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HAWAIIMEDICAL

JOURNALDecember 1997 ISSN: 0017-8594Volume 56, No. 12

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HAWAIIMEDICAL

JOURNAL(USPS 237-640)

Published monthly by theHawaii Medical Association

Incorporated in 1856 under the Monarchy1360 South Beretania, Second Floor

Honolulu, Hawaii 96814Phone (808) 536-7702; Fax (808) 528-2376

EditorsEditor: Norman Goldstein MD

News Editor: Henry N. Yokoyama MDContributing Editor: Russell T. Stodd MD

Editorial BoardVincent S. Aoki MD, Benjamin W. Berg MD,

John Breinich, Satoru Izutsu PhD,James Lumeng MD, Douglas G. Massey MD,Myron E. Shirasu MD, Frank L. Tabrah MD,

Alfred D. Morris MD

Journal StaffManaging Editor: Becky KendroEditorial Assistant: Carol Uyeda

OfficersPresident: John S. Spangler MD

President-Elect: Leonard R. HowardSecretary: Roger T. Kimura MDTreasurer: Charles R. Kelley MD

Past President: Carl W. Lehman MD

County PresidentsHawaii: Lorvaine Sonoda-Fogel MDHonolulu: William M. Dang Jr. MD

Maui: Jon Betwee MDWest Hawaii: Au Bairos MDKauai: Gerald McKenna MD

Advertising RepresentativeRoth Communications

960 Prospect Street, Suite 11Honolulu, Hawaii 96822

Phone (808) 545-4061Fax (808) 545-4094

The Journal cannot be held responsible for opinions expressed inpapers, discussion, communications or advertisements. The advertising policy oftheHawaiiMedicalJournal is governed by therules of the Council on Drugs of the American Medical Association. The right is reserved to reject material submitted for editorialor advertising columns. The Hawaii Medical Journal (USPS237640) is published monthly by the Hawaii Medical Association(ISSN 0017-8594), 1360 South Beretania Street, Second Floor,Honolulu, Hawaii 96814.

Postmaster: Send address changes to the Hawaii MedicalJournal, 1360 South Beretania Street, Second Floor, Honolulu,Hawaii 96814, Periodical postage paid at Honolulu, Hawaii.

Nonmember subscriptions are $25. Copyright 1995 by theHawaii Medical Association. Printed in the U.S.

Contents

Editorial

Norman Goldstein MD 341

President’s MessageLeonard Howard MD 342

Christmas PoemsRobert Flowers MD 342

Letter to the EditorJon M. Portis MD 343

CommentaryIrwin Schatz MD 345

The Association of Helocobacter Pylon with Intestinal TypeGastric Adenocarcinoma in a Hawaii PopulationHausen Cheong MD, Patti Char MS, Yuan Chang MS, Stanley S. Shimocta MD 348

Newborn Hearing Screening in HawaiiJean L. Johnson DrPH, Nancy L. Kuntz MD, Calvin Ci. Sia MD,Karl R. White PhD, Roma L. Johnson MA 352

News and NotesHenry Y. Yokoyama MD 357

Classified Notices 358

Index for 1997 359

I-

—a

All rights reserved by the artist.

Cover art and descriptive text by Dietrich Varez, Volcano, Hawaii.

Dancer

Surrounded by a lei of Lehua blossoms, this dancer of Hawaiistrikes the classic hula pose.

che Hawail Medical ]ournal staffwould like to wish you a joyous holidayseason! We would like to express ourappreciation to all the Contributingwriters, volunteerpeer reviewers andcopy editors who have assisted usthroughout the year.

HAWAII MEDICAL JOURNAL, VOL 56. DECEMBER 1997339

Join us in the quest forcontinued medical excellence.

You are invited to attend.

— Friday Noon Conference —

LuncheonStraub Allergy Department - Case Reviews

Jeffrey C. Kam, MDDecember 5, 1997, 12:30 - 1:30 p.m.

Doctors Dining RoomLearning Objectives —

At the conclusion, participants will be able to:• Evaluate Drug Allergies.• Understand available test and limitations to drug

allergies.• Recognize Hereditary Angloedema vs. Acquired

Angioedema.We would like to acknowledge the Educational Grant from Pfizer Labs.

— Friday Noon Conference —

All Stings Considered: First-Aid & MedicalTreatment of Hawaii’s Marine Injuries

Craig Thomas, MD & Susan ScottJanuary 9, 1998, 12:30 - 1:30 p.m.

Doctors Dining RoomLearning Objectives —

At the conclusion, participants will be able to:• Understand the latest first aid and medical

treatments of Hawaii’s jellyfish stings.• Recognize and treat ciguatera and scombroid fish

poisoning.• Understand the incidence of drowning in Hawaii.

— Friday Noon Conference —

LuncheonCurrent Trends in Alzheimer’s Disease

and DementiaGary W. Steinke, MD

January 30, 1998, 12:30 - 1:30 p.m.Doctors Dining RoomLearning Objectives —

At the conclusion, participants will be able to:

• Gain knowledge about current research as to thetheory and treatment of Alzheimer’s Disease.

• Understand the genetics of the dementiasyndrome.

• Identify conditions that are necessary for thediagnosis of dementia of the Alzheimer’s type.

We would like to acknowledge the Educational Grant from Pfizer Labs.

Join your Straub colleagues as we strive for

continuing medical excellence.

Straub Clinic & Hospital, Inc. is accredited by

the Hawaii Medical Association to sponsor

continuing medical education for physicians.

Straub designates this educational activity

for a maximum of one credit hour in

Category 1 of the Physician’s Recognition

Award of the American Medical Association.

Each physician should claim only those

hours of credit that he/she actually spent in

the educational activity.

StraubWhen it really mattersVisit Straub’s homepage at httpfiwwwstraabhealthcom

Please call Fran Smith at 522-4471 for more information.

Editorial

Peer Review

Norman Goldstein MDEditor

As readers of the Journal know, our published manuscripts arepeer-reviewed. Our Peer Reviewers are the authorities in manyspecialties of medicine as well as family and general practice.

Our readers also have diverse backgrounds and interests in manyfields of medicine. While some of our manuscripts may seemspecialized - such as our Special Issues on Ophthalmology, mostphysicians find some interest in all of our manuscripts. Highlyspecialized papers are usually not appropriate for our Journal, andare referred to other publications.

Many physicians spend a great deal of time reviewing the manuscripts sent to them by the Journal Editor, and also responding to thereviewers criticisms of their own papers. The Editor and GuestEditors of our Special Issues also spend countless hours, indeeddays, fine-tuning the process of manuscript peer review.

As Drummond Rennie MD, Deputy Editor (West) of JAMAnoted, peer review educates everyone concerned, and is comfortingto editors and to the scientific community, who believe that attemptsto make what seems to be an arbitrary process more democratic.’

In a publication of the Council of Biology Editors, Inc., PeerReview in Scientific Publications,2Rennie further states:

“It is my bias that almost every manuscript that I havehandled as an editor has been proved by the scrutiny ofreviewers. Some papers have been turned from mediocre to

I-

excellent by the extraordinary efforts of dedicated reviewers. At the very least, authors have had the benefit of freshsets of eyes, and on a few occasions, the reviewers havesaved the author from public humiliation. It is also my biasthat, though I have witnessed all sorts of misconduct duringthe review process, from flagrant plagiarism to unconscionable delay, from malicious slander to willful suppressionof new ideas, editorial peer review is a process that has beenmore beneficial than harmful. It is difficult for me toimagine publication without such review, and if orderlyreview were abolished tomorrow in favor, say, of someenormous electronic bulletin board, I would become disoriented as well as unemployed.”2

As Editor of the Journal, I have the same bias. I also have had theopportunity to review dozens of manuscripts submitted for publication, as well as an opportunity to expand my personal reading andknowledge in many fields of medicine - not only in my specialty ofdermatology.

My personal mahalo to our peer reviewers. We continue to be fair,honest, and expeditious in our evaluation and publication of ourmanuscripts.

As the interest in our Journal has increased in the past three or fouryears, we have received some manuscripts for which we have had noreviewers on our panel. We must expand our Peer Review Panel. Ifyou would like to serve the Journal as a peer reviewer in thefollowing fields, please fax or mail your interest to the EditorialOffice fax 808-528-2376.

ReferencesRennie D. Problems in peer review and fraud; cleave over to the sunnier side of doubt. In: BalancingAct: Essays to Honor Stephen Lock, Editor BMJ. London England; The Keynes Press; 1991:9-19.

2. Rennie, D. Peer Review in Scientific Publishing. Papers from the 1st lntemational Congress on PeerReview in Biomedical Publications.

. .- .< — — .— — —. — — I

Peer Reviewers Needed

El Adolescent Medicine El Pain ManagementEl Addiction Medicine El Pathology, GeneralEl Family Medicine El Physical Medicine &El Gastroenterology Rehabilitation

El Genetics El Psychiatry - ChildEl Gynecology El Preventive MedicineEl Hematology El Public HealthEl Insurance Medicine El RheumatologyEl Legal Medicine El Sleep Disorders

El Military Medicine El Undersea MedicineEl Neurology El Urology

El Neonatal-perinatal El OtherEl MedicinerL.J Nutrition

El Otolaryngology

Fax back to Journal Office at (808) 528-2376or mail to: Hawaii Medical Journal

1360 S. Beretania Street, Second FloorHonolulu, Hawaii 96814

I would like to serve as a Peer Reviewer in the above field(s) of Medicine.

Name

Address

1

Phone

E-mail

Fax

HAWAII MEDICAL JOURNAL. VOL 56, DECEMBER 1997341

D Presidents Message Poems

Leonard Howard MD

I am now able to speak to you fromthe viewpoint of riding on the back ofthe tiger rather than just anticipatingwhat it might be like. We have severalissues that are keeping us busy at yourHMA headquarters. As for the newprovider agreement with HMSA, weare actively exploring several coursesof action to resolve some of the problem areas. The important point aboutthis is that the HMA is unable to giveyou a recommendation as far as yoursigning or not signing the contract. Wehave made arrangements for you to

obtain legal help in reviewing the contract in order to make aninformed decision. Call the HMA headquarters to obtain informa

tion on this help.I met with Mr. Robert Nickel and Dr. Richard Chung at HMSA to

follow up on resolution #9 passed by the house ofdelegates concern

ing the physician incentive bonus payments. After listening to their

full presentation of the program, it does not sound as bad as we had

first thought. We have made arrangements for informational brief

ings at HMA headquarters to fully explain the program and answer

your questions. We will send the issue to the HMAIHMSA ClaimsReview Committee for their review and recommendation.

I have completed the restructuring of the committees to put

priority where our mission statement dictates. The less active

committees will be turned into either subcommittees or ad hoccommittees depending on their activity in the past year and how they

relate to the mission. Four large umbrella committees have beenestablished: Legislative, Communications, Peer Review, and PublicHealth. These committees will include in their membership thechairs of the sub and ad hoc committees assigned to them. Commit

tee chairs will report to Council on a periodic basis, and to theExecutive Committee with any priority items.

Council will meet every other month, and an expanded ExecutiveCommittee made up of the usual Executive Committee plus the fivecounty presidents will meet on the alternate months for extended

informational exchange. My goal is that every member of the HMA

knows what their organization is doing for them. In knowledge their

is strength and unity. Lack of knowledge sows dissent: thus the push

for disseminated knowledge of our activities. Liberal use of fax will

keep the leadership up to date with what is going on, and they will

be able to brief their colleagues at the local level. All communica

tions from the members in the front lines will be much appreciated.

Together we can become the representational and advocacy force

that we dreamed of in the reorganization discussions.

An Island Sort of Christmas

Sunny days with blustery windAnd magnificent surf the currents send.Verdant mountains that twinkle at nightsLike oversized fur trees with Christmas tree lights.

But here on this island the peaks are too lowFor God’s winter blessing—the gift of fresh snow!Still deep in these tropics we’re fantasy locked—There’s snow on store windows and most trees are flocked.

There are Santas at malls all dripping with sweatWrapped in their furs like all Santas you’ve met.The people are buzzing in their skins of all huesExcited for the season that brings us good news—

Good news of a Babe and the message of peace,And a message of hope that never will cease—So here in Hawaii, by day and by nightIt’s an island sort of Christmas—and we do it up right!

Christmas Ballet

I stopped the car for Susan to shopAt the autoteller.. and out she hopped.I glanced away while she worked the machineTo study the mountains, covered in green.

Robert S. Flowersfrom Paiko Peninsula

My eyes returned to the front of the bankWhere she took her cash and murmured a “thank”

For modern technology which never sleeps,And gives back on holidays, the money it keeps.

She smiled as she turned to approach the car,But such as the winds here in Christmas are -

They lifted her hat with its embroidered sashAnd she lunged for it using the hand with the cash!

Those winds who targeted first her hat,Seized on that handful of bills stacked so fat!They swirled in the air as high as the roof—Reminiscent of movements in a Keystone Cops spoof!

She looked like a puppy, snapping at flies,Grasping for “twenties” espied by her eyes.Leaping and jumping in a comic balletA scene I’ll remember ‘til I’m old and gray.

Leonard R. Howard MD

HAWAII MEDICAL JOURNAL, VOL 56, DECEMBER 1997

342

Pirouettes, and toe stands, arabesques, swan divesFouettes and entrechats, unusual for wives.Then all of a sudden the wind stilled its force,But the “twenties” recovered were deficient, of course!

Letter to the Editor

A lone one was missing: I joined in the search,Scouring the shrubs and the trees for a “perch”At last we found it - But I really must say...I’d surely have paid it...for that Christmas Ballet!

Thank you for Christmas Joys

For trees to climbAnd words that rhymeFor pools to splashAnd clay to mashFor balls to kickAnd berries to pickFor piles of leavesAnd Christmas EvesFor frozen pondsAnd snowy frondsFor spills and thrillsOn powder hillsFor twinkling lightsAnd shiny brightsFor Christmas treatsAnd cookies to eatFor stars in spaceAnd Saving Grace

We thank you, God.Amen.

Jon M. Portis MDPresident of the Hawaii

Ophthalmological Society

Robert S. FlowersHonolulu, Hawaii

Congratulations on publishing the two recent “Special Issues onOphthalmology.” I am sure these issues will be read thoroughly andeven kept as a reference by your many readers. Thanks again forcontributing to ophthalmology in Hawaii.

Robert S. FlowersHonolulu, Hawaii

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Commentary

Humor, Humility, and a Little Bit of Hubris:Why they may be relevant to an incoming class

of 60 medical school freshmen.

Irwin Schatz MDProfessor of Medicine

John A. Burns School of MedicineUniversity of Hawaii

President Mortimer, Dean Hammar, colleagues, incoming Classof 2001, guests. Jam deeply honored to be asked to give this addressand I thank you for that privilege.

Please understand that my comments are specifically directed atthese young people. Anybody else can listen in if they want. And so,to the students: Aloha and welcome.

You have heard and will hear more about the symbolic significance of the white coat. Twill only add that in my view the white coatwas first instituted as a symbol, not only ofcleanliness and neatness,but also as a great leveller, so that all medical students, residents andphysicians would be considered equal in the eyes of the patient. Thissoon broke down, however, probably because younger-lookingfaculty didn’t want to be confused with residents or, heaven forbid,medical students. So faculty deliberately wore longer coats, with thechief walking around with the longest coat ofall, reaching his ankles. As a matter of fact,when I first came here in 1975, I altered thattradition somewhat; I find long coats bulky anduncomfortable, and therefore ordered short whitecoats for myself. When I wore one the first time,I was told by a colleague that I needed a longercoat because otherwise I would be mistaken fora student. I might add that I’ve aged considerably since then and I doubt that the confusionwould exist today. Over the years, however,I’ve considered that remark a real compliment.

Now, let us get on the substance of this talk.Today is the start of the payoff for long andarduous pre-med studies. You got in to medicalschool, and I congratulate you. As a matter offact, this represents one of the five great milestones in your life: The other four are birth,marriage, death, and the day you pay off yourstudent loan. In the four years ahead, youwill look back upon this ceremony and realizethat as of this date, August 8, 1997, you beganthe process of forgetting everything you learnedin college. You will find slipping away fromyour mind the carefully memorized names ofHawaiian monarchy, English romantic poets,and the body parts of frogs. Instead, a whole newarray of facts and skills will be yours to assemble and to integrate; my task today will be totry to put some of your new experiences in

perspective.Normally, students who attend a commencement or convocation

address remember very little of what the speaker has said; they canhardly wait to get to the post-ceremony parties and start their newlives. One hopes that there is a slight difference here today, if onlybecause you may wonder if there is something Twill say which willget you through the first hurdle you face: called the triple jumpexercise. As some of you may know, this simple exam is a combination oral and written evaluation of your progress, and is really notas forbidding as it sounds or as it may have been described to you.

You will be getting all kinds of advice over the next four years;some good, some scary, and some good and scary. I don’t knowwhere mine will fit, but I offer it with the full knowledge andexpectation that much of what I say will be forgotten immediately.I do want you to remember a few vital points however: they areimportant and are simply this: That you must approach these nextfour years remembering what I call the three H’s: humor, humility,and a tiny bit of hubris. But before we get into these three H’s, let meoffer some preliminary musings on the medical school experiencein general.

How does one describe the process of turning students intophysicians? Very bright medical educators have been examiningthis issue for many years and they have come up with one conclusion: They don’t know. It is really impossible to fully understandthis transformation from student into physician—and yet it is as realas the nose on my face, which my children describe as copious.Somewhere between the middle of the third year and the end of the

in the

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HAWAII MEDICAL JOURNAL, VOL 56, DECEMBER 1997345

fourth year of school, the student becomes, in fact, a learning

physician. This is a mysterious transformation characterized by aconfident approach to the patient and an ability to collect, synthesizeand integrate the accumulated data, although somewhat slowly.This almost magical event occurs in virtually everyone. We don’tknow why or how it happens, but you will all undergo it, and Icontinue to be amazed by it. I would suggest, however, that there isone aspect of it over which you may have some control, and that isthat each time you become a physician for a patient, you remember

the basic underlying processes, the basic pathophysiology, that havemade that individual a patient. Unfortunately, problem-based learning, of which I am a real fan, requires that you learn much of thisbasic science outside of the classroom, at home or in the library. Icannot stress how important this is for you. For example, it is as vitalthat you understand the hemodynamics of congestive heart failureas it is for you to appreciate the community resources available forhelping that patient. We must not let the pendulum swing so far backthat we forget that the practice ofmedicine, after all, is both a scienceand an art. It is true that as medical technology has expanded overthe past 30 years, we surely have neglected the art part; there are toomany physicians who demonstrate less humanity than they should,and who have become excessively entranced by the gadgetry ofmedical care, to the detriment of human relationships and thepatient-physician interaction. The learning ofempathy—what Martin

Buber has called “the land thou” has, in greatpart, suffered. But youdevelop an empathic connection with the patient, and still have

a thorough understanding of the science of that patient’s condition.Unfortunately, today that balance is sometimes out of kilter. jj ifyou don’t know the basic science, if you don’t understand apatient has complaints, then being a humane, compassionate andempathic caregiver will not be enough for your role as a physician.

It is as harmful to the patient for whom you care, for you to forgetthe science of his disease as it is for you to forget the art of takingcare of her. This requires that you couple your humanity, compassion and empathy with a thorough understanding of the pathophysi

ology of the patient’s disorder.I must confess also my concern for what I feel is the excessive

concentration on so-called alternative medicine, about which manyof us hear so much from the media. It is easy to believe that someonehas discovered a mysterious method of relieving pain, quellinganxiety, and curing disease. The fact is that cures, the realbreakthroughs, are always dependent on hard scientific achieve-

ments. The advances in public health and the extension of our liveshave been due to science: antibiotics, the heart-lung machine, potentvaccines, cardiac pacemakers, new drugs, and the revolution inmolecular genetics are just a few of the accomplishments derivedfrom laboratory science and controlled clinical testing. They werenot produced out of thin air by untested, non-scientific remediesmarketed to an easily seduced and unsophisticated public. Theyhave had to show their value in the only arena that really counts: therandomized, controlled clinical trial. You must now become thedefenders of clinical science, requiring that all so-called cures besupported by firmly-based evidence, and not by anecdotes. Suchtestimonials are characterized by the fervor of their proponents, andnot by the demonstration of any scientific rigor.

If, during your careers, you become firmly convinced that someform of alternative medicine works, then I challenge you to explorewhy. Research is never easy, and breakthroughs in medicine requirehard and sometimes disappointing effort. But that’s the only way wewill make the necessary advances in our health care.

Now let us get back to the three H’s which I mentioned earlier. Letus start with the last of these. How many of you know what thedefinition of hubris is? Well, I’ll tell you. It is really just anexaggerated pride or self-confidence.

And how does hubris apply to you? Well, as fearful as you may beof what is to come, I can assure you that all of you, with perhaps atiny exception, will graduate as physicians four years hence. Youare an intellectual elite; you represent the top 0.5 percent ofacademic capability in this country. Of the thousands of medical

students with whom I have had the privilege and pleasure ofassociating over the past 36 years, virtually all have mastered theenormous volume of facts and skills required for them to becomephysicians. You can do it and you will do it. I can guarantee you that.And so you are entitled to a tiny bit of hubris— not enough to distort

your personalities and make you unpleasant, but sufficient so that

you are aware of your capabilities. Self-confidence is important;

self doubt must be abolished.The second of these H’s is humility. And even though Ijust told

you, you are the smartest group of students extant, you are nowentering an entirely new and different arena. Your teachers willexpect you to perform and they will not lower their standards in anyway to accommodate your potential underachievements. As accomplished as you might have been in English or history or art orchemistry, or pharmacology or genetics, your knowledge, or if I

may use a term with which you may be familiar,your database, is negligible now. In fact, you areessentially a tabula rasa, a blank slate.

And so the message is clear. You mustlearn how to learn, and you must accept thetechniques that are provided for you as vehiclesforyour learning. This medical school discardedthe traditional lecture format several years ago.Instead, it adopted the problem-based learningsystem, about which you may have heard. Now,I hope you agree with some of the conceptsinherent in PBL even though you may not feelthat the system as it is designed is ideally suitedto your particular capabilities. I can assure youthat there has never been a medical studentanywhere who has not thought that they could

HAWAII MEDICAL JOURNAL, VOL 56, DECEMBER 1997

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formulate a particular course better than their teachers. And pleaseremember that your teachers were all students of medicine or of thebasic sciences at one time in their past. They have been there; theyknow what you will be going through. I believe that you will findPBL a good way to learn, particularly if it is front-loaded withcritically spaced and relevant lectures.

Finally, and perhaps most important; you must not ever lose yoursense of humor. I mean humor in its broadest conception: not onlymust you be able to laugh at yourself and your colleagues, but youmust also approach your work within a proper perspective. Yourmindset should not be one that says I will work my tail off and I don’thave time for any kind of recreation. This spells disaster. Thesocialization that is absolutely essential if you are to maintain somedegree of a well-rounded student life is yours for the asking. Youneed to get out, have afew beers with your colleagues, run, surf, playtennis, and take some of the weight off your life on a regular andrecurring basis. Ifyou do so, you will lead a more enriched, fulfillingand successful student life.

Be prepared to laugh at yourself—remember that your colleaguesand your teachers may laugh at you but they don’t do so out of anyfeeling of derision. Laughter is a great leveller, and if we are unableto laugh at ourselves, then we are unable to laugh at the world or evenunderstand it.

And so my message to you today really centers on five issues: first,that the equilibrium between the art and science of medicine is vital;second, that alternative medicine must be judged by the same rules

that we use for traditional medical practice; and third, fourth andfifth, that a little bit of hubris, some humility, and a great deal ofhumor are essentials in your approach to medical student life. I wishyou Godspeed, good luck and I’ll see you on the wards.

Editor’s Note:This presentation was given at the White Coat Ceremony for

incoming medical students on August 8, 1997. Irwin J. Schatz MD,MACP came to Hawaii from the University of Michigan to serve asProfessor and Chairman of the Department of Medicine at ourMedical School in July 1975, a position he held for 15 years. DrSchatz has also served on the Editorial Board of the Journal.

Dr Schatz’s 1997 presentation is far from the introduction madeto my Medical School Class of ‘59. Our Professor of Anatomyintroduced himself, then welcomed the 150 students by saying,“Gentlemen and ladies (there were 15), look to your right, now lookto your left. At the end of this year, one of you will not be with us.”And he was not kidding!

Only two of the three survived that first year. Today, the University of Hawaii Medical School, and most of the medical schools inthe US, screen students very carefully before accepting them, andthe faculty tries to keep the attrition rate “a tiny exception.” Mahalo,Dr Schatz.

HAWAII MEDICAL JOURNAL. VOL 56, DECEMBER 1997

347

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The Association of Helicobacter Pylonwith Intestinal Type Gastric

Adenocarcinoma in a Hawaii Population*Hausen Cheong MD, Patti Char MS, Yuan Chang MS, Stanley S. Shimoda MD

American-Japanese Th Ha wall with gastric cancer have characteristics intermediate to those in Japan and the maTh/and United States.Japanese and maThiand U.S. studies have found Helicobacterpylon is associated with intestinal type gastric adenocarcinoma.The present Hawaii study confirmed this association which isindependent of Japanese race (27.6% intestinal type and 4.5%diffuse type were H. pylon/positive, p=0. 031, n=80).

IntroductionRecent studies have found an association between H. pylon and

gastric neoplasm.1’2Ninety-five percent of gastric neoplasms areadenocarcinomas.3There are two subtypes of gastric adenocarcino

mas, the diffuse type and the intestinal type. Intestinal type ofgastric

adenocarcinomas have goblet cells within the neoplastic tissue and

have a better prognosis.4These histological subsets were studied

specifically by Parsonnet, et al, who discovered that H. pylon was

present in 89% of intestinal type cases compared with only 32% of

diffuse type cases.56Recently, Parsonnet’ s findings were confirmed

in Japan by Endo, et al, who found that 82% of 34 patients with

intestinal type gastric cancer had H. pylon compared with 29% of21

patients with diffuse type.7 The purpose of this study was to verify

the association between H. pylon and intestinal type gastric adeno

carcinoma in a Hawaii study population that includes a sizable

subpopulation of American-Japanese who are known to have an

incidence of gastric cancer intermediate to the native Japanese and

mainland U.S. study populations.

* Division of GastroenterologyDepartment of Internal MedicineJohn A. Bums School of MedicineUniversity of Hawaii at ManoaKaiser Permanente HospitalMoanaluaKuakini Medical Center

Address Reprint Request to:Stanley S. Shimoda, M.D.,Division of Gastroenterology,Department of Internal Medicine321 North Kuakini St., Suite #503,Honolulu Hawaii 96817

MethodsIn a period of 16 months from January 1990 through April 1991,

80 patients with gastric adenocarcinoma were identified through thetumor registries at two Honolulu hospitals, Kaiser Permanente and

Kuakini Medical Center. The registries also provided information

regarding age, race and sex of these patients.Pathology slides stained with hematoxylin and eosin (H&E) from

the 80 gastric adenocarcinoma cases were examined blindly by one

of two examiners (Y.C.). Each patient’s set of slides were examined

by light microscopy at 1 OOx magnification over 25 fields whichincluded both pericancerous non-neoplastic tissue and neoplastic

tissue. The examiner determined the histological type (intestinal or

diffuse) of each case.The examiner also determined the absence or presence of

H. pylon. A slide positive for H. pylon was defined as the presence

of 5 or more curvilinear bacilli within a single lOOx field. Greater

magnification was used as necessary to help identify the H. pylon

bacilli. This design was selected to reduce false positives. One slide

representative of intestinalization without H. pylon and a second

slide of H. pylon without intestinalization, were inserted with each

set of slides as controls.All H. pylon positive slides and an equal number of randomly

selected H. pylon negative slides from the same hospital were

identified. These slides were randomized and re-examined by a

second blinded observer using the same technique mentioned above

(H.C.).Statistical analyses were performed using SPSS (Statistical Pack

age for Social Sciences version 4.2).

ResultsFifty-eight of the 80 adenocarcinoma cases (73%) were of the

intestinal type, while the remaining 22 cases (27%) were of the

diffuse histological type. Table 1 shows that H. pylon was present

in 16 of the 58 intestinal cases (27.6%) compared with only one of

the 22 diffuse cases (4.5%), a difference which was statistically

significant (Fisher’s exact test: p=O.O3l).A comparison of cases with and without H. pylon by age, gender,

hospital site and Japanese race is presented in Table 2. None of the

comparisons was statistically significant.The reexamination by a second blinded examiner of 17 H. pylon

positive cases and 17 randomly selected negative cases, stratified by

hospital, showed complete agreement between the two observers.

This resulted in a Cohen’s kappa coefficient of 1.00 (p <0.001).

Controls were correctly identified 100% of the time in both the

HAWAII MEDICAL JOURNAL, VOL 56, DECEMBER 1997

348

Table 1.—The Relationship of Helicobacter pylon to GastricAdenocarcinoma

original trial and the validity trial.

Histological Type

DiscussionThe present study found a statistically significant relationship

between H. pylon and intestinal type gastric adenocarcinoma whichis consistent with previous studies.57 The study’s stringent criteriafor H. pylon positivity resulted in a prevalence less than that ofprevious reports. In contrast to previous studies, no significantrelationship between age and H. pylon was found using cutoffs of50, 55, 60, 65 and 70 years of age.2 This result may be due to thepreponderance of subjects similar in age; 88% of the study population was 60+ y.o.

This Hawaii study is unique in that it represents an American-Japanese population with a gastric cancer mortality rate that is inbetween those of Japan and the mainland United States. Gastriccancer is the second leading cause of cancer mortality in Hawaiiamong American-Japanese males with an age adjusted mortalityrate of 15.9 per 100,000.8 In Japan, the male age adjusted mortalityrate is 32.8 per 100,000 whereas in the United States this mortalityrate is 5.0 per 100,000. Gastric cancer is the most common cause ofcancer mortality in Japan compared to being the 7th most commoncause of cancer deaths in the United States.9Parsonnet’ s study wascarried out on the West Coast of the United States where there is asmall Japanese population whereas Endo’s study in Japan was of aJapanese population. American-Japanese comprise 22% ofHawaii’spopulation, but 76.3% ofthepresent study’s population. ‘°Parsonnet’ sand Endo’s results show similar H. pylon prevalence in their studypopulation despite different Japanese populations which wouldsuggest that H. pylon positivity was not associated with Japaneserace. This was consistent with the present study which found thatH. pylon positivity was not associated with Japanese race (see Table2).

Another Hawaii study published by Nomura found the presenceof anti-H. pylon IgG antibodies in 94% of the stored serum samplesbelonging to 109 American-Japanese males who developed gastriccarcinoma. This case-control study showed that gastric cancer isassociated with H. pylon in both the intestinal and diffuse subgroups. Intestinalization was found to be present in 73.0% ofNomura’s population compared to 72.5% in the present study’spopulation. This suggests that the two populations are similar.Despite having similar American-Japanese populations, it is notpossible to compare Nomura’ s H. pylon antibody study to thepresent light microscopy study. The present study detected the

16

16

13

4

8

9

14

3

42

21

50

13

57

6

25

38

8.00

4.16

0.34

1.35

1.59

1.07, 351

0.53, 187

0.07, 1.92

0.40, 4.50

0.37, 9.67

Table 2.—Helocobacter pylon and Various Characteristics AmongGastric Adenocarcinoma Cases

95%H. pylon H. pylon Odds Confidence

Characteristic Present Absent Ratio LimitHistology

__________ ________ ______________

Intestinal_type

___________ ________ _______________

Diffuse type

__________ _______ ______________

Hospital

___________ ________ _______________

Kuakini

___________

Kaiser

Age (years)

__________ _______ _______________

>60

___________ ________ _______________

60

Gender

female

male

Race

Japanese

___________ ________ _______________

Non-Japanese

*= Referent Group

47

16

presence ofH. pylon by biopsy at the time ofdiscovery of the cancerwhereas the antibody assay for H. pylon only indicates exposure tothis pathogen. In a stored serum study, it is possible to miss cases ofH. pylon associated with gastric cancer if infection occurred afterthe serum was drawn. The average time between phlebotomy andcancer diagnosis was 13 years in the stored serum study. Anotherproblem is that antibody titers may also become negative ifH. pylondisappeared more than 1 year prior to sampling. On the other hand,in a light microscopy study, it is possible to miss cases of H. pylonassociated with cancer where the pathogen disappeared after thecancer developed or where an inadequate stain is used. The neoplastic tissue, especially of the diffuse type, may present an environmenthostile to H. pylon growth.’

In summary, this Hawaii study confirms the relationship betweenH. pylon and intestinal type gastric adenocarcinoma as found instudies in Japan and the mainland United States. The associationbetween H. pylon and intestinal type adenocarcinoma was notaffected by age, gender, institution, or Japanese race.

AcknowledgmentsThe authors thank the late Takuji Hayashi MD, Kuakini Medical

Center, Department of Pathology for his help with this project.Thanks also to Stanley Loo MD, Kaiser Permanente, Department ofPathology; Abraham Nomura MD, Kuakini Medical Center, Japan-Hawaii Cancer Study; and Cyrus E. Rubin MD, University ofWashington, Division of Gastroenterology for their assistance.

References1. Nomura A, Stemmermann G, Chyou P, Kato I, Perez-Perez GI, Blaser MJ, Helicobacterpyloriinfection

and gastric carcinoma among Japanese Americans in Hawaii. N Eng J Med. 1991; 325:1132-1136.2. Eurogast Study Group. An International Association Between Helicobacterpylori Infection and Gastric

Cancer. Lancet. 1993; 341:1359-1362.3. Parsonnet J, Friedman GD, Vandersteen DP, et al. Helicobacter pylon infection and the risk of gastric

carcinoma. NEngJMed. 1991; 325:1127-1131.

Intestinal Type Diffuse Type# of cases (%) # of cases (%)

H. pylon Present 16 (27.6%) 1 (4.5%)

H. pylon Absent , 42 (72.4%) 21(95.5%)

Total 58(100%) 22 (100%)

HAWAII MEDICAL JOURNAL, VOL 56. DECEMBER 1997349

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DESCRIPTION: Lac-Hydrin is a formulation of 12% lactic acid neutralized with ammoniumhydroxide, as ammonium lactate, with a pH of 4.4-5.4. Lac-Hydrin Cream also contains water, lightmineral oil, gtyceryl stearate, polyrsryl 100 stearate, propylene glycol, polyoxyl 40 stearate, glycerin, cetyl alcohol, magnesium aluminum silicate, laureth-4, methyl and propyl parabens, methyl-cellulose, and quaternium-15. Lactic acid is a racemic mixture of 2-hydroxypropanoic acid and hasthe following structural formula:

COON

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CH3CLINICAL PHARMACOLOGY: Lactic acid is an alpha-hydroxy acid. It is a normalconstituent of tissues and blood. The alpha-hydroxy acids (and their sells) are felt to act as humectants when applied to the skin. This property may influence hydration of The stratum corneum. Inaddition, tactic acid, when applied to the skin, may act to decrease corneocyte cohesion. Themechanism(s) by which this is accomplished is not yet known.

An in s/So study of percutaneous absorption of Lac-Hydrin Cream using human cadaver skinindicates That approximately 6.1% of the material was absorbed after 68 hours.INDICATIONS AND USAGE: Lac-Hydrin Cream is indicated for the treatment of ichthyosis vulgaris and xerosis.CONTRAINDICATIONS: None known.WARNING: Use of this product should be discontinued if hypersensitivity to any of the ingredientsis noted. Sun exposure (natural or artificial sunlight) to areas of the skin treated with Lac-HydrinCream should be minimized or avoided (see Precautions section).PRECAUTIONS: General: For external use only. Stinging or burning may occur when applied toskin with fissures, erosions, or that is otherwise abraded (for esample, after shaving thelegs).Caution is advised when used on the face because of the potential for irritation. The potentialfor post-inflammatory hype- or hyperpigmentation has not been studied.Information for patients: Patients using Lac-Hydrin Cream should receive the followinginformation and instructions:1. This medication is to be used as directed by the physician, and should not be used for any dis

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4. If the skin condition worsens with treatment, the medication should be promptly discontinued.Carcinogenesis, Mutagenesis, Impairment of Fertility: Carcinogenesis: A long-term photocarcinogenicity study in hairless albino mice suggested that topically applied 12% ammonium lactate cream enhanced the rate of ultraviolet light-induced skin tumor formation. Although the biologic significance of these results to humans is not clear, patients should minimize or avoid use ofthis product on areas of the skin that may be exposed to natural or artificial sunlight, including theface. Long-term dermal carcinogenicity studies in animals have not been conducted to evaluate thecarcinogenic potential of ammonium lactate.Pregnancy: Terafogenic effects: Pregnancy Category C. Animal reproduction studies have notbeen conducted with Lac-Hydrin Cream. It is also not known whether Lac-Hydrin Cream cancause fetal harm when administered to a pregnant woman or can affect reproduction capacity.Lac-Hydrin Cream should be given to a pregnant woman only if clearly needed.Nursing Mothers: Although lactic acid isa normal constituent of blood and tissues, it is not knownto what extent this drug affects normal lactic acid levels in human milk. Because many drugs areexcreted in human milk, caution should be exercised when Lac-Hydnn Cream is administered toa nursing woman.

Pediatric Use: The safety and effectiveness of Lac-Hydrin Cream have not been established inpediatric patients less than 12 years old. Potential systemic tosicity from percutaneous absorptionhas not been studied. Because of the increased surface area to body weight ratio in pediatricpatients, the systemic burden of lactic acid may be increased.ADVERSE REACTIONS: In controlled clinical trials of patients with ichthyosis vulgaris, the mostfrequent adverse reactions in patients treated with Lac-Hydrin Cream were rash (including erythema and irritation) and burning/stinging. Each was reported in approximately 10-15% of patients.In addition, itching was reported in approximately 5% of patients.

In controlled clinical trials of patients with xeroxis, the most frequent adverse reactions inpahents treated with Lac-Hydrin Cream were tmnsient burning, in about 3% of patients, stinging,dry skin and rash, each reported in approximately 2% of patients.DOSAGE AND ADMINISTRATION: Apply to the affected areas and rub in thoroughly. Use twicedaily or as directed by a physician.HOW SUPPUED: Lac-Hydrin Cream is available in cartons of 280 g (2-140 g plastic tubes). Storeat controlled room temperature, 15-30C )59-86T).

©1994 WESTWOOD-SQUIBBPHARMACEUTICALS INC.Buffa)o. N.Y., U.S.A. 14213A Br)stol-Myers Squibb Company

4. Lauren, P. The two histological main types of gastric carcinoma:diffuse sect so-called )ntesbnal-type carcinoma. Acta PatholetM)crobio)Scand. 1965; 64: 31-49.

5. ParsonnetJ. He))cobacter py)ori and Gastric Cancer. Gastroentero)Clln North Am. 1993; 22: 89-104.

6. Parsonnet J, Vandersteen D, Goates J, Sibley RK, Pritikin J, ChangY. He)icobacterpy)or)infecton in intestinal- and diffuse- type gastricadenocarcinomas. J Nat) Cancer Inst. 1991; 9: 640-643.

7. Endo S, Ohkusa T, Okayasu I, Tamura Y, Saito V. Detection otHe)icobacter pylori in eariy gastric cancer: comparison betweenintestinal and diffuse type gastric adenocarcinomas. Castroentero)ogy. 1992; 102 (part 2): A64.

8. Hawaii Tumor Registry. Age-adjusted incidence and mortality rates(per 100,000) by ethnicity and sex, Hawat, 1983-1886. Honolulu.Hawaii Tumor Registry, 1991.

9. Parker S, Tong T, Bolden S, Wingo PA. Cancer Statistics, 1997. CACancer JC))n. 1997; 1:5-27.

10. State Department of Health, Health Surveillance Program. State otHawaii 1986 Ethnic percentage distribution. In: Oyama NM, ed. Stateof Hawaii Native Hawaiian Health Data Book 1990. Honolulu. Officeot Hawaiian Affairs, 1990,

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Newborn Hearing Screening in HawaiiJean L. Johnson DrPH*, Nancy L. Kuntz MD**, Calvin C.J. Sia MD***, Karl R. White PhD****

Roma L. Johnson MA*****

In 1989, Surgeon General C. Everett Koop challenged parents,

physicians, state agency staff, and researchers to work together tofind better ways to identify young children with hearing impair

ments. He urged that by the year 2000 all children with significant

hearing impairments be identified before 12 months of age’2Today,Hawaii is screening more than 90% of its births and is on thethreshold of achieving this Year 2000 Health Goal. Only a handful

of other states, e.g., Rhode Island, Utah, Colorado, Iowa, andWyoming, have made substantial strides toward this goal, and only

Rhode Island has implemented a statewide program similar to

Hawaii’s.This Year 2000 Goal was set because of the failure of the nation

to improve the age of early identification of early loss, despite

decades of efforts.3Prior to 1993, the average age of identification

of a child with severe-to-profound hearing loss was approximately

2-1/2 years, with significant mild-moderate hearing loss not identi

fied until after 5-6 years of age.4’5A 1987 study in Hawaii found that

the average age of identification for severe-to-profound hearing loss

ranged from 2.8 months to 4.4 years, depending on where the child

lived and the family’s health insurance coverage.6

Why Early Identification is ImportantWhile the devastating effect of severe-to-profound hearing loss

has long been recognized,7’8only recently have the negative conse

quences of mild-to-moderate bilateral or unilateral hearing loss

become evident.3 Emerging brain research on the critical impor

tance of auditory competence during the first three years of lifeunderscores the importance of identifying any hearing loss as early

in life as possible to assure that the acquisition of communication

skills is not delayed.9-” Obviously the greatest emotional and

functional impact of hearing disability is on the newborn and the

family.

‘Zero to Three Hawaii Project“Family Health Services Division***carnegie Project****National Center for Hearing Assessment & Management, Utah State University

Newborn Hearing Screening Program

Moreover, parents have been concerned over the delay in identi

fying their children’s hearing loss. As reported in a 1995 study, few

parents of hearing impaired children were satisfied with the age at

which their child’s impairment had been confirmed. More than

three-fourths of the parents surveyed would have welcomed aneonatal hearing screening program.’2

Not only does undiagnosed hearing loss in infants have negative

consequences for the family, the community also suffers. An analy

sis for the United States Department ofEducation concluded that the

cost for special education services in a self-contained classroom is

approximately three times the cost of a regular classroom. If a child

requires a residential program, the cost is approximately ten times

more per year.’3 Identifying hearing disability before 12 months of

age, providing the children with appropriate medical and audiologi

cal management, and enrolling them in early intervention programs,

substantially reduces the need for extensive special education ser

In recognition of the importance of the early detection of hearing

loss, and with the increasing availability of reliable technology,’5-’8

these and many other articles over the past two years, both in Europe

and the United States, recommend implementation of universal

newborn hearing screening.8”9-2’That it is now both possible and

feasible to lower the age of identification of hearing loss is now

widely recognized.22-25Articles now address the importance of the

issues of legal liability and quality assurance.26

Hawaii Begins Reaching for the GoalWith the support of the Hawaii Chapter of the American Academy

of Pediatrics and the Hawaii Speech-Language-Hearing Associa

tion, legislation was introduced in 1990 to mandate universal

newborn hearing screening in Hawaii. In May 1990, Governor

Waihee signed Act 85 (HRS §321.361-363) into law in celebration

of Better Speech and Hearing Month.27The act assigns responsibility to the Department of Health (DOH)

in four areas:1) develop methodology for identification and intervention;

2) develop guidelines for screening, identification, diagnosis,

and monitoring;3) develop a plan to involve parents in the medical and

educational follow-up and management of the hearingimpairment; and

4) develop a plan for the collection of data and programevaluation.

Hawaii’s legislation does not mandate a particular methodology

or technology. The DOH has specifically elected not to adopt rules

for the implementation of the program in order to enable the program

HAWAII MEDICAL JOURNAL. VOL 56, DECEMEER 1997

352

to be responsive to any new technology or methodology consistentwith the goal of early identification of hearing loss.

With the support of the Hawaii Chapter of the American Academyof Pediatrics and the Pediatric Committee of Kapiolani MedicalCenter for Women and Children (KMCWC), newborn hearingscreening began in 1992, using otoacoustic emissions screening.Kaiser Medical Center began screening in April 1992, utilizingunilateral automated auditory brain stem (ABR) screening. Screening was expanded to Maui Memorial Hospital (MMH) in February1993. The Queens Medical Center began screening in July 1993.Tripler Army Medical Center implemented screening in the Spring1996.

Currently, all but one of the smaller birthing facilities have beenproviding universal newborn hearing screening. Kona CommunityHospital is now the only hospital in the state not providing newbornhearing screening. Thus, hearing screening is now available to 96%of all newborns in the state. With the exception of Kaiser MedicalCenter, all hospitals use bilateral otoacoustic emissions as themethod of screening.

Otoacoustic omissions (OAEs) are acoustic responses associatedwith the normal hearing process. OAEs are produced in the inner earand can be measured with a low-noise microphone placed in the earcanal. These responses are commonly elicited by the use of briefacoustic stimuli such as clicks. Research has demonstrated thepracticality of using OAEs to identify hearing loss in newborns.3

The use of this technology for newborn hearing screening has thefollowing advantages: 1) simplicity: no advanced technical trainingis required for administration; 2) rapidity: detection of OAEs can beachieved in less than 5 minutes for both ears; 3) noninvasiveness: theacoustic probe is placed into the external ear canal using an impedance probe protector without support; 4) objectivity: a visual recordof cochlear response is provided for future reference; and 5) sensitivity: this technique is sensitive to hearing loss down to 25 decibelHL.

As Table 1 shows, the percentage of children screened since thebeginning of the program has been progressively increasing.

Operation of the Screening ProgramSince its inception, the screening program has been an example of

private-public partnership. The DOH provides seed money in theform of equipment, supplies, technical support, training, and (in theearly years) personnel to do the screening. The DOH began with thelargerhospitals, gradually transferring support to the smaller birthing

centers as the larger hospitals could assume the cost of the program.As hospitals begin receiving revenues from billing for the services,each hospital gradually assumes the cost of direct screening operations. The data-tracking system is operated by the DOH. The DOHcontinues to provide training, technical support, and quality assurance.

Hospitals use a variety of personnel for screening. Larger facilities such as KMCWC, MMH, Queens, and Tripler use full-time,dedicated screeners. Smaller facilities rely on nursing staff (e.g.,Wilcox Memorial Hospital) or volunteers (e.g., Hilo CommunityHospital).

Infants are generally screened within the newborn nursery, or, ifthe nursery’s noise-level is unacceptable, in an adjacent room. Bestresults are obtained after the first 24 hours following the birth. If aninitial response is not obtained, several efforts are made to secure aresponse. If a response still cannot be secured, the infant is scheduledto return for a rescreen as soon as possible. If responses cannot beobtained during the second screening, the infant is referred for adiagnostic ABR evaluation.

Since newborn hearing screening is standard-practice-of-care ineach hospital, parental permission is not required. Parents andpediatricians are informed whenever responses are not obtainedfrom the newborn. For those newborns for whom screening cannotbe completed prior to discharge, parents are notified that the childwas not screened and parents are offered the opportunity to return forout-patient screening.

Intervention ServicesA universal screening program is obviously only the first aspect

of the system of care necessary to reduce the negative consequencesof congenital hearing loss.5,28 Whenever responses are not obtainedduring the second screening (anywhere in the state), a referral ismade to the Newborn Hearing Screening Program for assistance inscheduling the AI3R. The services provided to the child and familyare tracked through a data management system.

If the diagnostic evaluation identifies the child as having asignificant hearing loss, a referral is immediately made to theHawaii Keiki Information Services System (H-KISS) for assignment of a care coordinator through the Zero-to-Three HawaiiProject. The care coordinator, working closely with the family andin collaboration with pediatrician or the child’s medical home,arranges for appropriate intervention services. A significant hearingloss makes a child eligible for services under Part H of the Individuals with Disabilities Education Act (IDEA).

The care coordinator works with the family to assure that all thediagnostic and necessary medical services are obtained. Fitting ofamplification at the earliest possible age is the highest priority.Additionally, all other services needed for the optimal habilitationof the child are made available. These services include auditorytraining, speech-language therapy, child development services,parent training and counseling, sign-language instruction, and othereligible services needed by the family. Every effort is made toprovide the family with information and support for a full range ofoptions for communication and early education.

Services continue until the child reaches the age of three. Transition planning occurs between the age of 2-1/2 and 3 years todetermine the most appropriate services after the age of three. Manychildren at the age of three have been successfully transitioned into

Table 1.—Percentage of Newborns Screened by Year in Hawaii’sNewborn Hearing Screening Program

Year Percentage1992 19%

1993 44%

1994 55%1995 65%1996 79%1997 95%

HAWAH MEDICAL JOUIRNAL, VOL 56, DECEMBER 1997353

community preschool programs with supportive services. Others

become eligible for IDEA services through the Department of

Education.

Results for HawaiiThe results for Hawaii unequivocally demonstrate that newborns

can be effectively screened, with drastic reductions in the age of

identification and the time of amplification. The data for the past

decade are displayed in Table 2. The table shows that many of the

children are being aided prior to six months of age. Unfortunately,

speedy provision of amplification remains a problem, largely be

cause of the policies of some third-party insurers. The expedited

provision of amplification requires increased attention.

Exact cost estimates are elusive, but the range within the state is

from $30-50 per child screened. These ranges are consistent with

national averages. Hawaii’s cost range compares well, being the

least expensive per case identified of any newborn screening pro

gram. Table 3 compares the cost of identifying one child with

significant permanent hearing loss with the cost of identifying

children with hypothyroid, PKU, cystic fibrosis, and HGB. As the

table shows, the cost per child for hearing screening is several times

larger than tests for the other conditions, but the cost is several times

less for each confirmed diagnosis.

Related EventsIncreasing attention at the national level has focused on universal

hearing screening since Hawaii passed its legislation. In March

1993, a Consensus Panel of the National Institutes of Health con

cluded that all infants should be screened for hearing impairment

with a test that measures for otoacoustic emissions.29 NIH also

recommended that all infants with a significant hearing loss be

identified by three months of age, with intervention beginning prior

to six months of age.Other organizations have urged stepped-up identification of hear

ing loss in children. In 1994, the American Academy of Pediatrics,

along with four other professional organizations, drafted a joint

position statement calling for the early detection of hearing loss.3B

Representative James Walsh (R-NY) introduced the Infant Hearing

Screening/Hearing Loss Testing Act in the 104th Congress. The

legislation would mandate hearing testing for all newborns, requir

ing private insurance companies and Medicaid to cover the cost of

the screening. Hawaii was the first state to pass legislation; now

Connecticut has become the fifth state in the nation to mandate

newborn hearing screening.Additionally, the Maternal and Child Health Bureau funded a

grant in 1996 to encourage states to implement universal newborn

hearing screening programs. The Centers for Disease Control, in

collaboration with the Office of Special Education and Rehabilita

tive Services and the Maternal and Child Health Bureau, is funding

a new study to explore various models of statewide tracking and data

management for newborn hearing screening programs.

Case StudiesThree case studies from Hawaii demonstrate the critical impor

tance of relying on objective, universal screening versus subjective

pediatric and family surveillance for early identification.

Case 1When a newborn was identified by the screening program and was

undergoing diagnostic evaluation, the audiologist, observing the

auditory behaviors and speech patterns of the infant’s three-year-old

sister, was alerted to the possibility of hearing loss in the sister. Both

children were found to have a moderate-to-profound bilateral hear

ing loss. Neither the girl’s parents nor her pediatrician had raised the

possibility that she might have a hearing loss. The younger brother

is now in preschool with age-appropriate communication skills.

Sadly, the older sister, remains in a special education class with

delayed receptive and expressive language skills.

In at least two other families, older siblings with hearing loss have

been identified as a result of the referral of the newborn for

diagnostic evaluation after the infants failed the hospital screening.

In one family, two older siblings were identified with the same

pattern of hearing loss as the newborn.

Case 2This child, born at one of the birthing centers providing newborn

hearing screening, was not screened prior to discharge. A letter from

the hospital’s audiologist informed the parents that screening was

not done, but was available on an out-patient basis. A copy of the

letter was sent to the child’s pediatrician. The letter encouraged the

Table 2.—Age of Identification and Amplification of Newborns in Hawaii

Average Age Average AgeBirth Year Identified Aided

1987* 42 months 50 months

1991 17 months 19 months

1992 12 months 16 months

1993 6 months 11 months

1994 10 months 16 months

1995 6 months 12 months

1996 3 months 7 months

‘For births for previous five years where complete information could be obtained.

Table 3.—Comparative Cost of Identification of Various Conditions inNewborn Screening Programs (31)

Sensorineural CysticHearing Loss Hypothyroid Ejosis b

Frequency 564(1)per 100,00 376(2) 25 7 50 13births

Average ageof diagnosisif unscreened 30 3-12 3-12 42 3-36(in months)

Cost of screen $25 $3 $3 $3 $3per child

Cost perconfirmed $4,440 (1)diagnosis $6,650 (2) $10,800 $40,500 $6,000 $23,100

(1) Unilateral(2) Bilateral

HAWAII MEDICAL JOURNAL, VOL 56, DECEMBER 1997

354

References1. Koop CE. We can identity children with hearing impairment before their first birthday. Seminars in

Healing. 1993, 14:1, Forward.2. U.S. Department of Health and Human Services. Healthy people 2000: National health promotion and

disease prevention objectives. 1990, Washington, DC: Public Health Service.

3. Mauk GW, Bebrens TR. Historical, political, and technological context associated with early identiticahon of hearing loss. Seminars in Hearing, 1993, 14:1 1-17.

4. White KR, Bebrens RT. Preface. Seminars in Hearing. 1993, 14:1.5. A Reportto the Congress of the United States Toward Equality: Education of the Deaf. The Commission

on Education of the Deaf, 1988.6. Johnson JL, Mauk GW, Takekawa KM, Simon PR, Sia CCJ, Blackwell PM. Implementing a statewide

system of services for infants and toddlers with hearing disabilities. Seminars in Hearing. 1993, 14:1,105-119.

7. Downs MP. Universal newborn hearing screening—theColorado story. mtemationalJournal PediatricOtolatyngology. 1995, 32:3, 257-259.

8. Bluestone CD. Universal newborn screening for hearing loss: Ideal vs. reality and the role ofotolaryngologists. Otola,yngology-Head-Neck Surgery. 1996, 115:1, 89-93.

9. Ruben RJ. The ontogeny of human hearing. ACTA Otolaryngology. 1992, 112:2, 192-196.10. KuhI PK, Williams KA, Lacerda F, Stevens KN, Lindelom B. Linguistic experience alters phonetic

perception in infants by 6 months of age. Science. 1992, 31:255 (5044), 600-608.11. Ruben RJ, Rapin I. Plasticity of the developing auditory system. Annals of Otolaryngology. 1980,89,

303-311.12. Watkin PM, Beckman A, Baldwin M. The views of parents of hearing impaired children on the need for

neonatal hearing screening. British Journal of Audiology. 1995,29:5,259-262.13. Moore MT, Steele D. The Relationship Between Chapter 1 and Special Education Services for Mildly

Handicapped Students: A Study of the National Assessment of Chapter 1. 1988. Decision ResourcesCorporation, Washington, DC.

14. Watkins S. Long-term effects of home intervention with hearing-impaired children. American Annals ofthe Deaf 1987, 132,267-271.

15. Daemers K, Drickx JD, Van-Driessche k, Somers T, Offeciers FE, Govaerts PJ. Neonatal hearingscreening with otoacoustic emissions: An evaluation. ACTA Otorhinolaryngology-Belgium. 1996,50:3,203-209.

16. Maxon AB, White KR, Behrens TR, Vohr BR. Referral rates and cost efficiency in a universal newbornhearing screening program using transient evoked otoacoustic emissions. JoumalAmericanAcademyofAudiology. 1995, 6:4, 271-277.

17. Watkin PM. Outcomes of neonatal screening for hearing loss by otoacoustic emission. ArchivesDiseases of Children. 1996, 75:3, 158-168.

18. White KR, CulpepperB, Maxon AB, VohrBR, MaukGW. Transient evoked otoacousticemission-basedscreening in typical nurseries. International Journal Pediatric-Ofolaryngology. 1995, 33:1, 17-21.

19. Grandori F, Lutman ME. Neonatal hearing screening programs in Europe: Towards a consensusdevelopment conference. Audiology, 1996, 35:6, 291-295.

20. Oudesluys-MurphyAM, van-Straaten HL, Bholasingh R, van-Zanten GA. Neonatal hearing screening.European Journal Pediatrics. 1996, 155:6, 429-435.

21. Huynh MT, Pollack RA, Cunningham RA. Universal newborn hearing screening: Feasibility in acommunity hospital. Journal of Family Practice. 1996, 42:5, 487-490.

22. Watkin PM. Neonatal otoacoustic emission screening and the identification of deafness. ArchivesDiseases of Children. 1996, 74:1, 16-25.

23. Comerford DG, Watson C, Khan MS, Hussain SS. An assessment of the impact of screening on theearlier detection of infant hearing loss. Clinical Otola,yngology. 1995, 20:6, 536-539.

24. Parving A, Salomon G. The effect of neonatal universal hearing screening in a health surveillanceperspective—a controlled study of two health authority cfistncts. Audiology. 1996, 35:3, 158-168.

25. Vohr BR, Maxon AB. Screening infants for hearing impairment. Journal Pediatrics. 1996, 128:5, 710-4.

26. Tharpe AM, Clayton EW. Newborn hearing screening: Issues in legal liability and quality assurance.American Journal of Audiology. 1997,6:2,5-12.

27. Hawaii Legislature, Act 85 Session Lawn of Hawait, 1990, HSR 321.361-363. A Bill forNewborn HearingScreening. Honolulu, HI.

28. Johnson JL, Yuen J, Nishimoto P, Johnson RC, Johnson RL. Family-centered care: Thriving in Hawaiiunder part H. Clinics in Communication Disorders. 1994, 4:4, 254-265.

29. NIH Consensus Panel. Early Identification of Hearing Impairment in Infants and Young Children. 1993,Washington, DC.1

30. Joint Committee on Infant Hearing. Joint committee on Infant hearing 1994 position statement.Pediatrics, 1995,95:1, 152-156.

31. Yoshinaga-Itano C, SedeyA, Apuzzo M, Carey A, Day D, Coulter D. Predictors of success: The effectof early identification on the development of deaf and hard-of-hearing infants and toddlers. Presentationat National Institutes of Health Conference, May 1997.

parents to bring the baby in for screening, but they chose not to doso. When this child was 2 1/2, the family began to suspect that thechild might have a hearing loss. They consulted the pediatrician atthe age of 2 years nine months. This child was found to have abilateral severe-to-profound hearing loss with severely delayedspeech and language development. Obviously the child would havebenefited from early identification. The parent regretfully remembered vividly the earlier notification about the availability of thescreening service.

Case 3A child failed the initial hospital screening and was scheduled to

return. Despite notification letters to the parents and pediatrician, thechild was not brought in for the second screening. At the age of 11months, the pediatrician became suspicious about the child’s hearing and made a referral for a diagnostic audiological evaluation. Thechild was found to have a severe bilateral hearing loss.

SummaryHawaii has been a pioneer and national leader in implementing

universal newborn hearing screening. In fact, Hawaii is one of onlytwo states (Rhode Island is the other) which have a statewidenewborn hearing screening program in which 95% or more of allnewborns are screened. Hawaii is the best example of a trulyintegrated system of services to provide effective intervention for allinfants and toddlers who are identified as having a hearing loss.

The success of the newborn hearing screening program is measurable in two ways: 1) all available information indicates that nota single infant with hearing loss has been missed by the screeningprocess and not a single infant has been misdiagnosed as havinga hearing loss; and 2) many of the children identified with hearingloss by the newborn hearing screening program have transitionedout of the early intervention program with age-appropriate developmental and communication skills.

The success of Hawaii’s program is a tribute to the enthusiasticsupport and collaboration of legislators, pediatricians, hospital staff,and DOH personnel.

mel r. hertz MBA, CFPCertified Financial Planner

AcknowledgementThe authors wish to acknowledge the contribu

tions of Caroline Thomas, whose dedication to theNewborn Hearing Screening Program, despite massive losses in resources, has assured its continuation and success.

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Life in These Parts

A Father’s Letter to SantaMy 5-year-old boy scribbled out his Christmas

list. It’s there by the fire place. The Coke” andM&M’s”‘ are from him, in case you’re hungry.You know 5-year-olds these days. The Cheezits”are from me.

Santa, if you don’t mind. I thought I’d go aheadand leave my list, too. It’s long, but do what youcan.

It’s all I want for Christmas.

Christmas List from His FatherSanta, let my little boy grow up still believing

that he has the funniest dad in the neighborhood.Give him many close friends, both boys and

girls. May they fill his days with adventure,security and dirty fingernails.

Leave his mom and me some magic dust thatwill keep him just the size he is now. We’djust assoon he stayed 5-years-old and 3 feet, four inches.

If he must grow up, make sure he still wants tosit on my lap at bedtime and read “The Frog andthe Toad.”

If you can help it, Santa, never let him be sentinto war. His mother and I love our country, butwe love our 5-year-old boy more.

While you’re at it, give our world leaders acopy of “The Killer Angels,” Michael Shaara’sretelling of the Battle of Gettysburg. May itremind them that too many moms and dads havewept at Christmas for soldiers who died in battles

that needn’t have been fought.Let our house always be filled with slamming

doors and toilet seats, which are official soundsof little boys.

Break it to him gently, Santa, that his dad won’talways be able to carry him to bed at night orbrush his teeth for him. Teach him courage in theface of such change.

Let him understand that no matter how nice youare to everyone, the world will sometimes breakyour heart. As you know, Santa, a child’s feelingsare fragile as moth wings.

Let him become a piano player, a soccer star ora priest. Or all three. Anything but a tax-and-spend Democrat.

Give him a hunger for books, music and geography. May he be the first kid in kindergarten tobe able to find Madagascar on a map.

The kid’s a born artist, Santa, so send morecrayons. May our kitchen window and refrigerator doors be ever plastered with his sketches ofsurreal rainbows and horses with big ears.

Through the years, steer him oh so carefully tothat little girl destined to be his bride. Let hismother and me still be around when he walks herdown the aisle. If there’s ajust God, let her daddybe obscenely rich.

Grant him a heart that will cherish what hisparents did right and forgive us for the mistakeswe surely will have made over a lifetime ofraising him.

Let him not hold it against us that he was bornwith my chin and his mother’s ears. Time willteach him that these are God’s ways of girdinghim for life’s adversities.

Hold him steady on the day that he learns thetruth about you and the Easter Bunny. May hetake the news better than I did.

While you’re flying around the heavens, Santa,make sure God has heard our prayer for this child:Lead my little boy not into temptation; deliverhim from evil.

Be careful out there, Santa. And close the flueon your way up.

(Ed. This touching letter was included with agroup gift from the Kuakini Radiology Group:HowardArimoto, Donaldikeda, DonnKumasaki,Gordon Ng, DavidSakuda, Ted Watanabe, JamesYamasaki. Thanks fellars).

Physician MovesAugust:

OB Gyn man Richard Ikehara joined the Central Medical Clinic at 321 N. Kuakini St., Ste 201.Plastic surgeon Eugene Smith opened his practice at 3 locations: St. Francis Medical Plaza-West,Ste. 100; St. Francis Medical Office Bldg., Ste.301.; Plastic Surgery Center of the Pacific at 677AlaMoanaBlvd., Ste. 1011.September:

AnesthesiologistDerekKen Matsushige joinedthe Physician’s Anesthesia Service Inc. at 321 N.Kuakini St., Ste. 306.

City physician John Hall resigned Sept. 10,three months after charging that Mayor Jeremy

Harris’ administration catered to the United Public Workers’ head Gary Rodrigues by notcrackingdown on drug use by union workers.

Personal GlimpsesDavidLee Pang, 86, still in active practice after

58 years, spends 6 hours aday at his office. Davidsays, “I enjoy working. It is my hobby. Instead ofplaying golf, I come here to talk to my patients.The day goes by fast. As long as I’m healthy andmy mind is clear, I’m going to keep practicing.”

Osamu Fukuyama, 48, came to the U.S. in1968 when student protesters with Molotov cocktails took over the prestigious Tokyo Universitywhere he attended. They were protesting theVietnam War and the U.S. military presence inJapan. Osamu attended UC-Berkeley and UHSchool ofMedicine. “Medicine has changed drastically in the last 20 years, but it’s still a veryhonorable profession. There is meaning in thethings I do every day. It’s given me a lot ofsatisfaction.”

Dr Fitness Health TipsProblem: Golfer with wide feet and tight shoes.Solution: Put on shoes. Mark with ball point penthe widest point of shoe. Take off shoe. Withsharp knife make an “X” through the shoe aboutthe size of a dime. This will relieve pressure onthe first bone of your foot.Second solution: Buy the next larger size shoeand a heel spacer for the shoe.

Problem: Surfer has hamstring strain.Solution: There is no quick cure. Simple hamstring strain usually takes 3 - 6 weeks to heal. Ifin the middle of the thigh, strain heals faster. Ifvery high or very low near the knee, the straintakes longer.

Problem: Getting Back in Shape.Solution: A good rule is to take at least one fullmonth of gradual exercise for every year youhave been out of shape. If you want to try to hurry,do frequent light workouts in different sportseveryday. Example: 15-20 minutes light weightlifting 4- Sxlwk; jogging 1 mile 3 x wk; daily lightgeneral stretching and one sports game like tennis.

MiscellanyAn elderly couple died in a car accident. They

arrived in Heaven where St. Peter took them on atour of the premises. They were shown a palatialhome with swimming pool, next to a 18 hole golfcourse and in back were 3 enclosed tennis courts.“Why, we can’t afford all this,” said the husband.St. Peter: “Here in heaven, everything is free. Ofcourse you can afford it.”

They were shown the dining area where spreadbefore them was a feast with steaks, roasts, richdesserts, buttered rolls, etc. “Shouldn’t we bewatching our cholesterol levels?” asked the husband. St. Peter assured him, “You are now inHeaven. No one dies from heart problems.”

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HAWAII MEDICAL JOURNAL, VOL 56, DECEMBER 1997357

The husband turned to his wife, “Honey! If itweren’t for your oat bran muffins, we could havebeen here 10 years ago.”

While doing a locum for a doctor who did a lotof dental pre-op exams, I noted a concealed lookof disgust from the receptionist as I headed in foran easy dental pre-op.

“This one is an exotic dancer,” she warned.Knowing this didn’t really diminish the shock ofseeing the all-but-naked young woman perchedon the table with only a G-string.

I proceeded to take a BP, listen to all 18 lobesof her lungs and tried to determine if the muffledheart sounds were due to the mass of silicone orthe nervous adrenaline rushing through my ears.

When I’d completed the brief exam, she said,“Doctor, I have an embarrassing problem thatbothers me in my line of work. Ifyou could check,I think I have a hemorrhoid.”

In a flash, she deftly peeled off her G-string andwith one felt swoop tossed it right at me, strikingme on the side of the head where it promptlyhooked onto my ear before falling to my shoulder!

As it rested there unceremoniously, she gaspedand, with one hand to her mouth and the otherreaching towards me, said, “Oh, I’m so sorry, it’sjust a habit.”

To this day I know I hold the record for thelocum with the reddest face after seeing a patient.

Dr David Hepburn (Stitches Sept. ‘97)

PotpurriThe huge ship was barreling through the waters

one inky night (in the days before radar) and youcan imagine the captain’s indignation when hesaw up ahead other lights coming close.

Cholerically, he ordered the message sent ahead,“Veer off, you blasted idiot. This is a battle shipcoming toward you.”

And almost at once a message came back,“Well, think it over. This is a lighthouse comingtoward you.”

The patient sat in the dentist’s chair; head farback and mouth open. The dentist was about toinsert his instrument when the patient’s handseized the dentist’s testicle in a firm grip.

Smiling beautifically the patient said, “Nowdoctor, we’re not going to hurt each other, arewe?”

A veteran air pilot was undergoing a completephysical exam in order to qualify for a new typecommercial aircraft.

The veteran passed with flying colors and thedoctor said, “I must ask you one more psychiatricquestion. Tell me, sir, how long has it been sinceyou had a successful sexual experience with ayoung lady?”

The pilot’s eyes narrowed and he finally said,”!would say it was about 1955.”

The doctor was startled, “That long ago? Isn’tthat unusual?”

The pilot look at his wrist watch, “That’s not solong ago. It’s just 11:05 now.”

(Excerpts from Asimov Laughs Again)

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Announcement

General Practice Opened.—ln Kapahulu area by 20-year veteran of St. Francis ER. New patients welcomed; free parking; convenient hours; house calls(downtown Honolulu-Ama Haina). John WichmannWalczak MD at 750 Palani Avenue, Honolulu 96816.739-9483.Primary Care Physician.—Excellent opportunity toestablish practice on Maui. Ideal candidate will be self-motivated and have excellent clinical and interpersonal skills. Attractive cost sharing arrangement. FaxCV. to (808) 877-3146.Office Relocation.—Dr. Ronald Peroff, Queen’sPOB I, 1380 Lusitana Street, Suite 910, Honolulu, HI96813. New phone 599-NOSE (6673), Fax 599-4605.

Misc.

Latex Glove Relief.—Latex glove sensitivity protectantspray, immediate reduction of Type I irritation fromlatex gloves, duration 100+ hand washes/4/8/16 hrs.Free evaluation sample to USAIAPO address physicians. Limited time, 1 sample per office. Otherproducts: Scalp Itch Reducer gel and Skin Itch Reducer gel, soothing relief, duration varies from 8-48hrs, results vary per individual, Sahara Cosmetics,(808) 735-8081, P0 Box 10869, Honolulu, Hawaii96816-0869, USA, leave name on answering machineor send letterhead or business card to above address.

Business Opportunity

Wanted

Wanted.—Partner to join booming practice in paradise. Must have solid clinical background. BC/BPoccupational physician preferred but all qualified primary care applicants will be considered. This is anexceptional no money down” opportunity for the entrepreneurial minded practitioner. Call Dr. ScottMcCaffrey at (808) 676-5331 for more details.

Classified NoticesTo place a classified notice:

HMA members —Please send a signed and typewritten ad to the HMA office. As a benefit of membership,

HMA members may place a complimentary one-time classified ad in HMJ as space is available.Nonmembers.—Please call 536-7702 for a nonmember form. Rates are $1.50 a word with a minimum of 20

words or $30. Not commissionable. Payment must accompany written order.

Veteran Certified Petroleum Geologist.—Wishes toteam up with oil and gas investment capital finder.Excellent remuneration. (614) 453-9231 or fax (614)450-7507.

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Misc for SaIe.—Desk 60” x 30’ $50.; Credenza 71” x18’ $100, Xerox Model 5309, 1 yr old , $525. Ask forNelson 536-7702.Give-A-Way.----Burroughs Pegboard accounting system. Call Jean Frissell 536-0779.

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HAWAII MEDICAL JOURNAL. VOL 56. DECEMBER 1997

358

INDEX to the Hawaii Medical JournalVolume 56, 1997

Compiled by Marlene M. Ah Heong, Carolyn S.H. Ching and Christine Sato of the Hawaii Medical library

Keyword Index

ACCIDENTS, AVIATION. Tragedy in Guam: one doctor’schronicle [Military medicine], 56(1 l.):307ACQUIRED IMMUNODEFICIENCY SYNDROME. Ocular manifestations of the acquired immunodeficiency syndrome, 56(IO):285ADENOCARCINOMA. The association of helicobacter pyIon with intestinal type gastric adenocarcinoma in a Hawaiipopulation, 56(12):348ADVANCE DIRECTIVES. Efficacy of advance directives ina general hospital, 56(8):203AMERICAN MEDICAL ASSOCIATION. President’s message, 56(9):224ANATOMY. The integration of clinical skills and clinicalanatomy in medical education [Medical school hotline],56(4):89ANISAKIASIS. Diphyllobothriasis after eating raw salmon,56(7): 176AOKI, MITSUO. Documentary on the work of Dr MitsuoAoki: looking for families to sharetheirexperiences, 56(5): 111ARM INJURIES. Common sports injuries teen by theprimarycare physician part I: upper extremity, 56(1 l):324ARNOLD, HARRY L., JR. The Harry L. Arnold Jr-MDHawaii Medical Journal Case of the Month [Editorial],56(11):305ASIA. Seventh annual Asia Pacific military medicine conference: KualaLumpur, Malaysia [Military medicine], 56(6): 143ATI’ITUDE. Humor, humility, and a little bit of hubris: whythey maybe relevant to an incoming class of 60 medical schoolfreshmen, 56(12):345AUSTRALIA. Voluntary euthanasia in the Northern Territory-Australia, 56(3):69BACTEREMIA. Emergency department versus office settingand physician/patient kinship effects in the diagnostic andtherapeutic choices of febrile children at risk for occult bacteremia, 56(8):209BIOLOGICAL SCIENCES. The role of the basic sciences inmedical education [Medical school hotline], 56(2):32— Modifications to the problem-based learning (PBL) curriculum increase opportunities for learning basic sciences[Medical school hotline], 56(3):54CANNABIS. Federal foolishness and marijuana. 1997 [classical article], 56(4):84CARDIOLOGY SERVICE, HOSPITAL. Cardiothoracic surgery at Tripler Army Medical Center [Military medicine],56(3):58CASE MANAGEMENT. Information technology in the healthcare industry, 56(6):l44CATARACT. Current status of the treatment of cataract,56(1O):276CENTER OF EXCELLENCE IN DISASTER MANAGEMENT AND HUMANITARIAN ASSISTANCE. Disastermedicine in Honolulu [Military medicine], 56(2):33CEREBROVASCULAR DISORDERS. Stroke awarenessmonth [Editorial], 56(5):108— Honolulu Heart Program, an epidemiology study of coronary heart disease and stroke [Book review], 56(1 l):309CHILD. “KITS” for improved immunization of Kauai children, 56(5):l21— Emergency department versus office setting and physician!patient kinship effects in the diagnostic and therapeuticchoicesof febrile children at risk for occult bacteremia, 56(8):209

CLINICAL CLERKSHIP. From Hilo to Waianae a community-based clerkship [Medical school hotline], 56(8):201CLINICAL COMPETENCE. The integration ofclinical skillsand clinical anatomy in medical education [Medical schoolhotline], 56(4):89CLINICAL RESEARCH CENTER. The birth of the RCMIClinical Research Center is ajoint venture of the University ofHawaii and Kapiolani Health, 56(4):93CONGRESSES. Seventh annual Asia Pacific military medicine conference: Kuala Lumpur, Malaysia [Military medicine], 56(6): 143CORONARY DISEASE. The Honolulu Heart Program, anepidemiology study of coronary heart disease and stroke[Book review], 56(1 l):309COVER ILLUSTRATIONS. Keiki Maui, 56(l):3— Hawaiian holua sledder, 56(2):27— Damien, 56(3):5 1— Hawaiian swimmers, 56(4):83— Hawaiian surfers, 56(5): 107— Hawaiian wrestlers, 56(6): 135— Hawaiian runners, 56(7):167— Hawaiian canoe paddlers, 56(8):195— Puako, 56(9):223— Pueo, 56(l0):267— Ulu, 56(1 1):303— Dancer, 56(12):339CURRICULUM. The role of the basic sciences in medicaleducation [Medical school hotline], 56(2):32—integration ofclinical skills and clinical anatomy in medicaleducation [Medical school hotline], 56(4):89—Public health in medical education [Medical school hotline],56(7):174CYTOMEGALO VIRUS RETINITIS. Ocular manifestationsof the acquired immunodeficiency syndrome, 56(lO):285DAMIEN, FATHER, 1840-1889. Damien, 56(3):51DECISION MAKING. The death of an innocent, 56(3):59—Emergency department versus office selling and physician!patient kinship effects in the diagnostic and therapeutic choicesof febrile children at risk for occult bacteremia, 56(8):209DECISION-MAKING, COMPUTER-ASSISTED. Information technology in the health care industry, 56(6):144DELIVERY OF HEALTH CARE. Information technology inthe health care industry, 56(6):t44DEMOGRAPHY. Temporal trends in maternal characteristics and pregnancy outcomes: their relevance to the provisionof health services. Hawaii, 1979-1994, 56(6): 149— Student profile - class of 2001 at the John A. Burns Schoolof Medicine [Medical school hotlinel, 56(9):224DIABETES MELLITUS. Diabetic retinopathy [corrected andrepublished in Hawaii Med J 1997 Oct;56(I0):279-80],56(9):24l— Diabetic retinopathy [corrected and republished articleoriginally printed in Hawaii Med J 1997 Sep; 56(9): 241-4],56(10):279DIABETES MELLITUS, NON-INSULIN DEPENDENT.Non-insulin dependent diabetes mellitus: an epidemic amongHawaiians. 56(1): 14DIABETIC RETINOPATHY. Diabetic retinopathy [correctedand republished in Hawaii Med J 1997 Oct;56(10):279-80],56(9):24I— Diabetic retinopathy [corrected and republished articleoriginally printed in Hawaii Med J 1997 Sep: 56(9): 241-4],56(l0):279

DIAGNOSTIC IMAGING. Multi-center sestamibi parathyroid imaging study in Hawaii, 56(5): 114DIPHYLLOBOTHRIASIS. Diphyllobothriasis after eatingraw salmon, 56(7): 176DISASTER PLANNING. Disaster medicine in Honolulu[Military medicine]. 56(2):33DISEASE TRANSMISSION. Diphyllobothniasis after eatingraw salmon, 56(7):176DRUG AND NARCOTIC CONTROL. Federal foolishnessand marijuana. 1997 [classical article], 56(4):84EDITORIALS. Panel will study the right to doctor-assistedaid-in-dying [Editorial], 56(1):5— words of Hippocrates!, 56(l):9— Editorial, 56(2):29— D.A.D.D. - doctor assisted death with dignity [Editorial],56(3):52— Federal foolishness and marijuana. 1997 [classical article],56(4):84— Editorial, 56(4):86— Stroke awareness month [Editorial], 56(5): 108—Congratulations to Dr Reginald Ho [Editorial], 56(6):136— Patient groups call on Congress to fully fund the Food andDrug Administration [Editorial], 56(7): 168— Robert A. Nordyke MD, 56(7):168— Editorial, 56(8):197— last days of a Hawaii labor leader. 1997 [classical article],56(8): 198— Editorial, 56(9):224— catalyst model. 1987 [classical article], 56(9):226—Ophthalmology special issuepartll [Editorial], 56(I0):268— Harry L. Arnold Jr.-MD Hawaii Medical Journal Case ofthe Month [Editorial], 56(1 1):305—Commentary, 56(Il):3ll— Peer review [Editorial], 56(12):341— Humor, humility, and a little bit of hubris: why they may berelevant to an incoming class of 60 medical school freshmen,56(12):345EDUCATION, MEDICAL. The role of the basic sciences inmedical education [Medical school hotline], 56(2):32— Modifications to the problem-based learning (PBL) curriculum increase opportunities for learning basic sciences[Medical school hollineJ, 56(3):54— integration ofclinical skills and clinical anatomy in medicaleducation [Medical school hotline], 56(4):89— Implications of genetic research for medical practice andeducation [Medical school hotline], 56(6): 140—Public health in medical education [Medical school hotlinej,56(7): 174— Role of the clinical faculty in pediatric medical education[Medical school hotlineJ, 56(1 1):306EDUCATIONAL MEASUREMENT. An update on theUSMLE and performance of medical students at the John A.Burns School ofMedicine [Medical school hotlineJ, 56(l0):269EMERGENCY SERVICE, HOSPITAL. Application of informed consentprinciples in the emergency department evaluationoffebrilechildren atriskforoccultbacteremia, 56(1 1):3 13ETHICS, MEDICAL. The death of an innocent, 56(3):59EThNIC GROUPS. Student profile - class of 2001 at the JohnA. Burns School of Medicine [Medical school hotline],56(9):224EUTHANASIA. Voluntary euthanasia in the Northern Territory-Australia, 56(3):69EYE DISEASES. Ocular manifestations of the acquired im

HAWAII MEDICAL JOURNAL, VOL 56. DECEMBER 1997359

munodeficiency syndrome, 56(l0):285EYE INFECTIONS, PARASITIC. External

ophthalmomyiasis, a disease established in Hawaii, 56(l):10

EYE INJURIES. Ocular trauma, 56(10):292EYEBANKS. Corneal and refractive surgery, 56(9):252

FACULTY, MEDICAL. Role of the clinical faculty in pediatric medical education [Medical school hotlinel, 56(1 l):306

FEVER OF UNKNOWN ORIGIN. Emergency department

versus office setting and physician)patient kinship effects in

the diagnostic and therapeutic choices of febrile children atrisk, 56(8):209FOOD PARASITOLOGY. Diphyllobothriasis after eatingraw salmon, 56(7):176FORENSIC ANTHROPOLOGY. Tragedy in Guam: one

doctor’s chronicle [Military medicine], 56(1 1):307GENETICS, MEDICAL. Implications of genetic research for

medical practice and education [Medical school hotline),

56(6): 140GLAUCOMA. Glaucoma, 56(9):235GOVERNOR’S BLUE RIBBON PANEL ON LIVING AND

DYING WITH DIGNITY. D.A.D.D. - doctor assisted death

with dignity [Editorial], 56(3):52GUAM. Tragedy in Guam: one doctor’s chronicle [Military

medicine], 56(1 1):307GULBRANDSEN, CHRISTIAN L. JABSOM dean retires.

1997 [classical article], 56(6): 138HAMMAR, SHERREL L. JABSOM dean retires. 1997 [clas

sical article], 56(6):138HAND INJURIES. Common sports injuries seen by the pri

mary care physician part I: upper extremity, 56(1 1):324

HAWAII. Project caring for life—long term care funding

altemative, 56(7): 181— History of ophthalmology in Hawaii, 56(9):229

— Advances in ophthalmic plastic, reconstructive and orbital

surgery in Hawaii, 56(9):248— Ophthalmology in Hawaii 1997 and beyond, 56(9):256

— All stings considered first aid and medical treatment of

Hawaii’s marine injuries [Book review], 56(1 1):309HAWAII COALITION FOR HEALTH. The words of

Hippocrates!, 56( t):9HAWAII MEDICAL ASSOCIATION. President’s message,

56(1):5— President’s message, 56(2):30— President’s message, 56(3):54— Council highlights, 56(4):98— President’s message, 56(6):138— Council highlights, 56(6): 155— Council highlights, 56(7): 186— President’s message, 56(8): 197— President’s message, 56(9):224—Council highlights, 56(9):258— President’s message, 56(lO):268—Council highlights, 56(I0):295— Presidents message, 56(1 1):305— Presidents message, 56(l2):342HAWAII MEDICAL JOURNAL. Index to the Hawaii Medi

cal Journal, 56(12):362HAWAII MEDICAL LIBRARY. Report from the Hawaii

Medical Library, 56(5):l 12HEALTH CARE COSTS. The last days of a Hawaii labor

leader. 1997 [classical article], 56(8):l98HEALTH MAINTENANCE ORGANIZATIONS. Commen

tary, 56(ll):311HEARING DISORDERS. Newborn hearing screening in

Hawaii, 56(l2):352HELOCOBACTER PYLORI. The association ofhelocobacter

pylon with intestinal type gastric adenocarcinoma ins Hawaii

population, 56(12):348HISTORY OF MEDICINE. History of ophthalmology in

Hawaii, 56(9):229Pediatric ophthalmology and sirabisnsus manag crent in

Hawaii, 56(l0):274— Current status of the treatment of cataract, 56(10)276

HO, REGINALD. Congratulations to Dr Reginald Plo [Editm

naIl, 56(6):136HONOLULUHEARTPROGRAM.TheHonoiuioFiar:Pro

gmen. aiiepidenokgy

stroke [Book review], 56(1l):309HOSPITALS, GENERAL. Efficacy of advance directives in

a general hospital, 56(8):203HUMAN RIGHTS.Pain reliefasabasic human right. 56(8): 199

IMMUNIZATION PROGRAMS. “KITS” for improved im

munization of Kauai children, 56(5):121INDEX. Index to the Hawaii Medical Journal, 56(12):359

INFORMATION SYSTEMS. Information technology in the

health care industry, 56(6):l44INFORMED CONSENT. Application of informed consent

principles in the emergency department evaluation of febrile

children at risk for occult bacteremia, 56(1 1):3 13

INSTRUCTIONS TO AUTHORS. Hawaii Medical Journal

instructions to authors, 56(2):41— Hawaii Medical Journal instructions to authors, 56(6): 157

INSURANCECARRIERS. The wordsofHippocrates!, 56( l):9

INTERNATIONALEDUCATIONALEXCHANGE.Therole

of international medicine in medical education [Medical school

hotline], 56(l):6INTERNSHIP AND RESIDENCY. Residency spotlight on

ophthalmology [classical article], 56( lO):272

JAPANESE. The Honolulu Heart Program, an epidemiology

study of coronary heart disease and stroke [Book review],

56(1 l):309— association of helocobacter pylon with intestinal type

gastric adenocarcinoina in a Hawaii population, 56(12):348

JOHN A BURNS SCHOOL OF MEDICINE. The role of

international medicine in medical education [Medical school

hotline], 56(1):6— role of the basic sciences in medical education [Medical

school hotline], 56(2):32— Modifications to the problem-based learning (PBL) cur

riculum increase opportunities for learning basic sciences

[Medical school hotline], 56(3):54— integration ofclinical skills and clinical anatomy in medical

education [Medical school hotline], 56(4):89

— birth of the RCMI Clinical Research Center is a joint

venture of the University of Hawaii and Kapiolani Health,

56(4):93— JABSOM dean retires. 1997 [classical article], 56(6): 138

—Public health in medical education [Medical school hotline],

56(7): 174— From Hilo to Waianaeacommunity-basedclerkship [Medi

cal school hotline], 56(8):20l— Student profile - class of 2001 at the John A. Burns School

of Medicine [Medical school hotline], 56(9):224

— An update on the USMLE and performance of medical

students at the John A. Burns School of Medicine [Medical

school hotline], 56(l0):269— Role of the clinical faculty in pediatric medical education

[Medical school hotline], 56(1 1):306— Humor, humility, and a little bit of hubris: why they maybe

relevant to an incoming class of 60 medical school freshmen,

56(12):345KAPIOLANI HEALTH RESEARCH INSTITUTE. Thebirth

of the RCMI Clinical Research Center is ajoint venture of the

University of Hawaii and Kapiolani Health, 56(4):93

KAUAI. “KITS” for improved immunization of Kauai chil

dren, 56(5):12ILEGISLATION. DRUG. Federal foolishness and marijuana.

1997 [classical article], 56(4):84LETTERS TO THE EDITOR. Letters to the editor, 56(1):5

Chicken skin time, 56(2):29— [re: Hawaii Medical Journal special issues on death and

dying], 56(4):86— [re: Hawaii Medical Journal special issues on death and

dying], 56(4):86— [re: Hawaii Medical Journal special issues on death and

dying], 56(4):86— [re: Hawaii Medical Journal special issues on death andh5—.-’

— [re: Hawaii Medical Journal special issues on death and

dying], 56(4)86[ro: Hawaii Medical Journal special issues on death and

dying]. 56(4):87-—[c: Hawad hlorhaslJocroal sprain! issues on death and

— [re: Hawaii Medical Journal special issues on death and

dying], 56(4):l00— Physician-assisted dying: the coming debate, 56(5): 108

— Ire: Special issues on Ophthalmology], 56(l2):343

LICENSURE, MEDICAL. An update on the USMLE and

performance of medical students at the John A. Burns School

of Medicine [Medical school hotline], 56(tO):269

LONG-TERM CARE. Project caring for life—long term care

funding alternative, 56(7): 181MACULAR DEGENERATION. Loss of reading and central

vision due to macular diseases - therapeutic management,

advances and limitations, 56(9):245MALAYSIA. Seventh annual Asia Pacific military medicine

conference: Kuala Lumpur, Malaysia [Military medicine],

56(6): 143MANAGED CARE PROGRAMS. ThewordsofHippocrates!,

56(I):9MARINE TOXINS. All stings considered first aid and medi

cal treatment of Hawaii’s marine injuries [Book review],

56(1 l):309MATERNAL-CHILD HEALTH SERVICES. Temporal

trends in maternal characteristics and pregnancy Outcomes:

their relevance to the provision of health services. Hawaii,

1979-1994, 56(6):149MCELRATH, ROBERT. The last days of a Hawaii labor

leader. 1997 [classical articlel, 56(8): 198MEDICAL ASSISTANCE. Project caring for life—long term

care funding alternative, 56(7):I8lMEDICAL INFORMATICS APPLICATIONS. Information

technology in the health care industry, 56(6): 144METHAMPHETAMINE. Methamphetamine abuse: an over

view for health care professionals, 56(2):34MILITARY MEDICINE. Seventh annual Asia Pacific mili

tary medicine conference: Kuala Lumpur, Malaysia [Military

medicine], 56(6): 143MOTHERS. Temporal trends in maternal characteristics and

pregnancy outcomes: their relevance to the provision of health

services. Hawaii, 1979-1994, 56(6): 149MYIASIS. External ophthalmomyiasis, a disease established

in Hawaii, 560): 10NATIVE HAWAIIANS. Non-insulin dependent diabetes

mellitus: an epidemic among Hawaiians, 56(l):14NEONATAL SCREENING. Newborn hearing screening in

Hawaii, 56(12):352NORDYKE, ROBERTA. Robert A. NordykeMD, 56(7):I68

OCCULT BACTEREMIA. Application of informed consent

principles in the emergency department evaluation of febrile

children at risk for occult bacteremia, 56(11 ):3 13OPHTHALMOLOGY. History of ophthalmology in Hawaii,

56(9):229— Advances in ophthalmic plastic, reconstructive and orbital

surgery in Hawaii, 56(9):248— Ophthalmology in Hawaii 1997 and beyond, 56(9):256

— How to become an ophthalmologist: preface to Residency

spotlight on ophthalmology, 56(I0):271— Residency spotlight on ophthalmology [classical article],

56(i0):272— Pediatric ophthalmology and strabismus management in

Hawaii, 56(lO):274OPTIC NEURITIS. Recent advances in the management of

optic neuritis, 56(lO):28tORGAN PROCUREMENT. The role of the physician in the

organ donation process, 56(4):96OTITIS MEDIA. Application of informed consent principles

in the emergency department evaluation of febrile children at

risk for occult bacteremia, 56(1 l):3 13PACIFIC. Seventh annual Asia Pacific military medicine

conference: Kuala Lumpur, Malaysia [Military medicine],

56(6):143PACIFIC BIOMEDICAL RESEARCH CENTER. The birth

“thhe RCMT CIthO-al Research Cenwris aoiet,entore of the

University of Hawaii and Kapiolani Health, 56(4):93

PACIFIC DISASTER MANAGEMENT INFORMATION

NF.TWORK. Disaster medicine in Honolulu [Military n.edi

cine], 56(2):33PAIN. Pain relief an a basic huma” rib’..56(5) 199PP’PflVP(5T5 rnTcTrsvre SA.,r,

HAWAII MEDICAL JOURNAL. VOL 56, DECEMBER 1997

360

athyroid imaging study in Hawaii, 56(5): 114PARATHYROID GLANDS. Multi-center sestamibi parathyroid imaging study in Hawaii, 56(5):114PARENTS. Application of informed consent principles in theemergency department evaluation of febrile children at riskfor occult bacteremia, 56(1 1):3l3PATIENT ADVOCACY. The death of an innocent, 56(3):59PEDIATRICS. Pediatric ophthalmology and strabismus management in Hawaii, 56(10):274— Role of the clinical faculty in pediatric medical education[Medical school hotline], 56(1 l):306PEER REVIEW, RESEARCH. Peer review [Editorial),56(l2):34lPHYSICIAN’S PRACTICE PATTERNS. Emergency department versus office setting and physician/patient kinshipeffects in the diagnostic and therapeutic choices of febrilechildren at risk for occult bacteremia, 56(8):209PHYSICIAN’S ROLE. The role of the physician in the organdonation process, 56(4):96PHYSICIAN-PATIENT RELATIONS. An open letter to myson. 1996 [classical articlel, 56(2):30— Patient-physician covenant, 56(5):129— Commitment to my patients, 56(8):208PHYSICIANS. Robert A. NordykeMD, 56(7):t68PHYSICIANS, FAMILY. Common sports injuries seen bythe primary care physician part 1: upper extremity, 56(1 l):324POETRY. I can do that, 56(8):202— An island sort of Christmas, 56(12):342— Christmas ballet, 56(12):342— Thank you for Christmas joys, 56(12):343POPULATION SURVEILLANCE. “KITS” for improvedimmunization of Kauai children, 56(5): 121PREGNANCY. Temporal trends in maternal characteristicsand pregnancy outcomes: their relevance to the provision ofhealth services. Hawaii, 1979-1994, 56(6):149PREGNANCY OUTCOME. Temporal trends in maternalcharacteristics and pregnancy Outcomes: their relevance to theprovision of health services. Hawaii, 1979-1994, 56(6): 149PREVALENCE. Non-insulin dependent diabetes mellitus: anepidemic among Hawaiians, 56(1): 14PROBLEM-BASED LEARNING. Modifications to the problem-based learning (PBL) curriculum increase opportunitiesfor learning basic sciences [Medical school hotline], 56(3):54—From Hilo to Waianae a community-based clerkship [Medical school hotline), 56(8):20IPUBLIC HEALTH. Public health in medical education [Medical school hotline], 56(7):174PUBLIC OPINION. Rxemedy survey of 30,000 Americansage 55 and over indicates strong support for the right to die,56(3):74RADIOLOGY. Tragedy in Guam: one doctor’s chronicle[Military medicine], 56(l1):307RELIEF WORK. Disaster medicine in Honolulu [Militarymedicine], 56(2):33RELIGION AND MEDICINE. The death of an innocent,56(3):59RESEARCH. The birth of the RCMICIinicaI Research Centeris a joint venture of the University of Hawaii and KapiolaniHealth, 56(4):93RETINAL DETACHMENT. Flashes, floaters, retinal tearsand retinal detachment, 56(9):238RETINAL PERFORATIONS. Flashes, floaters, retinal tearsand retinal detachment, 56(9):238RETINAL VEIN OCCULSIONS. Retinal venous occlusivedisease, 56(10):289RETINOPATHY OF PREMATURITY. Retinopathy of prematurity, 56(9):240RIGHT TO DIE. Panel will study the right to doctor-assistedaid-in-dying [Editorial], 56(1 ):5— D.A.D.D. - doctor assisted death with dignity [Editorial],56(3):52— Assisted suicide in Switzerland: when is it permitted?,56(3):63— Voluntary euthanasia in the Northern Territory-Australia,56(3):69— Rxemedy survey of 30,000 Americans age 55 and overindicates strong support for the right to die, 56(3):74

RISK FACTORS. Glaucoma, 56(9):235SALMON. Diphyllobothriasis after eating raw salmon,56(7): 176SENSITIVITY AND SPECIFICITY. Multi-center sestamibiparathyroid imaging study in Hawaii, 56(5): 114SPORTS MEDICINE. Common sports injuries seen by theprimary care physician part I: upper extremity, 56(1 I):324STOMACH NEOPLASMS. The association of helocobacterpylon with intestinal type gastric adenocarcinoma in a Hawaiipopulation. 56(I2):348STRABISMUS. Pediatric ophthalmology and strabismusmanagement in Hawaii, 56(10):274STUDENTS, MEDICAL. Student profile-class of 2001 at theJohn A. Burns School of Medicine [Medical school hotline],56(9):224— update on the USMLE and performance of medical students at the John A. Burns School of Medicine [Medicalschool hotline], 56(10):269— Humor, humility, and a little bit of hubris: why they may berelevant to an incoming class of 60 medical school freshmen,56( 12):345SUBSTANCE ABUSE. Methamphetarnine abuse: an overview for health care professionals, 56(2):34SUICIDE, ASSISTED. Panel will study the right to doctor-assisted aid-in-dying [Editorial], 56(1 ):5— D.A.D.D. - doctor assisted death with dignity [Editorial],56(3):52— Assisted suicide in Switzerland: when is it permitted?,56(3):63— Voluntary euthanasia in the Northern Territory-Australia.56(3):69SURGERY. EYE. Corneal and refractive surgery, 56(9):252SURGERY. PLASTIC. Advances in ophthalmic plastic, reconstructive and orbital surgery in Hawaii, 56(9):248SWITZERLAND. Assisted suicide in Switzerland: when is itpermitted?, 56(3):63TECHNETIUMTC99MSESTAMIBI.Multi-centersestamibiparathyroid imaging study in Hawaii, 56(5):I14TELEMEDICINE. Telemedicine today, 56(43:90TERMINALLY ILL. Documentary on the work of Dr MitsuoAoki: looking for families to share their experiences, 56(5): 111TREATMENT REFUSAL. The death ofan innocent, 56(3):59TRIPLER ARMY MEDICAL CENTER. Cardiothoracic surgery at Tripler Army Medical Center [Military medicine],56(3):58UNITED STATES FOOD AND DRUG ADMINISTRATION. Patient groups call on Congress to fully fund the Foodand Drug Administration [Editorial], 56(7): 168VITILIGO. A case report of extensive vitiligo, 56(23:37VITREOUS BODY. Flashes, floaters, retinal tears and retinaldetachment, 56(9):238WONG, ROBERT T. The catalyst model. 1987 [classicalarticle], 56(9):226WONG, STEPHEN. How to become an ophthalmologist:preface to Residency spotlight on ophthalmology, 56(1 0):27 1— Residency spotlight on ophthalmology [classical article],56(103:272WOUNDS AND INJURIES. All stings considered first aidand medical treatment of Hawaii’s marine injuries [Bookreviewl, 56(1l):309YANAGLMACHI, RYUZO. Ryuzo Yanagimachi, PhD: aworld class scientist [Medical school hotline], 56(5): 113

Author Index

AH HEONG MM. Index to the Hawaii Medical Journal,56( l2):359ALEXANDER GR. Temporal trends in maternal characteristics and pregnancy outcomes: their relevance to the provisionof health services. Hawaii, 1979-1994. 56(6): 149ALVARADO El. Role of the physician in the organ donationprocess, 56(4):96AMERICAN MEDICAL ASSOCIATION. Commitment tomy patients, 56(8):208ARAKAKI R. Non-insulin dependent diabetes mellitus: anepidemic among Hawaiians, 56(1): 14BARUFFI G. Temporal trends in maternal characteristics and

pregnancy outcomes: their relevance to the provision ofhealthservices. Hawaii, 1979-1994, 56(6): 149BASS JW. Diphyllobothriasin after eating raw salmon,56(7): 176BAUMAN KA. Public health in medical education [Medicalschool hotline], 56(7):l74BEDDOW R. Non-insulin dependent diabetes mellitus: anepidemic among Hawaiians, 56(1): 14BERG B. Disaster medicine in Honolulu [Military medicine],56(23:33— Seventh annual Asia Pacific military medicine conference:Kuala Lumpur. Malaysia [Military medicine], 56(6):143BERG NB. Tragedy in Guam: one doctor’s chronicle [Military medicine], 56(l1):307BOYCHUK RB. Emergency department versus office nettingand physician/patient kinship effects in the diagnostic andtherapeutic choices of febrile children at risk for occult bacteremia, 56(8):209BREINICH J. Report from the Hawaii Medical Library,56(5):112CAMARA JG. Advances in ophthalmic plastic, reconstructive and orbital surgery in Hawaii, 56(9):248CARR TG. Cardiothoracic surgery at Tripler Army MedicalCenter [Military medicine], 56(33:58CASE C. Rxemedy survey of 30,000 Americans age 55 andover indicates strong support for the right to die, 56(3):74CASSEN JH. Ocular trauma, 56(10):292CATALDI S. Rxemedy survey of 30,000 Americans age 55and over indicates strong support for the right to die, 56(3):74CATI’S AB. [re: Hawaii Medical Journal special issues ondeath and dying], 56(4):87CHANG Y. Association of helocobacterpylori with intestinaltypegastricadenocarcinomainaHawaiipopulation,56(12):348CHAPLIN G. Robert A. Nordyke MD, 56(7):I68CHAR P. Association of helocobacter pylon with intestinaltype gastric adenocarcinomainaHawaii population, 56(12);348CHEONG H. Association of helocobacter pylon with intestinal type gastric adenocarcinoma in a Hawaii population,56(123:348CHEUNG AHS. Multi-center sestantibi parathyroid imagingstudy in Hawaii, 56(5):I 14CHING CSH. Index totheHawaii MedicalJournal, 56(l2):359COELMN. Multi-center sestamibi parathyroid imaging studyin Hawaii, 56(5):1l4DANIEL Si. Information technology in the health care industry, 56(63:144DEFEO VJ. Ryuzo Yanagimachi, PhD: a world class scientist[Medical school hotline], 56(5):I 13DEMERS DM. Diphyllobothriasis after eating raw salmon,56(7): 176DROUILHET JH. Flashes, floaters, retinal tears and retinaldetachment, 56(93:238— Retinopathy of prematurity, 56(93:240— Diabetic retinopathy [corrected and republished in HawaiiMcdi 1997 Oct;56(10):279-80], 56(93:241— Diabetic retinopathy, 56(9): 241-4], 56(103:279EASAD. Birth of the RCMI Clinical Research Center isajointventure of the University of Hawaii and Kapiolani Health,56(4):93ELIASHOF BA. [re: Hawaii Medical Journal special issues ondeath and dying], 56(4):86FAULKNER GD. Current status of the treatment of cataract,56(103:276FLOWERS R. I can do that, 56(83:202FLOWERS RS. An island sort of Christmas, 56(I2):342— Christmas ballet, 56(I2):342— Thank you for Christmas joys, 56(12):343FONTANILLA L JR. death of an innocent, 56(33:59FRAZIER CA. Letters to the editor, 56(13:5FUDDY Li. Temporal trends in maternal characteristics andpregnancy outcomes: their relevance to the provision of healthservices. Hawaii, 1979-1994, 56(6): 149GEBAUER PW. [re: Hawaii Medical Journal special issues ondeath and dying], 56(4):86GOFF ML. External ophthalmomyiasis, a disease establishedin Hawaii, 56(1): 10GOLDSTEIN N. Panel will study the right to doctor-assisted

HAWAII MEDICAL JOURNAL, VOL 56, DECEMBER 1997361

aid-in-dying [Editorial], 56(1):5— Editorial, 56(2):29— D.A.D.D. - doctor assisted death with dignity [Editorial],

56(3):52— Editorial, 56(4):86— Stroke awareness month [Editorial], 56(5): 108

— Congratulations to Dr Reginald Ho [Editorial], 56(6): 136

— Patient groups call on Congress to fully fund the Food and

Drug Administration [Editorial], 56(7): 168Editorial, 56(8):197

— Editorial, 56(9):224—Ophthalmology special issuepartll [Editorial], 56(lO):268

— Harry L. Arnold Jr-MD Hawaii Medical Journal Case of

the Month [Editorial], 56(1 1):305— All stings considered first aid and medical treatment of

Hawaii’s marine injuries [Book review], 56(1 1):309

— Peer review [Editorial], 56(l2):341GREENE GM. From Hilo to Waianae a community-based

clerkship [Medical school hotline], 56(8):201

GREENWOOD F. Birth of the RCMI Clinical Research

Center is a joint venture of the University of Hawaii and

Kapiolani Health, 56(4):93HASTINGS JE. Telemedicine today, 56(4):90

HEINIZ Li.. Efficacy of advance directives in a general

hospital, 56(8):203HEW E. Multi-center sestamibi parathyroid imaging study in

Hawaii, 56(5):1 14HOUK JH. [re: Hawaii Medical Journal special issues on

death and dying], 56(4): 100HOWARD L. Presidents message, 56(1 1):305

— Presidents message, 56(12):342HUTCHJNSON JW. Diphyllobotisriasis after eating raw

salmon, 56(7):176ING MR. Pediatric ophthalmology and strabismus manage

ment in Hawaii, 56(10):274IZUTSU S. JABSOM dean retires. 1997 [classical article],

56(6):138— Student profile - class of 2001 at the John A. Burns School

of Medicine [Medical school hotline], 56(9):224

JOHNSON JL. Newborn hearing screening in Hawaii,

56( 12):352JOHNSON RL. Newborn hearing screening in Hawaii,

56(12):352JONES SD. Cardiothoracic surgery at Tripler Army Medical

Center [Military medicine], 56(3):58KASSIRER JP. Federal foolishness and marijuana. 1997

[classical article], 56(4):84KASUYART.Integrationofclinicalskillsandclinicalanatomy

in medical education [Medical school hotline], 56(4):89

KATSARSKY LG. Project caring for life—long term care

funding alternative, 56(7):181KIMURA R. Council highlights, 56(4):98

— Council highlights, 56(6): 155— Council highlights, 5 6(7): 186— Council highlights, 56(9):258— Council highlights. 56(l0):295KIPNIS K. Physician-assisted dying: the coming debate,

56(5): 108KOKAME GT. Loss of reading and central vision due to

macular diseases - therapeutic management, advances and

limitations, 56(9):245KORTVELESY S. Recent advances in the management of

optic neuritis, 56(10):281KRAMER KJ. Public health in medical education [Medical

school hotline], 56(7):174KUNTZNL. NewbomhearingscreeninginHawaii, 56(l2):352

LEHMAN CW. [re: Hawaii Medical Journal special issues on

death and dying], 56(4):86MADANAY LD. Multi-center sestamibi parathyroid imaging

study in Hawaii, 56(5): 114MANEA SJ. “Kl’l’S” for improved immunization of Kauai

children, 56(5):121MELISH J. Integration of clinical skills and clinical anatomy

in medical education [Medical school hotline], 56(4):89

MEYERS AD. Words of Hippocrates!, 56(l):9

MITSUNAGA RY. Role of the clinical faculty in pediatric

medicai education [Medical school hotline]. 56(1 1) :306

MOORE WF JR. [re: Hawaii Medical Journal special issues

on death and dying], 56(4): 86MOR JM. Temporal trends in maternal characteristics and

pregnancy outcomes: their relevance to the provision of health

services. Hawaii, 1979-1994, 56(6):149MORGAN El. Role of international medicine in medical

education [Medical school hotline], 56(l):6

MYERS GB. Diphyllobothriasis after eating raw salmon,

56(7): 176NAGUWA OS. Update on the USMLE and performance of

medical students at the John A. Bums School of Medicine

[Medical school hotline], 56(10):269NELLSTEIN ME. Cardiothoracic surgery at Tripler Army

Medical Center [Military medicine], 56(3):58

NELSON M. Integrationof clinical skills and clinical anatomy

in medical education [Medical school hotline], 56(4):89

ONAKA AT. Temporal trends in maternal characteristics and

pregnancy outcomes: their relevance to theprovision ofhealth

services. Hawaii, 1979-1994, 56(6): 149OSTERLUND H. Pain relief asabasic human right, 56(8):199

PELKE S. Birth of the RCMI Clinical Research Center is a

joint venture of the University of Hawaii and Kapiolani

Health, 56(4):93PERRON MB. Voluntary euthanasia in the Northern Terri

tory-Australia, 56(3):69PE’I]INELLID. Residency spotlight on ophthalmology [clas

sical article], 56(10):272PORTISJM. [re: SpecialissuesonOphthalmology), 56(12):343

PROCHAZKA El. Information technology in the health care

industry, 56(6):144RAYNER MD. Role of the basic sciences in medical educa

tion [Medical school hotline], 56(2):32REPPUN JIF. Catalyst model. 1987 [classical article],

56(9):226SAMS WM JR. Open letter to my son. 1996 [classical article],

56(2):30SATO C. Index to the Hawaii Medical Journal, 56(l2):359

SCHAR M. Assisted suicide in Switzerland: when is it permit

ted?, 56(3):63SCHATZ I. Humor, humility, and a little bit of hubris: why

they maybe relevant loan incoming class of 60 medical school

freshmen, 56(l2):345SCOGGIN JF. Common sports injuries seen by the primary

care physician part I: upper extremity, 56(1 1):324

SHIM WKT. [re: Hawaii Medical Journal special issues on

death and dying], 56(4):100SHIMODA SS. Association of helicobacter pylon with intes

tinal type gastric adenocarcinoma in a Hawaii population,

56(12):348SIA CCI. Newborn hearing screening in Hawaii, 56(12):352

SKIDMORE H. Birth of the RCMI Clinical Research Center

is a joint venture of the University of Hawaii and Kapiolani

Health, 56(4):93SMYSER A. Last days of a Hawaii labor leader. 1997 [clas

sical article], 56(8): 198SPANGLER JS. President’s message, 56(1):5

— President’s message, 56(2):30— President’s message, 56(3):54— President’s message, 56(6):l38— President’s message, 56(8):l97— President’s message, 56(9):224— President’s message, 56(lO):268

STODD RT. Weathervane, 56(l):22— weathervane, 56(2):46— weathervane, 56(3):78— weathervane, 56(4):102— weathervane, 56(5):130— weathervane, 56(6):l62— weathervane, 56(7):l90— weathervane, 56(8):2l8— Ophthalmology in Hawaii 1997 and beyond, 56(9):256

— weathervane, 56(9):262— weathervane, 56(l0):298— Commentary, 56(1l):3l 1— weathervane, 56(lI):334SUGIKI S. Glaucoma, 56(9):235

TAM EK. Implications of genetic research for medical prac

tice and education [Medical school hotline], 56(6):140

TAM LQ. Modifications to the problem-based learning (PBL)

curriculum increase opportunities for learning basic sciences

[Medical school hotline], 56(3):54TROCKMAN C. Birth of the RCMI Clinical Research Center

is a joint venture of the University of Hawaii and Kapiolani

Health. 56(4):93VAN DER VORT E. Chicken skin time, 56(2):29

VAREZ D. Pueo, 56(lO):267VAREZ D. Keiki maui, 56(l):3— Hawaiian holua sledder, 56(2):27— Damien, 56(3):5 1— Hawaiian swimmers, 56(4):83— Hawaiian surfers, 56(5):l07—Hawaiian wrestlers, 56(6):135— Hawaiian runners, 56(7): 167— Hawaiian canoe paddlers, 56(8):195— Puako, 56(9):223— Ulu, 56(1 l):303— Dancer, 56(12):339WEE TA. Case report of extensive vitiligo, 56(2):37

WENNER WB. [re: Hawaii Medical Journal special issues on

death and dying], 56(4):86WHEELER MS. Multi-center sestamibi parathyroid imaging

study in Hawaii, 56(5): 114WHITEKR.Newbornhearing screeningin Hawaii,56(12):352

WHITE RL. Honolulu Heart Program, an epidemiology study

ofcoronary heart disease and stroke [Book review], 56(1 l):309

WOLKOFF DA. Methamphetamine abuse: an overview for

health care professionals, 56(2):34WONG BMW. Ocular manifestations of the acquired immu

nodeficiency syndrome, 56(10):285WONG LML. Multi-center sestamibi parathyroid imaging

study in Hawaii, 56(5): 114WONG RT. History of ophthalmology in Hawaii, 56(9):229

— How to become an ophthalmologist: preface to Residency

spotlight on ophthalmology, 56( 10):27l

WONG VKW. Retinal venous occlusive disease, 56(10):289

YAIvIAMOTO OK. Corneal and refractive surgery, 56(9):252

YAMAMOTO LG. Emergency department versus office set

ting and physician/patient kinship effects in the diagnostic and

therapeutic choices of febnile children at risk for occult bacte

remia, 56(8):209— Application of informed consent principles in the emer

gency department evaluation of febnile children at risk for

occult bacteremia, 56(1 1):3 13YOKOYAMA HN. News and notes, 56(l):19

— News and notes, 56(2):42— News and notes, 56(3):75— News and notes, 56(4):99— News and notes, 56(5):l25— News and notes, 56(6): 158— News and notes, 56(7):! 88— News and notes, 56(8):216— News and notes, 56(9):259— News and notes, 56(10):296— News and notes, 56(1 l):33 1— News and notes, 56(!2):357YOSHIMOTO CM. External ophthalmomyiasis, a disease

established in Hawaii, 56(l):!0

HAWAS MEDICAL JOURNAL, VOL 56, DECEMBER 1997

362

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