthood or even elderly persons who work on computers are suffering needlessly. In days gone by, children were warned that reading in poor light or with awkward postures would ruin their eyes. Fortunately, problems were rarely faced. In contrast, today's computer-users may experience preventable vision problems. With images on the computer screen replacing printed words, the problem of asthenopia, i.c., eye-strain, is increasing manifold.

Vision and eye problems are common in our computer age and should not be ignored. Virtually, these can be corrected and avoided with proper adjustments in the work environment and the user's position in relation to the screen. Although there is no evidence of any permanent visual damage from the prolonged use of the computer, even temporary impairment can be troublesome.

The problem can be sometimes dangerous. For example, if computer-use at work impairs one's distance vision, driving home can be difficult.

The good news is that computers do not emit hazardous radiations (neither ultraviolet nor ionizing radiations). So even daily use for years together should not cause cataract or retinal burns. Nor is there any evidence that computer-use causes permanent myopia or near-sightedness or speeds up the development of myopia any more than reading books or doing any similar work does.

However, several surveys of people, who work on the computer, indicate that 75 per cent of them experience one or the other reversible eye problem. Even a name has been coined for such complaints — the "Computer Vision Syndrome" — by ophthalmologists. The symptoms may include the following:

* Temporary near-sightedness resulting in inability to focus clearly on distant objects for a few minutes after the use of computers.

* Eye-fatigue in the form of tired, aching eyelids.

* Sometimes double-vision or after-images may be there.

* Dry, irritated or watery eyes.

* Increased sensitivity to light.

* Headache, browache, neckache and backache owing to bad body postures.

The Computer-Related Problems Study Group says that several factors apply to computer-use like a poor position in relation to the computer screen and lighting that produces glare or reflection or images that are too dim or too bright. These factors are:

* Failure to blink often enough to moisten the eyes.

* Inappropriate glasses for the user's position and distance from the screen

* Minor visual defects gone unnoticed which are exaggerated by intense computer-use.

Minor and otherwise unnoticed refractive errors or imbalance between eyes can cause pronounced discomfort even after half an hour's use of computers.Correcting such problems with properly fitted lenses can dramatically increase comfort.

People, who wear bifocals or progressive lenses ( varifocal), are forced to tilt their heads back to see the screen. Even with a head tilt, the image is not as clear as it should be because the prescription issued for a reading lens is adjusted for the eye-to-page distance of 16 inches at an angle of 30° but computer screens are usually 20-24 inches away at an angle of 15°.So , even minor visual defects should be corrected with lenses prescribed especially for computers.

It is wise to tell the ophthalmologist or the optometrist your nature of work and your requirement for tailor-made prescription of glasses. If you do not have to see distant objects clearly while on the computer, a bifocal lens with a top, adjusted for a computer screen might be used. If distance vision must be clear while working on the computer, a bifocal lens with the upper part adjusted for distance and a larger lower segment for the computer is recommended. To minimise the flare, put the computer at right angle to the window or use a curtain to a cut-off light. Reduce the brightness of the lighting where you work.

Periodic rest-breaks are crucial. After every 20 minutes of working on a computer look up and focus a distant object for 2 minutes. During these 2 minutes do some stretching exercise for relieving tension on your neck and back. Frequent blinking and using eye-drops like Refresh Tears or Artificial Tears will help reduce dryness, irritation and the eye-strain.

Prof P.S. Sandhu heads the Department of Ophthalmology at G.G.S. Medical College, Faridkot.



Don't stop rescue operations

Dr B.C. Roy Award-winner, Brig (Dr) M.L. Kataria, who has seen action in all major wars of the recent past and supervised rescue and relief work from Mahatma Gandhi's days, says:

WE are witnessing the most inhuman act on the part of those who have taken the grim decision to stop rescue operations, both for the earthquake victims in Gujarat, and the entrapped miners in the collieries of Bihar.

It assumes criminal dimensions when miraculous survivors emerge alive from beneath tonnes of debris even 15 days after the tragedy — More so, when it is mostly the foreign agencies and the affected and aggrieved kith and kin who are engaged in rescue work!

The younger the entrapped victim, the greater are his or her chances of survival for an unpredictedly long time, as long as air can reach him or her from one crevice or the other in the debris.

The vital organs in the body have an immeasurable natural capacity to survive on air alone for a long time, while utilising the body's own water content, which constitutes more than 75% of its weight, and has its own reserves of nutrition as well.

There are instances of yogis who bury themselves in sealed pits and emerge alive after a month, living on the restricted air content of the pit.

When Vinoba Bhave decided to call it a day, he ate and drank nothing and passed into eternity by living on air alone for more than 60 days.

And who knows, the so-called last rescued survivor, a boy or a girl, may be a future Prime Minister, a genius, a Nobel laureate, a Buddha, a Jesus or a Gandhi, under whom I had the singular privilege to work near his ashrams — including one in Gujarat?

Man suffers his worst downfall when he attempts to play God.

Don't stop the rescue operations.

Every life has such value as none of us can assess!


Kids’ hospital care

THE average time that a child in America occupies a hospital bed varies considerably from state to state, researchers report in the inaugural issue of the journal Ambulatory Pediatrics. Kids’ length of stay ranges from a low of 2.7 days, on average, in Arizona to a high of four days in New York, they found. The national average length of stay for children and adolescents is 3.4 days. Researchers at the Agency for Healthcare Research and Quality (AHRQ) and Harvard University also found that the percentage of American children who are admitted to the hospital through the emergency room varies widely across states—from 9% to 23%. The analysis is the second in a series exploring kids’ access to and use of healthcare services. It is based on data from AHRQ’s Medical Expenditure Panel Survey as well as the Healthcare Cost and Utilisation Project, a public-private collaboration sponsored by AHRQ. "This second report provides a clear picture of the state of children’s healthcare in the United States and identifies gaps in the healthcare of America’s young.’’

"As would be expected, a considerably higher proportion of healthcare expenditures are paid out of pocket for uninsured children than for those children who are privately insured, who in turn have a larger proportion of expenditures paid out of pocket than those children who are publicly insured,’’ researchers reported. Overall, kids were responsible for more than $62 billion in total medical expenditures in 1996, or an average per child of $1019. — Reuters

Diabetes affects productivity & salary

Diabetes takes a substantial toll on patients’ pocketbooks as well as their health, researchers report. People with type 1 and type 2 diabetes are more likely to miss work than their healthy colleagues. As a result, their annual income may be reduced by as much as one-third, according to study findings published in the January issue of Diabetes Care. The report, based on data from 1989, found that diabetes reduced the annual income of US workers anywhere from $3,700 to $8,700. For example, the average healthy white American man aged 55 or older earned about $27,500, while a similar man with diabetes earned about $18,800, Dr. Ying Chu Ng, from Hong Kong Baptist University in China, and colleagues explain. People with diabetes were 3.5% less likely to be in the labour force than those without the disease, after adjusting for age, social circumstances and health status, the authors note. Diabetics who also have complications were 12% less likely to be employed, compared with diabetics who do not suffer from medical complications. And those with complications worked 3.2 fewer days every 2 weeks, results show. ``In sum, diabetes complications have an enormous effect on work loss.’’ — Suzanne Rostler

Flexible at work, happy at home

A little flexibility at work can stretch a long way when it comes to keeping employees happy and productive, a new report shows. According to a study published in Family Relations, individuals who believed that their manager was flexible with their work hours and work location were able to work more before reaching their breaking point—where competing demands felt overwhelming.

In an interview with Reuters Health, Dr. E. Jeffrey Hill from the School of Family Life at Brigham Young University in Provo, Utah, likened flexibility in the workplace to "a shock absorber for the stress of long work hours.’’ For example, having flexibility at work provides employees with more options for where to live and allows them to spend more time with children and on household chores—at little or no expense to the company, Hill and colleagues explain.

In this era of increasing workload, "flexibility in when and where work is done offers exciting possibilities for helping families to thrive,’’ Hill said. — Source: Family Relations

A promising male contraceptive

In a finding that may come as welcome news to women tired of being responsible for birth control, a new study shows that an experimental form of male contraception suppresses the production of sperm. The study provides some good news for men, too, since the contraceptive injections used in the study only have to be given every 6 weeks, not every week or two as in some other male contraceptives being tested. The regimen tested in the study includes a form of the male sex hormone testosterone, testosterone undecanoate, and norethisterone enanthate (NETE), a hormone used in some female contraceptives. Over the course of 24 weeks, all 28 healthy men in the study, who were aged 18 to 45, received a testosterone injection every 6 weeks. Half of the men were randomly selected to also receive NETE injections, while the other men took a placebo, or dummy pill, every day. Men in both groups experienced a decline in sperm count, but the reductions were larger in the men taking both hormones, according to Dr Eberhard Nieschlag and colleagues at the University of Munster in Germany. "In view of the excellent results and only minor side-effects, the combination of testosterone undecanoate and NETE offers great potential for the development of a hormonal male contraceptive,’’ the authors write. — Merritt McKinney (New York)



DR H.J. Singh of Jalandhar, a sleep disorder specialist, answers readers questions:

Q Is snoring a disease?
Snoring, mostly noticed amongst males, has been a matter of laughter as it is believed that the snorer is in a state of deep sleep. Few people are aware that snoring is a symptom of a malaise which, if not detected and treated in time, can lead to impotence, memory loss and even sudden death.

Q How is this disease known in medical parlance and how much common is it?
The medical term for the disease is "sleep apnoea syndrome". People afflicted with it snore and in snoring sometimes cease to breath altogether for seconds even up to a minute. The cessation of breathing is known as "apnoea". If the cessation period (apnoea) is of more than 10 seconds' duration and if the total number of apnoeas cross 30 during an eight hour sleep, it calls for immediate treatment by a doctor.

Q What are the known symptoms of the disease?
The common symptoms include restless sleep that does not refresh, nocturnal choking, feeling drunk in the morning and reduced libido. Nocturnal choking usually happens when patients wake up with the awareness that they cannot inhale, which is an alarming symptom that passes within seconds. Daytime sleepiness is the main symptom of the disease and it may be serious enough to ruin the patient's life by making it impossible for him to work, drive or even complete a conversation. In some cases sleepiness results in road accidents.

Q What is actually this disease?
The disease is more of a syndrome. Normally, during sleep, the muscles which control the tongue and the soft palate hold the airway open. If these muscles relax, the airway becomes narrower, which causes snoring and breathing difficulties. If these muscles relax too much, the airway can be completely blocked, preventing breathing. This is obstructive sleep apnoea.

Alcohol: Those who take sleeping pills or alcohol may find their passage walls thickening and the passage itself getting narrower.

Heredity: It has some familial pattern, probably seen in such families as have maxilla and mandible set backwards, leaving a narrow upper airway.

Hypothyroidism also predispose one to the disorder which narrows the upper airway.

Obesity is another cause of sleep apnoea. Persons with collar-sizes more than 17 inches are more prone to sleep apnoea.

Q Is this disease dangerous for heart patients?

A People suffering from heart and lung diseases and developing sleep apnoea are likely to get a cardiac arrest.

Q How do you diagnose sleep apnoea?
The diagnosis consists of examining the patient for a full night period for anatomical defects, a check-up of the thyroid functioning and conducting a "sleep study".

A serious problem treated with operations in which the patients lose fail may be treated with the Continuous Positive Airway Pressure (C-PAP).