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We extend our deepest appreciation to all the peer

review volunteers who have contributed to the

Journal making it what it is today.

Milton]. Ackerman MD Norman Goldstein MD James Lumeng MD Randy Roth JD

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HAWAII MEDICAL

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Published monthly by the Hawaii Medical Association

Incorporated in 1856 under the Monarchy 1360 South Beretania, Suite 200 Honolulu, Hawaii 96814-1520

Phone (808) 536-7702; Fax (808) 528-2376

Editors Editor: Norman Goldstein MD

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

Editorial Board John Breinich MLS, Satoru Izutsu PhD,

Douglas G. Massey MD, Myron E. Shirasu MD, FrankL. Tabrah MD, Alfred D. Morris MD

Journal Staff Editorial Assistant: Drake Chinen

Officers President: Inam Ur Rahman MD

President-Elect: Patricia Lanoie Blanchette MD Secretary: Thomas Kosasa MD Treasurer: Paul DeMare MD

Past President: Sherrel Hammar MD

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The Journal cannot be held responsible for opinions expressed in papers, discussion, communications or advertisements. The advertising policy of the Hawaii Medical Journal is governed by the rules of the Council on Drugs of the American Medical Association. The right is reserved to reject material submitted for editorial or advertising columns. The Hawaii Medical Journal (USPS 237640) is published monthly by the Hawaii Medical Association (ISSN 00!7-8594), 1360 South Beretania Street, Suite 200, Honolulu, Hawaii 96814-!520.

Postmaster: Send address changes to the Hawaii Medical Journal, 1360 South BeretaniaStreet, Suite 200, Honolulu, Hawaii 96814. Periodical postage paid at Honolulu, Hawaii.

Nonmember subscriptions are $25. Copyright 2004 by the Hawaii Medical Association. Printed in the U.S.

Contents Hawaii Medical Journal Peer Review Panel List ................................................... 358

Editorial: Peer Review Panel & Translating Services in Hawaii Norman Goldstein MD ........................................................................................... 360

Book Review: Cross-Cultural Medicine Alfred D. Morris MD .............................................................................................. 361

Catastrophic Antiphospholipid Syndrome; A "CATASTROPHIC" Case of Systemic Lupus Erythematosus Jefferson R. Roberts MD and David R. Finger MD .................................................... 362

Problem Solving in Health Care: The Center for Health Outcomes Walton Shim MD, FACS, Steven H. Shaha PhD, DBA, and Bonnie Castonquay RN, MBA ............................................................................ 365

Medical School Hotline: Multimedia Solutions in a Problem-Based Learning Curriculum Jill Omori MD and Joshua Jacobs MD .................................................................... 369

Cancer Research Center Hotline: The Role of Polyamines in Human Cancer: Prospects for Drug Combination Therapies Andre S. Bachmann PhD ......................................................................................... 371

Index to Hawaii Medical Journal, Volume 63, 2004 Carolyn S.H. Ching MA, ML/S and Marlene M.A. Cuenca MLIS ................................ 375

Classified Notices ............................................................................................................... 381

Weathervane Russell T. Stodd MD ............................................................................................................ 382

Cover art by Dietrich Varez, Volcano, Hawaii. All rights reserved by the artist.

UH Rainbow Football

A design made for benefit of the UH football team.

-HAWAII MEDICAL JOURNAL, VOL 63, DECEMBER 2004 359

~ Editorial

Peer Review Panel

Translating Services in Hawaii

Norman Goldstein MD, FACP Editor, Hawaii Medical Journal

Peer Review Panel No peer reviewed Journal can exist without a panel of authorities

who are willing to take the time to read a manuscript, critique it, and

return it promptly. Our panel consists of very dedicated generalists

and specialists- members from the Hawaii Medical Association as

well as invited non-members. Some of the newer specialized peer

reviewers are experts in Barometric Medicine, Addiction Psychiatry,

Forensic Pathology, Pain Medicine, and Geriatric Medicine. (See

list of Peer Review Volunteers on p. 358)

The Editorial Board and I thank our peer reviewers for their con­

tinued service to the Journal.

Translating Services in Hawaii When I receivedCross-Cultura!Medicine, edited by Judy-Ann Bigby,

M.D., for a possible book review for the Journal, I thought of AI right

away. Al Morris, M.D., has practiced internal medicine in Hawaii

for more than 30 years. I knew him as a cardiologist /internist at

the Honolulu Medical Group. With his years of caring for patients

of all backgrounds and languages, now retired, I thought he would

give us an objective review of the problem, an ever-increasing one

here in Hawaii. That he did with his review on page 361. Mahalo

nui loa, merci, grazie, gracias, danke schon, dziekuje, asante, tack,

spasido Herr Professor Morris.

Practicing in Honolulu's Chinatown, I confront the problems of

translation services several times every day. Sometimes a patient will

come in with two or three friends or relatives who offer their help,

compounding the history, examination and recommended treatments.

Sometimes a patient will come in with his cell phone to call a son

or daughter who is at work attempting to serve as translator. As AI

Morris points out in this book review, non-family members are the

best translators. But the very best translators are professional ones

trained in medical problems.

For your interest, we did some investigational reporting about

the various payments for translation services in Hawaii:

• Medicare covers translation services only for Psychiatry.

• Kaiser Permanente system offers translations in house.

• Medicaid does cover services. Primary care physicians must

make a referral and may need prior authorization.

• Queen's Health Systems - Healthcare: no payments.

• HMSA: no payments.

Hawaii has the following primary language translators available

24/7: Fortunately, we have Helping Hands Hawaii, which is the most

commonly used translating service. Helping Hands Hawaii is a

nonprofit organization that sponsors the Bilingual Access Line

(BAL). Their professional interpreters have been trained in medi­

cal ethics , maintaining accuracy, confidentiality and neutrality in all

of their services. At this time, the following language translators

are available on Oahu: Cambodian, Cantonese, French, German ,

Ilokano, Japanese, Korean, Kosraen, Laotian, Mandarin, Marshal­

lese, Portuguese, Samoan, Spanish, Tagalog, Thai, Tongan, Trukese

(Chuuk), Vietnamese, & Visayan.

Neighbor island translation can be performed via the telephone

by calling Jessica or Mary at 536-7234. Should an interpreter be

required on-location, a bilingual access line will provide a translator

on your island, or might even fly a BAL interpreter in at the patient's

expense. Additionally, secondary language translation services are available

for the following languages:

Afghanistan Carolinian Fuzhou Kashmiri

Farsee Chamorro Georgian Kiribati

Pashto Chung Sam Greek Kurdish

African Cook Island Haitian Creole Lung Du

Nuev Maori Hakkanese Malay

Dinka Creole Hawaiian Maori

Shilluki Croatian Hebrew Marianas

Moru Czech Hindi Nepalese

Swahili Danish Hmong Norwegian

American Sign Dutch Hungarian Pakistan (Urdu)

Language Farsee Ibanog Palau (Belau)

Arabic Persian Ilongo Pangasinan

ASL Fijian Indonesian Pashto

Bengali Finnish Iran (Farsee) Persian (Farsee)

Bulgarian Flemish Italian Polish

Burmese Fukien Javanese Ponape (Pohnpeian)

-HAWAII MEDICAL JOURNAL. VOL 63 , DECEMBER 2004

360

Pundi Sign Language Tahitian Turkish Punjabi Singhalese TaiShun Tuvalu Romanian Slovak Taiwanese Urdu Rota Solomon Islands Tamil Yap Russian Swahili TcheoChau Yiddish Serbo-Croatian Swedish Tibetan Yugoslavian Shanghaiese Szechuan Tokilau

These translators are not employees of the Bilateral Access Line, so the patient must arrange for the fees for services on an individual basis. Helping Hands Hawaii with the Bilingual Access Line, is located at 2101 North Nimitz Highway in Honolulu, HI 96819. The phone is 808-526-9724; fax is 808-524-4389, and e-mail address mail to: bal@ helpinghandshawaii.org.

Readers of the Journal should be aware of the new publication, the American Journal of Multicultural Medicine; volume I, No. I, 2004 was just published. Interesting articles in this first issue include Type II Diabetes: confronting the multicultural challenges; Allergic Rhinitis: cultural issues and diagnosis and management; and increasing diversity in clinical trial populations, a primary care opportunity. The web site is http://www.multiculturalmedicine. corn/.

The mission of this new publication is "to heighten awareness of and provide a forum for the racial, ethnic, and cultural perspectives that will improve communication and positive! y impact patient care, medical practices, and clinical outcomes." Robert C. Like, MD, Associate Professor & Director of the Center for Healthy Families and Cultural Diversity at the Robert Wood Johnson Medical School in New Brunswick, New Jersey, is the series editor.

ILl Book Review

Cross-Cultural Medicine

Edited by Judyann Bigby MD Illustrated. Appendix. References. Index. Pp ix 289. American College of Physicians I Philadelphia. 2003

Paperback $38.00

Book Review by Alfred D. Morris MD

The concepts and problems of cross-cultural medical practice are certainly familiar to any practicing physician in Hawaii. Known for and generally conceded to have the most diverse population in the United States and perhaps in the world for that matter, Hawaii has much to offer in this arena. Although noted for its ethnic toler­ance, the state probably has as much prejudice and lack of cultural understanding as any other area of comparable size and density of population. From the vantage point of forty-seven years living in this my adopted home state and practicing medicine here for over thirty years of that time, I gladly accept the thesis of this book as a much needed wake-up call for medical students, residents and practitioners, not to mention the most important group of all, the

professors and teachers of medicine. Nurses, social workers, every employee and employer, every inhabitant and tourist in fact may profit by a perusal of this study with contributions by a cross-section of educators. A nurse, two anthropologists, a Doctor of Education, another PhD, and five physicians, two of whom have MPHs, make for an eclectic set of experts. Most are from the New England area and the majority are physicians.

An excellent first chapter by the Editor lays out the ground work. Each of the subsequent six chapters, by a different contributor or set of contributors, focuses on a specially defined group of particular importance because of its being disadvantaged, oppressed, or dif­ferent culturally. Language is often the major problem. The eighth chapter addresses the role of spirituality and religion in shaping disease concepts and behaviors, with multiple examples. The final chapter by Dr. Bigby, attempts to energize the medical community to cope with the challenges which seem to be almost insurmount­able.

While I applaud the efforts, recognize the validity of the arguments, and support the needs expressed in this book, I feel constrained to point out some of the failings as well. The difficulties of achieving the ideal conditions desired are only briefly mentioned and viable approaches/solutions are given minimal attention. The theme of the book seems to be "a voice crying in the wilderness," with no help given for the listeners as to just how to get out of the "wilderness." In a pertinent example the author explains at length how a physi­cian must have a capable, medically trained, non-family member interpreter in order to give quality care to a patient who is perhaps illiterate, does not speak the same language, and has a totally dif­ferent concept of illness, the methods of care, and the role of the family. It is an ideal which is not compatible with the practice of a busy practitioner who needs to see patients on a very short allot­ment of time and, as pointed out, often is not reimbursed for such an interpreter. Indeed in any place other than the largest medical centers in major metropolitan areas such resources are rarely avail­able. The solo physician, and many groups of physicians, faced with this problem may do what little he/she can, but does not have the wherewithal to deal with the situation. The economic/time resources are not available to cope with an unrealistic expectation. The number of languages seems nearly infinite, the number of cultures beyond counting, and indeed each individual even in one's own culture is unique in beliefs and understanding. The best physicians try to cope with this situation, but if failure ensues must we fall on our scalpels screaming "communication is our greatest problem?"

A second difficulty I have with the book is the repeated use of the politically correct mantra against "profiling", "stereotyping", "pigeon-holing" and the like. Why spend many, many pages of statistical numbers characterizing specific groups, ethnic or other­wise, if we are not to view these groups as special, to be carefully scrutinized in regard to some specific parameters. In the name of sound public health it has even been recommended that all of certain groups undergo vaccination because we are unable to document reli­ably who has or has not been vaccinated. If we know that certain groups have a high incidence of tuberculosis or Hansen's disease, should we look at all patients, whether in that group or not, with the same intensity and suspicion? We are taught that pigeon-holing

See "Cross-Cultural Medicine" p. 370 -HAWAII MEDICAL JOURNAL, VOL 63, DECEMBER 2004

361

Catastrophic Antiphospholipid Syndrome;

A "CATASTROPHIC" Case of Systemic Lupus Erythematosus

The opinions and assertions contained herein are those of the authors and not to be construed as official policy of the Depart­ment of the Army or Department of Defense.

Authors: - Resident, Department of Medicine, Tripier Army Medical Center, Honolulu, HI 96859 (J.R.R.) - Chief, Rheumatology Service, Tripier Army Medical Center, Honolulu, Hl96859 (D.R.F.)

Correspondence to: MCHK-DM, Jefferson R. Roberts MD 1 Jarrett White Road TAMC, HI 96859 Ph: ( 808) 488-0301 Fax: (808) 433-2707 Email: jefferson.roberts@haw. amedd.army.mil

Abstract Less than 1% of patients with the antiphospholipid antibody syndrome (APS) can develop multiple, si­multaneous organ-system thromboembolic disease, which is referred to as the catastrophic antiphospholipid antibody syndrome (CAPS). Roughly one-half of these patients have systemic lupus erythematosus (SLE). Factors known to precipitate CAPS include infection, surgery, trauma, neoplasia, anticoagulation withdrawal, obstetric complications, and SLE flares. Optimal treatment includes anticoagulation and high-dose corticosteroids, although IVIG and plasma exchange may also have a role. The overall mortality of CAPS is roughly 50%, but prompt clinical recognition of this rare but devastating syndrome may lead to improved outcomes.

Catastrophic antiphospholipid antibody syndrome

(CAPS) is a rare clinical subset of the antiphospho­

lipid antibody syndrome (APS), occurring in less than

1% of patients. This syndrome presents acutely with

multi-organ thrombosis and failure, with an associ­

ated 50% mortality rate. We describe an illustrative

case and discuss risk factors, clinical features and

treatment options for this uncommon yet devastating

syndrome.

Case Report A37 year-old Caucasian female presented to our facil­

ity with a diagnosis of systemic lupus erythematosus

(SLE). Her disease was manifested previously by

arthritis, pleurisy, Raynaud's phenomenon, hypo­

complementemia, positive autoantibodies (antinuclear,

double-stranded DNA, and ribonucleoprotein) and a

positive lupus anticoagulant test without prior throm­

botic events. Her disease was stable on hydroxychloro­

quine and low-dose prednisone. Several months later,

she presented to her primary care clinic with symptoms

of dysuria and a urinalysis that revealed pyuria with

bacteruria. She was treated with sulfamethoxazole/tri­

methoprim, but presented at our institution three days

later complaining of nausea, vomiting, low-grade fever

and diffuse abdominal discomfort. Physical examination revealed mild tachycardia,

fever to 101.0 F, and diffuse abdominal tenderness -

without organomegaly or peritoneal signs. She was

neurologically intact and her skin exam did not reveal

cyanosis, livedo reticularis, petechiae or purpura.

Laboratory studies revealed a normal white blood cell

count of 5,900 per mm3 (3.5-11.0), low hemoglobin

5.7 g/dL(ll.7-15.7) and hematocrit 15% (35.1-47.1),

elevated mean corpuscular volume 112 fL (80-100),

and low platelet count of 113,000 ( 150,000-440,000).

The peripheral smear showed polychromasia, mild

thrombocytopenia without clumping, and no schis­

tocytes. Her serum creatinine, electrolytes, and

hepatic panel were normal but coagulation studies

revealed mild prolongation of prothrombin and partial thromboplastin times at 13 seconds (10.7-13.1) and

46 seconds (24-38), respectively. Fibrinogen was

normal but haptoglobin was < 20 mg/dl (30-200),

lactate dehydrogenase was elevated at 885 U/L (94-

250), Coomb's direct antibody test was positive and

the reticulocyte count was elevated at 16.7% (0.5-

1.5). Urinalysis was unremarkable except for trace

protein. She was felt to have profound hemolytic anemia,

which was treated with high-dose intravenous corti­

costeroids (1 ,000 mg of methylprednisolone twice

per day) and intravenous gammaglobulin (IVIG) (1

gram per kilogram). She was transfused with only one

unit of packed red blood cells because she had cross­

reacting antibodies to all other available units in our

blood bank. Her hematocrit stabilized at 26% and her

plateletcountimprovedto246,000. ThePTTremained

prolonged and did not correct with 1: 1 mixing studies,

lupus anticoagulant (by diluted Russell viper venom

time) was positive and fibrin D-dimer was elevated at

2.2 ug/mL(< 0.5). Computerized tomography of the

chest and abdomen revealed multiple bilateral lung

alveolar opacities, small bilateral pleural effusions,

pericholecystic fluid and hypodensities in the spleen

and kidneys consistent with infarctions. Her condition rapidly deteriorated, manifested by

increased respiratory distress and hypoxemia, which

ultimately required mechanical ventilation, along with

mental status changes. Pulmonary artery catheteriza­

tion showed elevated pulmonary arterial pressures with

HAWAII MEDICAL JOURNAL, VOL 63, DECEMBER 2004

362

a normal pulmonary capillary wedge pressure. Given her elevated D-dimer, hypercoagulability (positive lupus anticoagulant) and elevated pulmonary artery pressures, a diagnosis of pulmonary embolus was considered and thrombolytic therapy entertained. However, fibrinolytic therapy was felt to be relatively contraindicated given her acute mental status changes, profound anemia and mild thrombocytopenia without available blood product support in case of a hemor­rhage. A head CT was quickly done to assess for intracranial hemorrhage and a CT pulmonary angio­gram performed to evaluate for pulmonary embolus, but both studies were unremarkable.

Her pulmonary artery catheterization, chest radio­graph and clinical findings were felt to be consistent with adult respiratory distress syndrome (ARDS), but she eventually expired despite aggressive man­agement. An autopsy revealed splenic and renal infarctions with thrombosis, pericardia! and pleural effusions, and pulmonary edema. Several small and medium-sized vessels in both lungs had thrombi and a large thrombus was observed in her right ventricle. Her clinical findings ofhemolytic anemia, multi-organ thrombosis, and ARDS in association with positive lupus anticoagulant were consistent with a post-mor­tem diagnosis of CAPS.

Discussion CAPS was only recently described as a rare mani­festation of APS associated with multiple vascular occlusive events and multi-organ failure, with the first reported case in 1992 by Asherson. 1 He later provided a comprehensive and detailed review of the clinical and laboratory features of CAPS in 1998,2 but expanded this review three years later to include a total of 80 patients collected from multiple medical centers. 3

There is no general concensus regarding the diagnos­tic criteria for the diagnosis of CAPS, but most accept the presence of thrombotic vascular occlusion in at least three different organ systems, presenting acutely over days to weeks, in patients with antiphospholipid antibodies. 4 A recent international workshop on APS discussed diagnostic criteria for the classification of CAPS. They proposed four criteria, to include involvement of at least three organ systems and/or tissues, onset in less than one week, histopathologic confirmation of small vessel involvement in at least

one organ or tissue, and laboratory confirmation of anti phospholipid antibodies. A definite diagnosis of CAPS was considered when all four criteria were met, while a probable diagnosis was considered when only two organs and/or tissues were involved (Table 1).5.6

Thrombosis appears to occur equally in arteries and veins in CAPS, but females are affected three times more often than men, with the mean age of onset being 37 years.3 In a review of 1 ,000 patients withAPS over a seven-year period, the incidence of CAPS was noted to be 0.8%. Interestingly, CAPS was the presenting manifestation in 6 of the 8 patients who ultimately developed this. Roughly one-half of those affected with CAPS also had systemic lupus erythematosus (SLE) while the other half appeared to have primary APS (Table 2).7

The pathogenesis of CAPS is unknown, but pre­cipitating factors have been identified such as pre­ceding infections (35%), surgery or trauma (13%), neoplasia (8%), anticoagulation withdrawal (8%), obstetric complications (6%), SLE flares (5%), and oral contraceptive use (35% ). No precipitating factor is identified in approximately one-third of patients. 3

Kitchens discussed a "thrombotic storm" theory,8

where thrombosis leads to additional thrombosis and fibrinolytic shutdown. Others have proposed a "double/triple" hit theory, where a patient with SLE or malignancy has an infection, trauma, or surgery and anticoagulation is withheld, leading to a cascade of thrombotic complications.9

There are several common clinical and laboratory manifestations of CAPS (Table 2). The most common clinical findings include cardiopulmonary involve­ment (25%) (pulmonary embolus and ARDS), CNS involvement (22% ), abdominal pain (22% ), and fever (10%). These were all clinical manifestations noted in our patient. Less common presenting manifesta­tions include renal impairment ( 14%) and cutaneous involvement (9% ). Any organ system may ultimately be affected, but organs most commonly affected were kidneys (78% ), lungs (66% ), CNS (56%), heart (50%), skin (50%), and hematologic (with diffuse intravascu­lar coagulation) (25% ). Common laboratory findings include thrombocytopenia (60%), hemolytic anemia (39%), features of DIC (19%), and schistocytes on peripheral smear (9% ). As mentioned previously, all

Table 1.- Recently adapted diagnostic criteria for the classification of CAPS.5 •

Diagnostic criteria used in the classification of CAPS

1) Involvement of at least three or more organ systems and/or tissues

2) Onset in less than one week

3) Histopathologic confirmation of small vessel involvement in at least one organ or tissue

4) Laboratory confirmation of anti phospholipid antibodies

Definite diagnosis considered when all four criteria are met.

Probable diagnosis considered when only two organs and/or tissues are involved. -HAWAII MEDICAL JOURNAL, VOL 63, DECEMBER 2004

363

.

•

patients with CAPS have antiphospholipid antibodies,

with 86% having high-titercardiolipin antibodies and

68% having lupus anticoagulant.3

Many treatments have been used in CAPS, with

varying degrees of success (Table 3). Therapy with

anticoagulation (84%) and steroids (80%) was seen

most commonly in Asherson's review, but other

treatments include plasmapheresis (20%) and IVIG

( 19% ). Despite aggressive treatment, the mortality

rate of CAPS approaches 50%, with death typically

secondary to ARDS and/or multi-organ failure. No

therapeutic interventions have clearly been shown

to improve survival to date,3 although these patients

should be managed in an intensive care setting and

strong consideration should be given to the use of

anticoagulation and high-doses of steroids. Pos­

sible precipitating factors should be treated and or

eliminated. Antibiotics for suspected infections

should be given and debridement of necrotic tissue

should be performed. Second line treatment options

include IVIG and/or plasma exchange with or with­

out fresh frozen plasma. Cyclophosphamide should

be considered in patients not responding to therapy,

especially in the setting of an SLE flare. 5•6 Our patient

received high-dose corticosteroids and IVIG, but

did not receive anticoagulation, plasmapheresis or

cyclophosphamide. Our patient presented with severe hemolytic ane­

mia and rapidly developed multi-organ failure with

ARDS. Her case appears to be representative of the

typical clinical manifestations and outcome seen with

CAPS. Fortunately, this syndrome only occurs in less

than 1% of all patients with APS but usually presents

acutely. The diagnosis is usually made by clinical,

laboratory, radiologic and histopathologic findings

but ante-mortem diagnosis can be elusive. Increased

physician awareness of this syndrome hopefully will

result in more rapid diagnosis and treatment, though

it remains to be determined if this will ultimately lead

to improved clinical outcomes.

References 1. Asherson RA. The Catastrophic Antiphospholipid Syndrome. J Rheumatol

1992;19:508-12. 2. Asherson RA, Cervera R, Piette JC, FontJ, Lie JT, Burcoglu A, et al. Catastrophic

Antiphospholipid Syndrome- Molecular Mimicry? J Rheumatol 2000;27:12-4.

3. Asherson RA, Piette JC, Shoenfeld Y, Espinosa G, Petri MA, Lim E, et al. Catastrophic Antiphospholipid Syndrome. Clues to the Pathogenesis from a Series of 80 patients. Medicine 2001 ;80:355-77.

4. Levine JS, Branch OW, Rauch J. The Antiphospholipid Syndrome. N Engl J Med 2002;346:752-63.

5. Asherson RA, Cervera R, de Groot PG, Erkan D, Boffa MC, PietteJC. Catastrophic antiphospholipid syndrome: international consensus statement on classification criteria and treatment guidelines. Lupus 2003;12:530-534.

6. Erkan D, Cervera R, Asherson RA. Catastrophic Antiphospholipid Syndrome, Where Do We Stand? Arthritis Rheum 2003;48:3320-27.

7. Cervera R, Piette JC, Font J, Khamashta MA, Shoenfeld Y, Camps MT, et al. Antiphospholipid Syndrome. Clinical and lmmunolgical Manifestations and Patterns of Disease Expression in a Cohort of 1 ,000 Patients. Arthritis Rheum 2002;46:1019-27.

8. Kitchens SC. Thrombotic Storm: When Thrombosis Begets Thrombosis. Am J Med 1998;1 04:381-5.

9. Asherson RA. Antiphospholipid Antibodies, malignancy and paraproteinemias. J Autoimmun 2000;15:117-22.

Table 2.- Common clinical and laboratory findings in CAPS.

Clinical Laboratory

Cardiopulmonary Anticardiolipin antibodies (pulmonary embolus and ARDS)

CNS involvement Lupus anticoagulant (stroke and mental status changes)

Abdominal pain Thrombocytopenia

Fever Hemolytic anemia

Renal impairment Features of DIC

Cutaneous involvement Schistocytes

Table 3.- Therapeutic modalities used in the treatment of CAPS.

Anticoagulation

Corticosteroids

Antibiotics for suspected infections

Debridement of any necrotic tissue

Consider IVIG and/or plasma exchange as second line therapy

Consider cyclophosphamide if not responding to the above therapies

Until there•s a cure there•s the

American Diabetes Association.

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•

Problem Solving in Health Care: The Center for Health Outcomes

Additional Authors: • Melinda Ashton MD • Niraj Dasai MD • Lee Evslin MD • AI Fuse MD • Tad Jackson MD • Dew-Anne Langcaon MBA • Michael Mihara MD • Kenneth Robbins MD • Raul Rudoy MD • David Saito MD

Authors: - Immediate past Chief of Staff, Kapiolani Medical Center for Women and Children. Advisory Board Center for Health Out­comes, Pediatric Surgeon. (W.S.) - Biostatistician, Center for Health Outcomes. (S.H.S.) -Vice-President, Quality Hawaii Pacific Health. (B.C.)

Correspondence to: Bonnie Castonguay RN, MBA 55 Merchant St., 27th Fl. Honolulu, HI96B13 Ph: (BOB) 535-7649

The Problem There is no question that healthcare, and its caregiv­ers continue to achieve ever-better outcomes for their patients. Yet those of us within health care organiza­tions recognize that major improvements remain to be achieved in results, in organizational performance and in systems efficiencies. The Institute of Medicine Report entitled To Err is Human 1 served to remind us all that there is plenty of room for improvement especially in those complex processes that affect outcomes.

How does an organization transform itself from a "good enough place" for health care into one that is truly excellent, one that is focused on patient safety, optimal outcomes and fiscal accountability? How does an organization break out of its rut and achieve genuine, tangible and lasting improvements? How do we get physicians "on board"? How do practic­ing physicians who care become personally engaged in driving an organization to become the best it can be, yet still have time for a thriving practice and not compromise their income and patient loads? What methodology can be applied that will result in a pervasive, infectious culture of patient safety and excellence?

Just such a set of questions haunted the leadership at Hawaii Pacific Health (HPH) a few years ago. The purpose of this article is to trace the establishment of The Center for Health Outcomes (The Center) and describe both the approach and the successes achieved within an unprecedented short timeframe. It is our hope that describing the Center, its truly unique approach, and the fascinating impact it has had on our organization, will lead physicians and the organizations in which they practice to achieve similar breakthroughs.

The Challenge There are many models taken from industry which can be used with modifications for a healthcare system, but most methods fail to account for the difference in that health care in a community hospital is based on mostly voluntary, unremunerated cooperation of independent practitioners.

Historically, healthcare organizations have racked up an enviable array of improvements within opera-

-

tions, relying heavily on non-physicians to design and implement better processes and systems. But as organizations continue to learn, these operationally driven improvements such as Continuous Quality Improvement (CQI), Total Quality Improvement (TQI), Six Sigma, Airline Industry's blameless culture, W. Edwards Deming's Total Quality Management (TQM), can only scratch the surface of changing the fundamental outcomes of healthcare if they do not engage practicing physicians. Hence the nearly universal frustration among clinicians with the lim­ited successes of former approaches to continuous improvements.2

•3.4 To succeed in changing health

care, we must first succeed in engaging physicians. How can that physician engagement be successfully and productively achieved?

Physicians fundamentally are motivated by the drive to do "the right thing" for their patients. They are also sensitive to the needs of the organizations within which they practice and within which their patients receive care. Courses of action and treatment methods they pursue - the way they practice - are largely determined by their training, experience, and by information gleaned at medical meetings or from other industry sources. They seldom have the benefit of meta-analyses of the problems that currently engage them and their patients, often being so close to what they do that they cannot evaluate and consider treat­ment alternatives beyond their training or habits. In the absence of compelling data, physicians are stuck doing what has worked for them in the past.

Engaging physicians is fundamental, but not suf­ficient alone. Dr. John Wennberg suggests that the underlying ethos of physicians to do the right thing for patients will lead them to modify their behaviors or practice patterns if shown compelling outcomes data.5

•6 So providing data and relying on data becomes

a second fundamental need for success. Additionally, most physicians question the validity or credibility of data that put their "proven" practices at risk unless they were personally engaged in the study process that produced that data. Of course, personal involvement not only establishes the credibility of the data, but also makes implementation of change more readily achievable.

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THE PARADIGM

Systems Performance

Physician Practices And Patient Care

CHO: The Catalyst and Driving Force

The Hypothesis An important element in the Center's success is that physician practices and systems performance will not readily translate into improved quality and patient outcomes unless there is a continuous tension and expertise applied by a Catalyst for improvement. The Catalyst combines proven skills as a specialist in outcomes-focused improvement with methodological expertise in research methods and statistical analysis. He acts as a facilitator for many meetings with inter­personal and team leadership expertise. Thus through this Catalyst-facilitated methodology, physicians are guided to decide how to approach problems and apply proven statistical methods to study problems, reach conclusions, implement change and achieve transformations.

Methodology In May 2001 the Center's Board was established as a leadership group, consisting of eleven key people. The Board of eleven was comprised of eight physi­cians representing in equal numbers the two facilities at that time, and three non-physicians representing senior leadership, quality management leadership and the Catalyst. Among their first acts for the Center was to name itself. The Center's intent and mission are implicit in its name, that being to focus on im-

-

Quality Outcomes 1) Clinical Improvement 2) Cost Adjustment 3) Stakeholder Satisfaction 4) Improved Usage Access

proving outcomes associated with health and health care processes. The effectiveness of the endeavor was from the outset based on:

1. Physician Leadership and participation of practicing physicians

2. Buy-in and lasting support from the very highest administrative levels

3. Data Availability

4. A strong, dedicated Center Director

5. A skilled, credible, expert Catalyst

The Catalyst provided the expertise, credibility and rigor needed for meeting management, data, capture, subsequent analysis and rapid evaluation for deci­sion-making. Steve H. Shaha, PhD, DBA, filled this role and brought his skills as a credible established expert with advanced training in statistics, business, and continuous improvement to the organization.

The ultimate success of the Center required that an infrastructure of quality management resources be in place. To this end Bonnie Castonguay, Hawaii Pacific Health's quality management leader was included as

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a board member and named Executive Director of the Center for Health Outcomes.

Balanced Metrics: When we consider improve­ments in health care we intuitively understand that it should be something more than the "bottom line." It is an important concept that more than just profit or money is involved, that the totality of improvement is best measured or expressed as balanced metrics- the summation of 1) clinical improvement, 2) stakeholder satisfaction, 3) improved access and 4) cost adjust­ment. Although reduction in the last is frequently seen as the goal of industry, it is sometimes necessary to spend, or invest in change that will ultimately result in improved stakeholder satisfaction, access, and clinical outcome - all resulting in increased volume and efficiency.

Examples The approach and success of the Center is best

understood through reviewing a series of examples selected because they illustrate challenges taken on by physicians that range from proactive and introspective drives to improve, to reactive resolution of complex issues representing long-standing struggles unsolved by former methodologies:

1). Efficacy of Repeat Antenatal Ultrasound Antenatal ultrasound to screen for birth defects is performed routinely. However, the examination frequently is not able to visualize every organ system clearly to rule in or out all possible deformities. This results in a dilemma for the interpreting physician of whether or not to repeat the procedure. A study proposal was mounted to evaluate the ef­ficacy of repeating the procedure to provide more information. After reviewing 1,474 2"d trimester examinations over an eight month duration analyses focused on repeat examinations (n= 126); rationale for repetition and clinical accuracy corroborated by post partum chart reviews of both mother and baby. The perinatology service concluded and published results that showed no significant additional information was obtained by repeated tests, resulting in a significant saving of patient time, worry, and expense.

2). Newborn Readmissions A review of Kapiolani Medical Center for Women and Children's newborn readmissions indicated a rate higher than the national benchmark. Detailed investigation of this phenomenon included racial as well as epidemiological parameters. We found that all readmissions were justified because of jaundice, but that there was a statistically higher incidence of jaundiced Filipino babies which constituted a disproportionately larger minority than in the gen-

era! population. This has led to a further project of investigating bilirubin metabolism in Filipino babies and ethnic differences in post-natal care.

3). Sedation of Ventilated Adults One of our adult pulmonologists noted that ventilator weaning was not accomplished in a clearly defined fashion with criteria for either reducing or increasing the sedative drug Propofol. This frequently resulted in over sedated patients using more sedation than necessary or too rapid withdrawal of Propofol caus­ing increased agitation necessitating reinstitution of high doses of sedation.

Clearly defined guidelines utilizing the Motor Activ­ity Assessment Scale (MAAS) relative to clinical status and agitation were established for either decreasing or increasing specified doses of Propofol. The project involved pulmonologists, other physicians and hos­pitalists, nurses, respiratory therapists and others.

After establishing these clinical weaning parameters decannulation of these ventilated patients occurred more expeditiously and a significant cost saving from Propofol use was effected, so that a saving of approximately $350.00 per ventilator day was effected thus saving an estimated $60,000.00 annualy.

4). Procedural Sedation and Ancillary Service Scheduling A problem in the scheduling of ancillary studies such as Imaging and EEG/EKG is the need for a sedated or non-moving patient. This requires a complex coor­dination of schedules for patients, anesthesiologists, sedation recovery nurses and equipment. Under physician leadership and with administrative clout, a Center-launched effort was able to decrease the delays between scheduling and testing from an average of between two to four weeks (outliers were 3-4 months) to 4 days as an average, with more than 80% within a day of the scheduling call by the par­ent. Delays remain primarily attributable to parental needs and preferences, for which expanded hours of imaging service have already been implemented. Interdepartmental challenges had to be adjudicated, space allocations approved, new monitoring equip­ment had to be purchased, contracts with key seda­tion-related clinicians to be created or modified, and patient preference and prioritization factors for schedule times determined. The pool of sedation specialists had to be expanded in order to ensure coverage, credentialing criteria had to be considered, reimbursement negotiated for non-anesthesiologists. The Center provided an optimal forum for achieving these complex and "politically sensitive" goals in a minimal time frame with maximum benefit to all, especially the patients and anesthesiologists who are most affected by these processes.

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Discussion Health care organizations have historically struggled

to achieve improvements in health outcomes and

system enhancements due in great part to minimal or

only marginal physician engagement. Physicians have

often viewed administratively driven initiatives as re­

packaged attempts to control physician behavior rather

than efforts to engage physicians in genuine rethinking

and redesigning of the imperfect. Merely involving

physicians as invited participants rather than engaging

them as key players has led to minimal improvement.

Traditional approaches have failed to transform the

fundamental cultures of the organizations.

The Center represents a genuinely unique approach

to engaging practicing physicians in leading change

and thus transforming the organization. It acts as a

transformational agent for HPH and for its practitioners.

Three years of unprecedented success underscore the

wisdom of the approach adopted and the credibility

the Center has achieved among physicians and admin­

istrators alike. The approach, while unique, is generalized and

transferable. The Center serves to demonstrate that

improvement is achievable through a well-resourced

approach that is physician-led and data-rich. With

strong Center-like infrastructure backed by adminis­

trative buy-in, and with the skills and capabilities of

those involved, organizations can engage practicing

physicians in making a positive difference for all:

Patients, the organization, care givers at large, and

the physicians themselves. Everyone benefits.

References 1. Kohn, LT, Corrigan, JM, Molla SO, "To Err is Human" Institute of Medicine:National

Academy Press, 2000 2. Coughlin, K.M., et al 2001 Medical Outcomes & Guidelines Sourcebook. New

Yor11: Faulkner & Gray, 2000. 3. Shah a, S.H. "Strategic Teaming Across Multiple Disciplines.' Advance for Health

Information Executives. Vol. 3, No. 10, October, 1999. 4. Shaha, S. H. "Integrated Outcomes: Where CIOs Need to be Thinking." Health

ManagementTechnology. Vol. 9, No. 10, September, 1998. 5. Wennberg, JE, "The Dartmouth Atlas of Health Care in the United States"

American Hospital Publishing, Inc. p204, 1998. 6. Wennberg, JE, "Which Rate is Right?" NEJM 314:310-311

-HAWAI I MEDICAL JOURNAL, VOL 63, DECEMBER 2004

368

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National Cancer Institute

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l!i Medical School Hotline

Multimedia Solutions in a Problem-Based Learning Curriculum

roblem-based learning (PBL) has been utilized as the primary mode of curriculum delivery at the John A Burns School of Medicine since 1989. Its use has been evolving to best

fit the needs of the students. Some of the benefits of PBL include fostering self-directed and life long learning skills, teaching a broad spectrum of topics in the context of actual patient cases, and pro­moting the integration and application of knowledge. Despite the successes with PBL there are barriers to maximize the benefits of a PBL curriculum, especially in the clinical years. These barriers are being addressed by encouraging more discussion of psychosocial issues and mitigating the geographic challenges in the clinical years, through the use of multi-media.

Preclinical Uses In the first two years of the curriculum at JABSOM, students are exposed to physician-patient encounters in various educational set­tings. The centerpiece of curricular content delivery in this PBL school is the healthcare problem (HCP), the primary method of introducing the physician-patient relationship. For first and second year medical students, the HCP is typically a paper-based patient scenario. In addition, a few cases incorporate standardized patients (actors playing the role of the patient who was introduced in the HCP.) Students meet twice per week, each for three-hour sessions. Under the guidance of a faculty tutor, students proceed sequentially through each paper case. Problems are identified, patient diagnoses are hypothesized, and learning issues that need further study are identified. Because students define their learning content, course directors are challenged to create cases that inspire students to select topics emphasized on the syllabus. To supplement the paper HCPs, students participate in clinical skills sessions that focus primarily on physical examination skills with actual patients, or with each other, under the supervision of a practicing physician. Students experience 'real' physician-patient encounters. For a detailed account of the JABSOM PBL curriculum, please refer to Kasuya et. al 1

.

A major strength of PBL is the placement of the medical school curriculum within the context of the patient, thus giving relevance and cohesion to the vast amounts of medical facts and principles students must learn. This context motivates learning and possibly enhances retention2. A difficulty that students experience is in dis­cussing and learning psychosocial issues related to the HCP under study. To engage students more, a multimedia HCPhas been adopted

.Jill Omori MD, Assistant Professor, Family Medicine

and Community Health

.Joshua .Jacobs MD Assistant Professor, Medicine,

Family Medicine and Community Health

and adapted for the curriculum. This HCP, created by faculty at the University of Colorado School of Medicine, features video and audio clips of physician-patient interviews, consultant interviews, physical exam maneuvers, text, and a user-selectable laboratory exam results menu. This case has been adopted by five other schools of medicine for use in their curriculum3

.

All second year students progressed through the multimedia HCP. The format generated much discussion on the psychosocial aspects of the case. The students also enjoyed the physical exam video clips, and provided feedback that included comments such as "the visual aspects of the case makes it more real and memorable." Incorporating multimedia into JABSOM PBL has the potential to further the depth of student engagement in the patient's "experience", and may further stimulate learning and knowledge retention during the "preclinical" years of medical school. Plans are underway to investigate further the impact of multimedia on PBL. Additional multimedia solutions implemented at JABSOM in the preclinical setting have been previously described, and include an experimental immersive virtual reality patient encounter4

, and webpage access to static images5

.

Clerkship Uses Two major challenges of continuing PBL in the clinical clerkships are time and geography. Clinical disciplines struggle to fit in enough patient care experiences, didactics, and conferences into the students' rotations since there is often limited time for additional PBL group experiences. The Medicine clerkship has implemented on-line case presentations, some of which include use of multimedia. These cases are not structured as PBL, but exploit the advantages of the Web to address the difficulties of limited time in the clerkship. These cases can supplement full hands-on clinical electives.

In the Family Medicine clerkship, a significant barrier is that students are placed with community preceptors located throughout the state, including rural Oahu and the neighbor islands. This makes it difficult for students to meet on a regular basis for PBL groups. To address these problems, a series of web-based PBL cases have been created so that the students can complete assignments on-line throughout their clerkship, at their own individual pace.

Presented to the students are patient cases very similar to the HCPs that they work with in the pre-clinical years. Students go through the same steps in the PBL process on-line and are required -HAWAII MEDICAL JOURNAL, VOL 63, DECEMBER 2004

369

to come up with hypotheses and to explain their reasoning. They are expected to be able to adjust their differential diagnosis list as the case unfolds and as they obtain more information. Students must also list items that they feel would be relevant to access from the patient history, physical exam, and diagnostic studies and to explain why the items would be important, prior to providing this informa­tion during the web-cases. Students are provided the opportunity to ask a variety of history questions, examine all parts of the physical exam, and choose from a number of diagnostic studies for each of the patient cases. They are instructed to select only those that they think will be pertinent to that particular patient case. Their choices are recorded electronically and reviewed for patient relevance. In addition to the basic steps ofPBL, the students are also asked various questions throughout the case to stimulate learning issues. They are encouraged to come up with their own learning issues based on the information presented. Students are encouraged to research these areas while they are doing the cases from web-based resources provided for each case.

The web-cases allow the Family Medicine clerkship to provide a standardized curriculum to their students and encourage the continu­ation of the principles of PBL. Students complete the cases on their own time which allows for more clinical time with their preceptors and encourages the exploration of web-based medical resources, a part of the medical informatics curriculum for the Family Medicine clerkship. The web-cases have received excellent feedback from students and facilitates their use of the principles of PBL in their daily routine of patient-care in the outpatient setting.

Conclusion and Future Direction Effective use of multimedia has helped to maximize the benefits of PBL that includes addressing issues of culture (psychosocial discus­sion is not part of the culture of medical students), limitations in time, and geographical barriers. The new medical school campus in Kaka' ako also holds new promise for expanding the use of multimedia for students with the inclusion of intranet with web-based learning materials, increased use of multimedia in the HCPs for the first two years of the curriculum, and the extensive numbers of web-cases and online lectures. Although multimedia solutions will never replace the need for face to face PBL sessions, they will play a key role in optimizing their effectiveness for JABSOM' students.

References 1. Kasuya R, Greene G, Sakai D, Tam L. "University of Hawaii John A. Burns School of Medicine" in "A

Snapshot of Medical Students' Education at the Beginning of the 21st Century: Reports from 130 Schools." Academic Medicine September Supplement 2000;75(9):S72-S74.

2. Finucane PM, Johnson SM, Prideaux DJ; "Problem-based learning: its rationale and efficacy:· Med J Aust. 1998 May 4;168(9):445-8.

3. Kamin C; "LIVE: Learning through Interactive Video Education"; http://mama.uchsc.edu/pub/live/in­tro_pub.htm; Accessed 7/13/04.

4. Jacobs, J;Caudell, T;Wilks, D;Keep, M; Mitchell, S;Buchanan, H;Saland, L; Rosenheimer, J; Lozanoff, B; Lozanoff, S; Saiki, S; Alverson, D; "Integration of advanced technologies to enhance problem-based learning over distance: projectTOUCH:' Anal Record, 2003 Jan; 270B(1 ):16-22.

5. Seifried, SE; "Technology-based delivery of PBL curricular elements at JABSOM." Hawaii Med J 2000 Jun 59(6) 240, 284.

"Cross-Cultural Medicine" from p. 361

is always a danger in diagnosis and therefore a list of differential diagnoses is imperative to prevent diagnostic tunnel vision. We deal with unmanageable masses of information by pigeon-holing, by profiling, by stereotyping. The trick is not to let that blind us to the nuances of disease and diversity of patients. But without these sorting techniques we could never make a diagnosis.

Finally, I must point out that the book devotes a great amount of print to percentages and statistical profiles of various groups while at the same time explaining that no group is homogeneous. This makes for difficult, boring reading which can not possibly be as­similated. One might use the book as a reference if faced with one of the groups discussed, assuming you had no first hand information. Even if you do have first-hand knowledge it might be useful, since our experiential information is never complete or objective. The same criticism applies to the sections dealing with various religious and spiritual beliefs and practices affecting medical care. Indeed, as is pointed out over and over, this volume is only a small sampling covering only a tiny fraction of the cultures and ethnicities of this world. For example, Chapter 5 deals with care of "Asian-Ameri­cans." This subject alone deserves at least an encyclopedia.

A problem which is just touched upon is the small numbers of physicians (and other health care personnel) who come from many of the types of groups discussed in the book. Correcting this is desirable of course, but probably it has to solve itself over time in view of the economic, educational, and cultural hurdles. In fact my own view is that education, whether it be in language, health concepts, scientific method, or whatever, is essential for the populace as a whole and is the only feasible answer to the dilemmas posed in this book. Nevertheless, it is the mandate and requirement of all physicians to do what they are capable of doing in the setting in which they find themselves. It is unrealistic to expect any one individual to be competent in every culture with which he/she may have to deal. The solutions must come from the entire society, and most importantly from those members of the society that are under­served. Political will, economic resources, and above all education are essential. The job is not one which physicians or the medical profession alone can solve. This book points out what the problems are and urges the medical profession to contribute. As it has been famously said in another context "it is hard work," and by its very nature, I might add, will never be finished.

Alfred D. Morris MD

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~~ Cancer Research Center Hotline

Abstract Ornithine decarboxylase (ODC) and S-adenosylmethionine de­carboxylase (AdoMetDC) are two key enzymes in polyamine (PA) biosynthesis and their inhibition leads to PA pool depletion and cell growth arrest. OFMO and SAM486A are specific inhibitors of ODC and AdoMetDC, respectively, and are the only two PA inhibitors, which have been clinically evaluated in Phase II and Ill cancer tri­als. However, drug combination therapies expected to potentiate the effects of these drugs have yet to be systematically pursued. Human cancer trials (e.g. for the treatment of neuroblastoma pa­tients) using a DFMO! SAM486A cocktail, possibly combined with current cytotoxic drugs and concomitant with a ?A-deficient diet, are warranted.

The Role of Polyamines in Human Cancer: Prospects for Drug Combination Therapies

Andre s. Bachmann PhD, Assistant Professor,

Natural Products and Cancer Biology Program Cancer Research Center of Hawaii

Polyamine biosynthesis in mammalian cells The naturally occurring polyamines (PAs) are small aliphatic cat­ions identified over three centuries ago. PAs are found in all living cells and are responsible for a plethora of functions including cell growth, differentiation, apoptosis, and DNAreplication. 1-3 Mamma­lian cells produce the PAs putrescine, spermidine, and spermine.2

•4

The diamine putrescine is formed from ornithine via the action of ornithine decarboxylase (ODC), a key enzyme in PA biosynthesis (Fig. 1). Putrescine can be further converted into the higher PAs spermidine and spermine. The aminopropyl groups necessary for these conversions are provided via decarboxylation of S-adeno­sylmethionine (AdoMet) to decarboxylated S-adenosylmethionine

~c:::=::>~

rr ~UNa ~<==:=J~

ODC n r-- DFMO

~ ~ SAM486A --in AdoMe~ n ~ ~ ~n ~

Figure 1.-Simplified diagram of the polyamine (PA) biosynthetic pathway and associated amino acids of the urea cycle showing key enzymes ODC and AdoMetDC and their specific inhibitors DFMO and SAM486A, respectively. Abbreviations are: AdoMet, S-adenosylmethionine; AdoMetDC, S-ad­enosylmethionine decarboxylase;AS, argininosuccinate; DFMO, a-difluoromethylornithine (also known as Eflornithine);ODC, ornithine decarboxylase; SAM486A, 4-amidinoindan-1-one 2'-amidinohydrazone (also known as CGP48664A). -HAWAII MEDICAL JOURNAL, VOL 63, DECEMBER 2004

371

LAN-1 SKOV-3 ~

f~~ ....

,, .. ---~ ~~r

~h ~~ - ~, - 'r'· es: ·I! .. ·. . . ~ ~:; . .

l"tA, ,. "..tr/' -

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: ~t ~,l 4\. ~,A <Fo ~

~~ 111 ' .

I -.

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Figure 2.- Effect of 5 mM DFMO or 10 ~M SAM486A on the growth of MYCN-amplified and p53 mutant human neuroblastoma (NB) cell line LAN-1 and human ovarian cancer cell line SKOV-3. Cells were treated without or with indicated polyamine (PA) inhibitors DFMO or SAM486A for 3 days. Micrographs were taken using an inverted phase contrast microscope (Nikon). In comparison with the SKOV-3 ovarian cancer cells, the growth of LAN-1 NB cells was inhibited much more drastically and caused significant morphological changes after only 3 days of treatment. This suggests that NB cells are more responsive to PA inhibitors and that the clinically evaluated drugs DFMO and SAM486A might provide an alternative approach for the treatment of NB patients.

(dcAdoMet) (Fig. 1).5 The positively charged PAs allow for both

electrostatic and hydrophobic interactions with DNA, RNA, and proteins, thereby directly affecting gene regulation. There is also increasing evidence that PAs are involved at various stages of signal transduction, and, for example, regulate and phosphorylate important cellular components of the MAPK and PI3K signaling pathways6-

8

(our results, unpublished).

Polyamines are highly regulated during cell cycle progression Normal cell growth is orchestrated in a cyclic manner by the action of cyclins and cyclin-dependent kinases (cdks)9 and appropriate activation/ inactivation of these proteins is necessary for cell cycle progression. The cyclins A, B, D, and E form complexes with cor­responding cdks and specifically regulate the G /Sand G/M phases

of the cell cycle. Similarly, ODC and PA concentrations increase in

both cell cycle phases. 10•

11 This strong positive relationship to cell cycle regulation provides further evidence that PAs are intrinsically linked to cell growth and proliferation. 12

Elevated polyamine levels can lead to cancer PA levels are elevated in many types of cancer, and interference with PA biosynthesis has long been considered a promising therapeutic approach against proliferative diseases, including various malignan­cies. 13-22 ElevatedPA levels have also been detected in urine of cancer patients and can be measured in blood and cerebrospinal fluids. 11

.1 6·23

ODC has been known as a marker of carcinogenesis and tumor progression 24 and has been considered a proto-oncogene,25 which is transactivated by c-Myc. 26 The high enzymatic activities of ODC and AdoMetDC in rapidly growing cells and tissues, and especially,

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in tumor cells, rendered a rationale for designing pharmacological inhibitors, which selectively interfere with the natural biosynthesis of PAs and, consequently, prevent tumor cell growth.

The clinically established polyamine inhibitors DFMO and SAM486A Over the course of more than 30 years, many researchers have focused on the design and synthesis of inhibitors, which interfere with PA metabolism. 11 ·18-20 A large number of these synthetic inhibitors and PA analogues were evaluated in vitro, in cell culture experiments, and in animal cancer models. However, so far, only two PA inhibitors have further advanced to the clinical setting. The most prominent drug is the ODC inhibitor a-difluoromethylomithine (DFMO; also known as Eftomithine) (Fig. 1), which has been evaluated in Phase II and III cancer trials. 27-29 The second drug is the AdoMetDC inhibi­tor 4-amidinoindan-1-one 2' -amidinohydrazone (SAM486A; also known as CGP48664A) (Fig. 1), which was assessed in Phase I tri­als,30·31 and most recently, in a Phase II multicenter study. 32 Although monotherapy with DFMO has been disappointing in most cancer trials, the drug was found more effective as a chemopreventive agent based on its low toxicity. The reported side effects are relatively mild with occasional occurrence of temporary ototoxicity, diarrhea, and some neutropenia. Notably, DFMO is successfully used in the treatment of a number of parasitic diseases, including the infec­tion with Trypanosoma brucei gambiense, which causes African trypanosomiasis.33 Recent Phase II clinical trials with SAM486A in patients with relapsed or refractory non-Hodgkin's lymphoma were promising and the most frequent side effects included nausea, vomiting, diarrhea, asthenia, abdominal pain, and ftushing. 32

DFMO and SAM486A inhibit growth of human neuroblastoma cells Because DFMO and SAM486A are the only clinically evaluated PA inhibitors with a relatively high tolerance in patients, we have focused our own research on these two drugs and are studying their effects on human neuroblastoma (NB) cells. NB is an extra-cranial tumor in infants and originates from precursor cells of the peripheral (sympathetic) nervous system and usually arises in a paraspinal location in the abdomen or chest. 34 We found that NB cells respond more rapidly and more profoundly to the growth inhibitory effects of DFMO and SAM486A than, for example, ovarian cancer cells or other cell lines discussed in the literature (Fig. 2). To our knowledge, NB trials with DFMO or SAM486A have not been conducted thus far, and, given the need for new anti-neoplastic agents with novel mechanisms of action, such trials should be seriously considered. Our research further revealed that DFMO and SAM486A are effec­tive against NB cells with MYCN amplification (typically derived from more aggressive NB tumors, which metastasize and do not respond well to conventional chemotherapy) and with mutated tumor suppressor protein p53 (often found in relapsed and chemoresistant NB tumors), thus further supporting the use of these drugs for therapeutic NB treatments.

Prospective combination therapies for improved efficacy in cancer trials Although ODC has generally been considered as the enzyme catalyz­ing the rate-limiting step in PA biosynthesis, it has been shown that

-

the supply of dcAdoMet represents a second rate-limiting factor in PA biosynthesis,35 and therefore, the enzymeAdoMetDC represents a second rational target (Fig. I). Since the two enzymes are co-regu­lated by intracellular PA pools so that inhibition of one results in a compensatory increase in the other, it follows that targeted interfer­ence with a drug cocktail composed of ODC inhibitor DFMO and AdoMetDC inhibitor SAM486A (or other prospective PA inhibitors of clinical relevance) is likely to sharpen the antiproliferative effects by complete depletion of the PA pools. Such combination therapies could be further enhanced by the inclusion of retinoic acid (RA), a well-characterized agent that induces neuronal cell differentiation and is used in NB therapy.36 In addition, RA affects PA levels and inhibits ODC activity, 1·20·37·38 thus further contributing to the total depletion of PA pools. Finally, the combination of the cytostatic drug DFMO with SAM486A and some of the current cytotoxic drugs may provide a more powerful regimen against NB and other cancer types.

Conclusions PAs are intrinsically connected to cell growth and proliferation, and the inhibition of the sentinel PA biosynthetic enzymes ODC and AdoMetDC is considered a means to prevent cell proliferation by PA depletion, the blockade of cell cycle progression, and interfer­ence with signal transduction. DFMO and SAM486A have both been evaluated in human cancer trials, but so far, have only been studied individually. Thus, further studies assessing the efficacy of combined drug therapies are certainly warranted. The treatment of NB patients with a DFMO/ SAM486A cocktail, possibly in com­bination with RA and concomitant with a PA-deficient diet should be considered as an alternative protocol.

Acknowledgments This work was supported by a grant from the Hawaii Community Foundation (Robert C. Perry Fund,# 20022113) to Dr. A.S. Bachmann. Dr. Patrick Waster (Wayne State University, Ml) and Novartis (Basel, Switzerland) are thanked for providing the ODC inhibitor DFMO and the AdoMetDC inhibitor SAM486A, respectively. We are also indebted to Dr. Bonnie Warn-Cramer and Ms. Jennifer Seki (Cancer Research Center of Hawaii, HI) for the work with human ovarian cancer cells SKOV-3 and Mr. Mike Thorne (Hawaii Biotech, Inc., HI) for reviewing the manuscript.

For more information on the Cancer Research Center of Hawaii, please visit our web site at www.crch.org.

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30. Eskens, F. A., Greim, G.A., van Zuylen, C., Wolff, 1., Denis, L.J., Planting, A. S., Muskiet, F. A., Wanders, J., Barbel, N.C., Choi, L., Capdeville, R., Verweij, J., Hanauske, A. R., and Bruntsch, U. (2000) Clin Cancer Res 6, 1736-17 43.

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32. Pless, M., Belhadj, K., Menssen, H. D., Kern, W., Coiffier, B., Wolf, J., Herrmann, R., Thiel, E., Bootie, D., Sklenar, 1., Muller, C., Choi, L., Porter, C., and Capdeville, R. (2004) Clin Cancer Res 10, 1299-1305.

33. Heby, 0., Roberts, S.C., and Ullman, B. (2003) Biochem Soc Trans 31, 415-419. 34. Brodeur, G. M. (2003) Nat Rev Cancer 3, 203-216. 35. Pegg, A. E. (1988) Cancer Res 48,759-774. 36. Tuthill, M. C., and Wada, R. K. (2003) Hawaii Med J 62, 224-225. 37. Dawson, M.l., Chao, W. R., and Helmes, C. T. (1987) Cancer Res 47, 6210-6215. 38. Dawson, M. 1., Park, J. H., Chen, G., Chao, W., Dousman, L., Waleh, N., Hobbs, P. D., Jong, L., Toll,

L., Zhang, X., Gu, J., Agadir, A., Merchant, J. L., Bai, L., Verma, A. K., Thacher, S.M., Chandraratna, R. A., Shroot, B., and Hill, D. L. (2001) lnt J Cancer 91, 8-21.

Surprisingly, one million new cases of skin cancer are detected every year. One person an hour in the U.S. dies from melanoma, the deadliest form of skin cancer. If you spend a lot of time in the sun, you should protect yourself. One out of five Americans develops skin cancer during their lifetime. Don't be one of them. Stay out of the midday sun. Cover up. Wear a hat. Seek shade. And use sunscreen. For more information on how to protect yourself from skin cancer, calll-888-462-DERM or visit www.aad.org.

AMERICAN ACADEMY OF DERMATOLOGY

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Index to Hawaii Medical Journal Volume 63, 2004

Compiled by Carolyn S.H. Ching MA, MLIS and Marlene M.A. Cuenca MLIS

Keyword Index

ABNORMALITIES. Rates for specific birth defects among Native Hawaiians compared to whites, Hawaii 1986-2000, 63(8):238 ABSTRACTING AND INDEXING. Index to Hawaii Medical Journal volume 63, 2004, 63(12):375 ACCIDENTS, TRAFFIC. Doctors are most likely to be involved in auto accidents [Editorial], 63(1):4 ACUTE DISEASE. The virtual hospital: treating acute infec­tions in the home by telemedicine, 63(10):291 ADENOCARCINOMA. Are immune responses pivotal to cancer patient's long term survival? Two clinical case­study reports on the effects of morinda citrifolia (noni), 63(6):182 ADENOSYLMETHIONINEDECARBOXYLASE. The role of polyamines in human cancer: prospects for drug combina­tion therapies [Cancer research center hotline], 63(12):371 ADOLESCENT. Overweight and obesity, a worsening health problem particularly in children [Cancer research center hotline], 63(3):91 AGE DISTRIBUTION. Melanoma and Hawaii's youth, 63(3):87 AGED. Polypharmacy, complementary and alternative medicines (CAM), and cancer [Cancer research center hotline], 63(11):349 AMERICAN COLLEGE OF PHYSICIANS. HAWAII CHAPTER. Guest editor [Editorial], 63(9):257 --- What's old and still on the horizon history of the ACP­Hawaii [Editorial], 63(11):328 AMPUTATION, TRAUMATIC. An internationallandmine telehealth symposium between Hawaii and Thailand using an Internet2 and multi-protocal videoconferencing bridge, 63(10):294 ANACARDIACEAE. The ubiquitous contact dermatitis from mango, poison ivy, and other"poison" plants: a humorous and interesting review. 1968 [Classical article], 63(8):231 ANEMIA REFRACTORY. 5-azacitidine: an alternative treatment of myelodysplastic syndromes in patient with refractory responses to hematopoietic growth factor: a case report and review of literatures, 63( I): 14 ANGINA, UNSTABLE. Severity of chronic kidney disease did not influence bleeding during treatment of acute coronary syndromes, 63(11):333 --- Gender differences in therapy for patients admitted for unstable angina and myocardial infarction with underlying chronic kidney disease, 63(11 ):337 --- Bleeding risk in patients with underlying chronic kidney disease admitted for acute coronary syndromes, 63(11):344 ANTI-BACTERIAL AGENTS. Oral antibiotics and breast cancer [Editorial], 63(6): 172 ANTIPHOSPHOLIPID SYNDROME. Catastrophic an­tiphospholipid syndrome: a "catastrophic" case of systemic lupus erythematosus, 63(1 2):362 ARRHYTHMIA. Fatal postoperative arrhythmia in a man with a remote history of methamphetamine and cocaine use: a case report, 63(3):82 ASIAN AMERICANS. AANCARTcomes to Hawaii [Cancer research center hotline]. 63(6): 189 ASTHMA. A community-based asthma management program: effects on resource utilization and quality of life, 63(4):121

ATTITUDE OF HEALTH PERSONNEL. Physicians and complementary-alternative medicine: training, attitudes, and practices in Hawaii, 63(6): 176 --- Medicine, meditation, and Osler's aequanimitas, 63(7):201 --- virtual hospital: treating acute infections in the home by telemedicine, 63(10):291 AZACITIDINE. 5-azacitidine: an alternative treatment of myelodysplastic syndromes in patient with refractory responses to hematopoietic growth factor: a case report and review of literatures, 63(1):14 BOOK REVIEW. Public speaking made easy [Book review], 63(4): 105

I'm third: an american boy of depression years (Book review], 63(5):146 ---Cross-cultural medicine [Book review], 63(12):361 BREAST NEOPLASMS. Insulin-secreting cystosarcoma phyllodes of the breast: a case report and literature review [Residents' case series], 63(7):211 ---Oral antibiotics and breast cancer [Editorial], 63(6): 172 BUDGETS. Commentary. 2004 [classical article], 63(5):147 CADAVER. The JABSOM willed body donation program, a unique medical educational experience [Medical school hotline], 63(8):243 CANCERBIOMEDICALINFORMATICS GRID. The cancer Biomedical Informatics Grid (caB!G): pioneering an expan­sive network ofinformation and tools for collaborative cancer research [Cancer research center hotline], 63(9):273 CANCER RESEARCH CENTER OF HAWAII. University of Guam I Cancer Research Center of Hawaii partnership [Cancer research center hotline], 63(1):21 CARDIOVASCULAR DISEASES. Fatal postoperative ar­rhythmia in a man with a remote history of methamphetamine and cocaine use: a case report, 63(3):82 --- Management of patients with chronic kidney disease presenting with acute coronary syndrome, 63( II ):330 CAUCASIANS. Rates for specific birth defects among Native Hawaiians compared to whites, Hawaii 1986-2000, 63(8):238 CEREBROVASCULAR ACCIDENT. Traditional Chinese medicine: applications to heart disease and stroke [Edito­rial], 63(1):6 CHILD. Overweight and obesity, a worsening health problem particularly in children [Cancer research center hotline], 63(3):91 CHINN, PATRICIAL. Implementation of Hawaii's prepaid health care act: root cause of a health care monopoly [Edito­rial], 63(4): 104 CHYLE. Chyluria due to lymphatic filariasis: case report and review, 63(7):206 COCAINE. Fatal postoperative arrhythmia in a man with a remote history of methamphetamine and cocaine use: a case report, 63(3):82 COCKROACHES. The cockroach as a host for Trichinella and Enterobius vermicularis: implications for public health, 63(3):74 COLORECTAL CANCER. Ethnic disparities in colorectal cancer incidence and mortality in Hawaii [Cancer resarch center hotline], 63(2):54 COMMUNITY HEALTH SERVICES. A community-based asthma management program: effects on resource utilization and quality of life. 63(4):121 COMPLEMENTARYTHERAPIES.Physiciansandcomple--HAWAII MEDICAL JOURNAL, VOL 63, DECEMBER 2004

375

mentary-alternative medicine: training, attitudes, and practices in Hawaii, 63(6): 176 --- Polypharmacy, complementary and alternative medi­cines (CAM), and cancer [Cancer research center hotline], 63(Jl):349 CONGRESSES. HCMS 78th annual meeting and installation of officers [Editorial], 63(2):36 ---Guest editor [Editorial], 63(9):257 --- international Jandmine telehealth symposium between Hawaii and Thailand using an Internet2 and multi-protocal videoconferencing bridge, 63(10):294 --- HMA Annual Meeting 2004: multi-tasking in medical professions at the !48th annual meeting of the Hawaii Medical Association, 63(10):314 CORONARY DISEASE. Management of patients with chronic kidney disease presenting with acute coronary syndrome, 63(1 1):330 ---Severity of chronic kidney disease did not influence bleeding during treatment of acute coronary syndromes, 63(11):333

Gender differences in therapy for patients admitted for unstable angina and myocardial infarction with underlying chronic kidney disease, 63(11):337 --- Bleeding risk in patients with underlying chronic kidney disease admitted for acute coronary syndromes, 63(11):344 COVER ILLUSTRATIONS. Auku'u, 63(1):3 --- Hula kane, 63(2):31

Kalo, 63(3):63 --- Pele dispersing the hala, 63(4):103 --- Mele po, 63(5):143 --- Menehune, 63(6):171 --- Hulu ula, 63(7):199 --- Ku'i poi, 63(8):227 --- Kukini, 63(9):255

'Opae e, 63(10):283 --- Maika'i, 63(11):327 --- rainbow football, 63(12):359 CROSS-CULTURAL COMPARISON. Ethnic disparities in colorectal cancer incidence and mortality in Hawaii [Cancer research center hotline], 63(2):54

Patient characteristics, health status, and health-related behaviors associated with obesity, 63(5): 150 --- Rates for specific birth defects among Native Hawaiians compared to whites, Hawaii 1986-2000, 63(8):238 CULTURE. Cross-cultural medicine [Book review], 63(12):361 CURRICULUM. The role of curriculum review at the John A. Burns School of Medicine [Medical school hotline]. 63(1):18 --- Distance learning on the Internet: web-based archived cun-iculum, 63(10):287 DATABASES, BIBLIOGRAPHIC. ePoi: electronic pathways to online information facilitating access to Hawaii's online library resources [Medical school hotline], 63(5):157 DERMATITIS, CONTACT. The ubiquitous contact dermatitis from mango, poison ivy, and other"poison" plants: a humorous and interesting review. 1968 [Classical article], 63(8):231

Mango: Hawaii's forbidden fruit, 63(8):236 DEVELOPMENTALDISABILITIES. Augmentation of Spe­cial-needs Services and Information to Students and Teachers "ASSIST" a telehealth innovation providing school-based medical interventions, 63(10):300 DIABETES MELLITUS. Diabetes mellitus prevalence in out-patient Marshallese adults on Ebeye Island, Republic of the Marshall Islands. 63(2):45

DIGLYCERIDES. In search of novel molecular targets in cancer: the diacyglycerol pathways [Cancer research center hotline], 63(10):318 DISEASE FREE SURVIVAL. Are immune responses pivotal to cancer patient's long term survival? Two clini­cal case-study reports on the effects of morinda citrifolia (noni), 63(6):182 DOWN SYNDROME. Occurrence of neural tube defects and down syndrome among siblings, 63(4): 127 DRUG THERAPY. In search of novel molecular targets in cancer: the diacyglycerol pathways [Cancer research center hotline], 63(10):318 --- role of polyamines in human cancer: prospects for drug combination therapies [Cancer research center hotline], 63(12):371 ECHOCARDIOGRAPHY. A novel approach to tele-echo­cardiography across the Pacific, 63(10):310 ECONOMICS, HOSPITAL. Commentary. 2004 [classical article], 63(5): 147 EDITORIALS. Doctors are most likely to be involved in auto accidents [Editorial], 63(1):4 ---Traditional Chinese medicine: applications to heart disease and stroke [Editorial], 63(1):6

Publish your paper [Editorial], 63(2):32 --- HCMS 78th annual meeting and installation of officers [Editorial], 63(2):36 --- EMTALA/COBRA [Editorial], 63(3):64 ---Aloha HMA members [President's messsage], 63(3):66 --- voice of one ... the strength of many [Editorial], 63(3):67 ---America's health care mess [Commentary], 63(3):69

If restaurant's were run like doctors' offices [Commen­tary], 63(3):72 ---Implementation of Hawaii's prepaid health care act: root cause of a health care monopoly [Editorial], 63(4): 104 ---RobertA. Nordyke, MD July 14, 1919 -August 23, 1997 [Editorial], 63(5):144 ---FragmentsfromHawaii'smedicalhistory/NHCOE's2004 calendar [Editorial], 63(5): 145 ---Commentary. 2004 [classical article], 63(5):147 ---Oral antibiotics and breast cancer [Editorial], 63(6):172

Commentary, 63(6): 175 --- Sir William Osler [Editorial], 63(7):200 --- Oslerisms [Editorial], 63(8):228 ---American College of Physicians annual meeting- Hawaii Chapter: what's new on the horizon? [Editorial], 63(9):257 ---Guest editor [Editorial], 63(9):257 --- Telemedicine [Editorial], 63(10):284

Guest editor's message [Editorial], 63(10):284 --- What's old and still on the horizon history of the ACP­Hawaii [Editorial], 63(11):328 --- Journalism on the slopes of Haleakala [Editorial], 63(11):328 ---Peer review panel [Editorial], 63(12):360 ---Translating services in Hawaii [Editorial], 63(12):360 EDUCATION, DISTANCE. Distance learning on the Internet: web-based archived curriculum, 63(10):287 EDUCATION, MEDICAL. The role of curriculum review at the John A. Bums School of Medicine [Medical school hotline], 63(1):18 --- Experiencing life as a rural health professional [Medical school hotline], 63(6): 187 ---Teaching suturing in a workshop setting: a comparison of several models, 63(9):258 --- Integrating ecohealth in the School of Medicine [Medical school hotline], 63(10):316 --- Pathology and medical education [Medical school bot­line], 63(11):348 EDUCATION, MEDICAL, CONTINUING. Commentary. 63(6):175 EDUCATION. MEDICAL, UNDERGRADUATE. Address­ing Native Hawaiian health at the John A. Bums School of Medicine [Medical school hotline], 63(2):52 --- Clinical Laboratories of Hawaii presents an eclectic potpourri [Medical student papers], 63(3):73 --- Students teaching students: community health's School Health Education Program (SHEP) [Medical school hotline], 63(3):89 --- JABSOM's post-graduateevaluation: the intern residency program director [Medical school hotline], 63(7):214

--- John A. Bums School of Medicine class of 2008, profile [Medical school hotline], 63(9):271 --- Multimedia solutions in a problem-based learning cur­riculum [Medical school hotline], 63(12):369 ELEPHANTIASIS, FILARIAL. Chyluria due to lymphatic filariasis: case report and review, 63(7):206 EMERGENCY MEDICAL SERVICES. EMTALA/COBRA [Editorial], 63(3):64 EMERGENCY TREATMENT. EMTALA/COBRA [Edito­rial], 63(3):64 ENTEROBIUS. The cockroach as a host for Trichinella and Enterobius vermicularis: implications for public health, 63(3):74 ENVIRONMENTAL HEALTH. Integrating ecohealth in the School of Medicine [Medical school hotline], 63(10):316 ESOPHAGEALNEOPLASMS. Esophageal cancer surgery: lessons from I ,200 resections, 63(7):203 ETHNOPHARMACOLOGY. Ethnopharmacology and study of medical plants in the Pacific Islands [Cancer research center hotline], 63(5): 159 EVALUATION STUDIES. The role of curriculum review at the John A. Bums School of Medicine [Medical school hotline], 63(1):18 --- JABSOM's post-graduate evaluation: the intern residency program director [Medical school hotline], 63(7):214 EYE INFECTIONS, PARASITIC. Ophthalmomyiasis in Hawaii, 63(3):78 FAMILY HEALTH. Your family history can save your life [Cancer research center hotline], 63(8):245 FEES AND CHARGES. America's health care mess [Com­mentary], 63(3):69 FLOURIDATION. Water flouridation information found on the World Wide Web, 63(6): 185 FOOD ADDITIVES. Effects of upcountry Maui water addi­tives on health, 63(9):264 GUAM. A novel approach to tele-echocardiography across the Pacific, 63(10):310 HAWAII. Ethnic disparities in colorectal cancer incidence and mortality in Hawaii [Cancer resarch center hotline], 63(2):54 --- Ophthalmomyiasis in Hawaii, 63(3):78 --- Melanoma and Hawaii's youth, 63(3):87 ---Implementation of Hawaii's prepaid health care act: root cause of a health care monopoly. 2003 [classical article], 63(4):108 ---Fragments from Hawaii's medical history/NHCOE 's 2004 calendar [Editorial], 63(5): 145 ---Physicians and complementary-altemativemedicine: train­ing, attitudes, and practices in Hawaii, 63(6): 176 ---Rates for specific birth defects among Native Hawaiians compared to whites, Hawaii 1986-2000, 63(8):238 --- Hawaii/Pacific Basin Area Health Education Center (AHEC) is using technology to make the Pacific smaller, 63(10):285 --- international landmine telehealth symposium between Hawaii and Thailand using an Intemet2 and multi-protocal videoconferencing bridge, 63(1 0):294 ---Translating services in Hawaii [Editorial], 63(12):360 HAWAII BIRTH DEFECTS PROGRAM. Rates for specific birth defects among native Hawaiians compared to whites, Hawaii 1986-2000, 63(8):238 HAWAII HEALTH SYSTEMS CORPORATION. Com­mentary. 2004 [classical article], 63(5): 147 HAWAJIMEDICALASSOCIATION.AlohaHMAmembers [President's messsagej, 63(3):66 --- voice of one ... the strength of many [Editorial], 63(3):67 --- HMA Annual Meeting 2004: multi-tasking in medical professions at the !48th annual meeting of the Hawaii Medical Association, 63(10):314 HAWAII MEDICALJOURNAL. Publish your paper [Edito­rial], 63(2):32 --- Hawaii Medical Journal instructions to authors, 63(6):191 --- Hawaii Medical Journal (guidelines for submission), 63(7):218

Hawaii Medical Journal (guidelines for submission), 63(8):247 ---Peer review panei[Editorialj, 63(12):360

Index to Hawaii Medical Journal volume 63, 2004, -HAWAII MEDICAL JOURNAL, VOL 63, DECEMBER 2004

376

63(12):375 HAWAII/PACIFIC BASIN AREA HEALTH EDUCATION CE. How Hawaii/Pacific Basin Area Health Education Center (AHEC) is using technology to make the Pacific smaller, 63(10):285 HEALTH BEHAVIOR. Patient characteristics, health sta­tus, and health-related behaviors associated with obesity, 63(5): 150 HEALTH BENEFIT PLANS, EMPLOYEE. Implementation of Hawaii's prepaid health care act: root cause of a health care monopoly. 2003 [classical article], 63(4): 108 HEALTH CARE COSTS. America's health care mess [Com­mentary], 63(3):69 HEALTH EDUCATION. Students teaching students: com­munity health's School Health Education Program (SHEP) [Medical school hotline], 63(3):89

Comparing need between health occupation and health education schools: which schools benefit most from the School Health Education Program, 63(9):268 --- Hawaii/Pacific Basin Area Health Education Center (AHEC) is using technology to make the Pacific smaller, 63(10):285 HEALTH OCCUPATIONS. Experiencing life as a rural health professional [Medical school hotline], 63(6):187 HEALTH STATUS. Patient characteristics, health status, and health-related behaviors associated with obesity, 63(5): !50 HEART DISEASES. Traditional Chinese medicine: applica­tions to heart disease and stroke [Editorial], 63(1 ):6 HEART FAILURE, CONGESTIVE. The successful treat­ment of end stage of heart failure associated with complete right bundle branch block with biventricular pacemaker placement, 63(5): 155 HEMORRHAGE. Severe hemorrhagic complication of talc pleurodesis for idiopathic pleural effusion, 63(7):208

Severity of chronic kidney disease did not influence bleeding during treatment of acute coronary syndromes, 63(11):333 ---Bleeding risk in patients with underlying chronic kidney disease admitted for acute coronary syndromes, 63(11):344 HEMORRHAGIC FEVER WITH RENAL SYNDROME. Hemorrhagic fever with renal syndrome, 63(9):260 HISTIOCYTOSIS, NON-LANGERHANS-CELL. Hemo­phagocytic lymphohistiocytosis: a rare cause of pancytopenia, 63(9):262 HISTORY OF MEDICINE. Gerrit Parmele Judd MD 1803-1873 [Na kauka o Hawaii], 63(2): 34 ---Thomas Charles Byde Rooke MD 1806-1858 [Na kauka o Hawaii], 63(4):106

Surgical notes from ancient Tonga, 63(4):129 ---Fragments from Hawaii's medical history/NHCOE's 2004 calendar [Editorial], 63(5):145 HOME CARE SERVICES. The virtual hospital: treating acute infections in the home by telemedicine, 63(10):291 HONOLULU COUNTY MEDICAL SOCIETY. HCMS 78th annual meeting and installation of officers [Editorial], 63(2):36 HOSPITAL MORTALITY. Esophageal cancer surgery: les­sons from I ,200 resections, 63(7):203 IMMUNOGLOBULINS, INTRAVENOUS. Acute renal failure resulting from intravenous immunoglobulin therapy, 63(9):266 IN MEMORIAM. Gerrit Parmele Judd MD 1803-1873 [Na kauka o Hawaii], 63(2): 34 ---Thomas Charles Byde Rooke MD 1806-1858 [Na kauka o Hawaii], 63(4):106 INCIDENCE. Ethnic disparities in colorectal cancer in­cidence and mortality in Hawaii [Cancer resarch center hotline], 63(2):54 INFANT MORTALITY. Maternal predictors of infant health outcomes among Hawaiians, 63(2):40 INFANT, LOW BIRTH WEIGHT. Maternal predictors of infant health outcomes among Hawaiians, 63(2):40 INFORMATION DISSEMINATION. Water flouridation information found on the World Wide Web, 63(6): 185 INFORMATION SYSTEMS. ePoi: electronic pathways to online information facilitating access to Hawaii's online library resources [Medical school hotline], 63(5):157 INSULIN. Insulin-secreting cystosarcoma phyllodes of the breast: a case report and literature review [Residents' case

series], 63(7):211 INSULINOMA. Insulin-secreting cystosarcoma phyllodes of the breast: a case report and literature review [Residents' case series], 63(7):211 INSURANCE, HEALTH. America's health care mess [Com­mentary], 63(3):69 ---Implementation of Hawaii's prepaid health care act: root cause of a health care monopoly. 2003 [classical article], 63(4):108 --- [re: Prepaid Health Care Act], 63(6): 175 INSURANCE, HEALTH, REIMBURSEMENT. If restaurant's were run like doctors' offices [Commentary], 63(3):72 INTERNATIONAL COOPERATION. Walking in peace. 2004 [classical article], 63(6):173 INTERNET. Water flouridation information found on the World Wide Web, 63(6): 185 --- Distance learning on the Internet: web-based archived curriculum, 63(10):287

international landmine telehealth symposium between Hawaii and Thailand using an Intemet2 and multi-protocal videoconferencing bridge, 63(10):294 JOHN A. BURNS SCHOOL OF MEDICINE. The role of curriculum review at the John A. Burns School of Medicine [Medical school hotline], 63(1):18 ---Addressing Native Hawaiian health at the John A. Bums School of Medicine [Medical school hotline], 63(2):52 --- Students teaching students: community health's School Health Education Program (SHEP) [Medical school hotline], 63(3):89 --- Laboratory professionals: the "behind the scene" partner in hea1thcare [Medical school hotline], 63(4):133 --- JABSOM's post-graduate evaluation: the intern residency program director [Medical school hotline], 63(7):214 --- JABSOM willed body donation program, a unique medical educational experience [Medical school hotline], 63(8):243 ---John A. Bums School of Medicine class of 2008, profile [Medical school hotline], 63(9):271

Distance learning on the Internet: web-based archived curriculum, 63(10):287 ---Integrating ecohealth in the School of Medicine [Medical school hotline], 63(10):316 --- Pathology and medical education [Medical school bot­line], 63(11):348 --- Multimedia solutions in a problem-based learning cur­riculum [Medical school hotline], 63(12):369 JUDD, GERRIT PARMELE. Gerrit Parmele Judd MD 1803-1873 [Na kauka o Hawaii], 63(2): 34 KIDNEY FAILURE, ACUTE. Acute renal failure resulting from intravenous immunoglobulin therapy, 63(9):266 KIDNEY FAILURE, CHRONIC. Management of patients with chronic kidney disease presenting with acute coronary syndrome, 63(11 ):330 --- Severity of chronic kidney disease did not influence bleeding during treatment of acute coronary syndromes, 63(11):333 --- Gender differences in therapy for patients admitted for unstable angina and myocardial infarction with underlying chronic kidney disease, 63(11 ):337

Bleeding risk in patients with underlying chronic kidney disease admitted for acute coronary syndromes, 63(11 ):344 LABORATORY PERSONNEL. Laboratory professionals: the "behind the scene" partner in healthcare [Medical school hotline], 63(4):133 LETTERS TO THE EDITOR. [ re: Hawaii Medical Journal], 63(1):5 --- Hawaii physicians' support for assisted dying is grow­ing, 63(2):33 --- [re: physician assisted suicide], 63(3):68 --- [re: Prepaid Health Care Act], 63(6): 175 LIBRARIES, MEDICAL. ePoi: electronic pathways to online information facilitating access to Hawaii's online library resources [Medical school hotline], 63(5): !57 LIBRARY SERVICES. ePoi: electronic pathways to online information facilitating access to Hawaii's online library resources [Medical school hotline], 63(5):157 LIVER NEOPLASMS. Case report: a common presentation of a rare disease - hepatosplenic T-celllymphoma, 63( ll ):341 LUPUS ERYTHEMATOSIS. SYSTEMIC. Catastrophic

antiphospholipid syndrome; a "catastrophic" case of systemic lupus erythematosus, 63(12):362 LYMPHOMA, T-CELL. Case report: a common presenta­tion of a rare disease hepatosplenic T-cell lymphoma, 63(11):341 MANGIFERA. The ubiquitous contact dermatitis from mango, poison ivy, and other"poison" plants: a humorous and interesting review. 1968 [Classical article], 63(8):231

Mango: Hawaii's forbidden fruit, 63(8):236 MANUSCRIPTS, MEDICAL. Publish your paper [Edito­rial], 63(2):32 MAUL Effects ofupcountry Maui water additives on health, 63(9):264 MAUl MEMORIAL MEDICAL CENTER. Commentary. 2004 [classical article], 63(5): 147 MEDICAL ASSISTANCE. America's health care mess [Commentary], 63(3):69 MEDICAL INFORMATICS. The cancer Biomedical In­formatics Grid (caBIG): pioneering an expansive network of information and tools for collaborative cancer research [Cancer research center hotline], 63(9):273 MEDICINE, CHINESE TRADITIONAL. Traditional Chinese medicine: applications to heart disease and stroke [Editorial], 63(1):6 MEDICINE, TRADITIONAL. Ethnopharmacology and study of medical plants in the Pacific Islands [Cancer research center hotline], 63(5): 159 MEDITATION. Medicine, meditation, and Osler's aequa­nimitas, 63(7):201 MELANOMA. Melanoma and Hawaii's youth, 63(3):87 METHAMPHETAMINE. Acute coronary syndrome and crystal methamphetamine use: a case series, 63(1):8 --- Fatal postoperative arrhythmia in a man with a remote history of methamphetamine and cocaine use: a case report, 63(3):82 MICRONESIA. Diabetes mellitus prevalence in out-patient Marshallese adults on Ebeye Island, Republic of the Marshall Islands, 63(2):45 MINORITY GROUPS. University of Guam I Cancer Re­search Center of Hawaii partnership [Cancer research center hotline], 63(1):21 MODELS, ANIMAL. Teaching suturing in a workshop set­ting: a comparison of several models, 63(9):258 M ORINDA. Are immune responses pivotal to cancer patient's long term survival? Two clinical case-study reports on the effects of morinda citrifolia (noni), 63(6): 182 MORTALITY. Ethnic disparities in colorectal cancer incidence and mortality in Hawaii [Cancer resarch center hotline], 63(2):54 MULTIMEDIA. Multimedia solutions in a problem-based learning curriculum [Medical school hotline], 63(12):369 MYELODYSPLASTIC SYNDROMES. 5-azacitidine: an alternative treatment of myelodysplastic syndromes in patient with refractory responses to hematopoietic growth factor: a case report and review of literatures, 63(1):14 MYIASIS. Ophthalmomyiasis in Hawaii, 63(3):78 --- Unusual botfly skin infestation, 63(3):80 MYOCARDIAL INFARCTION. Acute coronary syndrome and crystal methamphetamine use: a case series, 63(1 ):8 --- Management of patients with chronic kidney disease presenting with acute coronary syndrome, 63(11):330 --- Severity of chronic kidney disease did not influence bleeding during treatment of acute coronary syndromes, 63(11):333 --- Gender differences in therapy for patients admitted for unstable angina and myocardial infarction with underlying chronic kidney disease, 63(11 ):337 --- Bleeding risk in patients with underlying chronic kidney disease admitted for acute coronary syndromes, 63(11 ):344 NATIVE HAWAIIAN CENTER OF EXCELLENCE. Ad­dressing Native Hawaiian health at the John A. Bums School of Medicine [Medical school hotline], 63(2):52 ---Fragments from Hawaii's medical history/NHCOE 's 2004 calendar [Editorial], 63(5): 145 NATIVE HAWAIIANS. Maternal predictors of infant health outcomes among Hawaiians, 63(2):40 ---Addressing Native Hawaiian health at the John A. Burns School of Medicine [Medical school hotline]. 63(2):52 ---Reducing cancer disparities for and with Native Hawaiians -HAWAII MEDICAL JOURNAL, VOL 63, DECEMBER 2004

377

[Cancer research center hotline], 63(7):216 ---Rates for specific birth defects among Native Hawaiians compared to whites, Hawaii 1986-2000, 63(8):238 NEOPLASMS.AANCARTcomes to Hawaii [Cancer research center hotline], 63(6):189 ---Reducing cancer disparities for and with Native Hawaiians [Cancer research center hotline], 63(7):216 --- Your family history can save your life [Cancer research center hotline], 63(8):245 ---cancer Biomedical Informatics Grid ( caBIG): pioneering an expansive network of information and tools for collaborative cancer research [Cancer research center hotline]. 63(9):273 --- search of novel molecular targets in cancer: the diacyglyc­erol pathways [Cancer research center hotline], 63(10):318 --- Polypharmacy, complementary and alternative medi­cines (CAM), and cancer [Cancer research center hotline], 63(11):349 --- role of polyamines in human cancer: prospects for drug combination therapies [Cancer research center hotline]. 63(12):371 NEURAL TUBE DEFECTS. Occurrence of neural tube defects and down syndrome among siblings, 63(4): 127 NORDYKE, ROBERT A. Robert A. Nordyke, MD July 14, 1919- August 23, 1997 [Editorial], 63(5):144

I'm third: an American boy of depression years [Book review], 63(5):146 OBESITY. Overweight and obesity, a worsening health problem particularly in children [Cancer research center hotline], 63(3):91 --- Patient characteristics, health status, and health-related behaviors associated with obesity, 63(5): !50 OFFICE MANAGEMENT. If restaurant's were run like doctors' offices [Commentary], 63(3):72 ONCOLOGIC NURSING. Oncology nurses ... who are we? [Cancer research center hotline], 63(4):135 ORNITHINE DECARBOXYLASE. The role of polyamines in human cancer: prospects for drug combination therapies [Cancer research center hotline], 63(12):371 OSLER, WILLIAM, SIR. Sir William Osler [Editorial], 63(7):200 --- Medicine, meditation, and Osler's aequanimitas, 63(7):201 --- Oslerisms [Editorial], 63(8):228 PACEMAKER, ARTIFICIAL. The successful treatment of end stage of heart failnre associated with complete right bundle branch block with biventricular pacemaker place­ment, 63(5):155 PACIFIC ISLANDS. Ethnopharmacology and study of medical plants in the Pacific Islands [Cancer research center hotline], 63(5):159 --- Hawaii/Pacific Basic Area Health Education Center (AHEC) is using technology to make the Pacific smaller, 63(10):285 --- Shriners Hospitals for Children, Honolulu's experience with telemedicine: program implementation, maintenance, growth, and lessons learned, 63(10):296 PANCYTOPENIA. Hemophagocytic lymphohistiocytosis: a rare cause of pancytopenia, 63(9):262 PATHOLOGY. Pathology and medical education [Medical school hotline], 63(11):348 PATIENT ACCEPTANCE OF HEALTH CARE. The virtual hospital: treating acute infections in the home by telemedi­cine, 63(10):291 PEDIGREE. Your family history can save your life [Cancer research center hotline], 63(8):245 PHILOSOPHY, MEDICAL. Medicine, meditation, and Osler's aequanimitas, 63(7):201 --- Oslerisms [Editorial], 63(8):228 PHYLLODES TUMOR. Insulin-secreting cystosarcoma phyllodes of the breast: a case report and literature review [Residents' case series], 63(7):211 PHYSICIANS. Doctors are most likely to be involved in auto accidents [Editorial]. 63(1 ):4 ---GerritParmeleJuddMD 1803-1873 [NakaukaoHawaii], 63(2): 34 ---Thomas Charles Byde Rooke MD 1806-1858 [Na kauka o Hawaii], 63(4):106 ---Physicians and complementary-alternative medicine: train­ing, attitudes, and practices in Hawaii, 63(6): 176

--- Problem solving in health care: the center for health outcomes, 63(12):365 PHYTOTHERAPY. Are immune responses pivotal to cancer patient's long term survival? Two clinical case-study reports on the effects of morinda citrifolia (noni), 63(6): 182 PLANTS, MEDICINAL. Ethnopharmacology and study of medical plants in the Pacific Islands [Cancer research center hotline], 63(5):159 PLEURALEFFUSION. Severe hemorrhagic complication of talc pleurodesis for idiopathic pleural effusion, 63(7):208 PLEURODESIS. Severe hemorrhagic complication of talc pleurodesis for idiopathic pleural effusion, 63(7):208 POLYAMINES. The role of polyamines in human cancer: prospects for drug combination therapies [Cancer research center hotline], 63(12):371 POLYPHARMACY. Polypharmacy, complementary and alternative medicines (CAM), and cancer [Cancer research center hotline], 63(11):349 PORTRAITS. Traditional Chinese medicine: applications to heart disease and stroke [Editorial], 63(1 ):6 --- HCMS 78th annual meeting and installation of officers [Editorial], 63(2):36 PRACTICE MANAGEMENT. If restaurant's were run like doctors' offices [Commentary], 63(3):72 PRENATAL CARE. Maternal predictors of infant health outcomes among Hawaiians, 63(2):40 PREPAID HEALTH CARE ACT. Implementation ofHawaii 's prepaid health care act: root cause of a health care monopoly. 2003 [classical article], 63(4):108 --- [re: Prepaid Health Care Act], 63(6): 175 PREVALENCE. Diabetes mellitus prevalence in out-patient Marshallese adults on Ebeye Island, Republic of the Marshall Islands, 63(2):45 PREVENTIVE HEALTH SERVICES. AANCART comes to Hawaii [Cancer research center hotline], 63(6): 189 PROBLEM SOLVING. Problem solving in health care: the center for health outcomes, 63(12):365 PROBLEM-BASED LEARNING. Multimedia solutions in a problem-based learning curriculum [Medical school hotline], 63(12):369 PROTEIN KINASE C. In search of novel molecular targets in cancer: the diacyglycerol pathways [Cancerresearch center hotline], 63(10):318 PUBLIC HEALTH. The cockroach as a host for Trichinella and Enterobius vermicularis: implications for public health, 63(3):74 QUALITY ASSURANCE, HEALTH CARE. Problem solving in health care: the center for health outcomes, 63(12):365 QUALITY OF LIFE. A community-based asthma manage­ment program: effects on resource utilization and quality of life, 63(4):121 QUENTIN BURDICK RURAL HEALTH INTERDISCI­PLINARY PROGRAM. Experiencing life as a rural health professional [Medical school hotline], 63(6):187 RAHMAN, INAM. Walking in peace. 2004 [classical article], 63(6):173 RARE DISEASES. Case report: a common presentation of a rare disease- hepatosplenic T-celllymphoma, 63(11):341 REMOTE CONSULTATION. Shriners Hospitals for Chil­dren, Honolulu's experience with telemedicine: program implementation, maintenance, growth, and lessons learned, 63(10):296 ---Augmentation of Special-needs Services and Information to Students and Teachers" ASSIST"- a telehealth innovation providing school-based medical interventions, 63(10):300 --- novel approach to tele-echocardiography across the Pacific, 63(10):310 RESEARCH. University of Guam I Cancer Research Center of Hawaii partnership [Cancer research center hotline], 63(1):21 ---cancer Biomedical Informatics Grid ( cal3IG): pioneering an expansive network of information and tools for collaborative cancer research [Cancer research center hotline], 63(9):273 RISK FACTORS. Your family history can save your life [Cancer research center hotline], 63(8):245 ROOKE,THOMASCHARLESBYDE.ThomasCharlesByde Rooke MD 1806-1858 [Na kauka o Hawaii], 63(4): 106 RURAL HEALTH SERVICES. Experiencing life as a rural health professional [Medical school hotline], 63(6): 187

SCHOOL HEALTH EDUCATION PROGRAM. Students teaching students: community health's School Health Educa­tion Program (SHEP) [Medical school hotline], 63(3):89 --- Comparing need between health occupation and health education schools: which schools benefit most from the School Health Education Program, 63(9):268 SCHOOLS. Comparing need between health occupation and health education schools: which schools benefit most from the School Health Education Program, 63(9):268 ---Augmentation of Special-needs Services and Information to Students and Teachers "ASSIST"- a telehealth innovation providing school-based medical interventions, 63(10):300 SEX FACTORS. Gender differences in therapy for patients admitted for unstable angina and myocardial infarction with underlying chronic kidney disease, 63(11):337 SHRINERS HOSPITALS FOR CHILDREN-HONOLULU. Shriners Hospitals for Children, Honolulu's experience with telemedicine: program implementation, maintenance, growth, and lessons learned, 63(10):296 SIBLINGS. Occurrence of neural tube defects and down syndrome among siblings, 63(4): 127 SKIN DISEASES, PARASITIC. Unusual botfly skin infesta­tion, 63(3):80 SOCIETIES, MEDICAL. HCMS 78th annual meeting and installation of officers [Editorial], 63(2):36

Aloha HMA members [President's message], 63(3):66. --- voice of one .. the strength of many [Editorial], 63(3):67 --- HMA Annual Meeting 2004: multi-tasking in medical professions at the !48th annual meeting of the Hawaii Medical Association, 63(10):314 SPEECH. Public speaking made easy [Book review], 63(4):105 SPLENIC NEOPLASMS. Case report: a common presen­tation of a rare disease - hepatosplenic T-cell lymphoma, 63(11):341 STOMACH NEOPLASMS. Are immune responses pivotal to cancer patient's long term survival? Two clinical case­study reports on the effects of morinda citrifolia (noni), 63(6):182 STUDENTS, MEDICAL. John A. Burns School of Medicine class of 2008, profile [Medical school hotline], 63(9):271 SUICIDE, ASSISTED. Hawaii physicians' support for as­sisted dying is growing, 63(2):33 --- [re: physician assisted suicide], 63(3):68 SURGERY. Surgical notes from ancient Tonga, 63(4):129 --- Esophageal cancer surgery: lessons from 1,200 resec­tions, 63(7):203 SUTURE TECHNIQUES. Teaching suturing in a workshop setting: a comparison of several models, 63(9):258 TALC. Severe hemorrhagic complication of talc pleurodesis for idiopathic pleural effusion, 63(7):208 TEACHING MATERIALS. Teaching suturing in a workshop setting: a comparison of several models, 63(9):258 TELECOMMUNICATIONS. How Hawaii/Pacific Basin Area Health Education Center (AHEC) is using technology to make the Pacific smaller, 63(10):285 --- international landmine telehealth symposium between Hawaii and Thailand using an Internet2 and multi-protocal videoconferencing bridge, 63(10):294 TELEMEDICINE. Telemedicine [Editorial], 63(10):284

Guest editor's message [Editorial], 63(10):284 --- virtual hospital: treating acute infections in the home by telemedicine, 63(10):291 --- Shriners Hospitals for Children, Honolulu's experience with telemedicine: program implementation, maintenance, growth, and lessons learned. 63(10):296 ---Augmentation of Special-needs Services and Information to Students and Teachers "ASSIST"- a telehealth innovation providing school-based medical interventions, 63(10):300 --- novel approach to tele-echocardiography across the Pacific, 63(10):310 THAILAND. An international landmine telehealth sympo­sium between Hawaii and Thailand using an Internet2 and multi-protocal videoconferencing bridge, 63(10):294 TONGA. Surgical notes from ancient Tonga, 63(4):129 TOXICODENDRON. The ubiquitous contact dermatitis from mango, poison ivy, and other"poison" plants: a humorous and interesting review. 1968 [Classical article], 63(8):231 TRANSLATIONS. Translating services in Hawaii [Edito--HAWAII MEDICAL JOURNAL, VOL 63, DECEMBER 2004

378

rial], 63(12):360 TREATMENT OUTCOME. Esophageal cancer surgery: lessons from I ,200 resections, 63(7):203 TRICHINELLA. The cockroach as a host for Trichinella and Enterobius vermicularis: implications for public health, 63(3):74 TRIPLERARMYMEDICALCENTER. A novel approach to tele-echocardiography across the Pacific, 63(10):310 UNIVERSITY OF GUAM. University of Guam I Cancer Research Center of Hawaii partnership [Cancer research center hotline], 63(1):21 WATER. Effects of upcountry Maui water additives on health, 63(9):264 WILLED BODY DONOR PROGRAM. The JABSOM willed body donation program, a unique medical educational experience [Medical school hotline ], 63(8):243

Author Index

BACHMANN AS. role of polyamines in human cancer: prospects for drug combination therapies [Cancer research center hotline], 63(12):371 BACLIG E. virtual hospital: treating acute infections in the home by telemedicine, 63(10):291 BAUMAN K. Diabetes mellitus prevalence in out-patient Marshallese adults on Ebeye Island, Republic of the Marshall Islands, 63(2):45 BECKHAM S. community-based asthma management program: effects on resource utilization and quality of life, 63(4):121 BELNAP C. Insulin-secreting cystosarcoma phyllodes of the breast: a case report and literature review [Residents' case series], 63(7):211 BERENBERG JL. Hemophagocytic lymphohistiocytosis: a rare cause of pancytopenia, 63(9):262 BERG BW. Guest editor's message [Editorial], 63(10):284 --- international landmine telehealth symposium between Hawaii and Thailand using an Intemet2 and multi-protocal videoconferencing bridge, 63(10):294 BERRY S. Hawaii/Pacific Basin Area Health Education Center (AHEC) is using technology to make the Pacific smaller, 63(10):285 BHAN R. Acute coronary syndrome and crystal metham­phetamine use: a case series, 63(1 ):8 BIRKMIRE-PETERS D. Distance learning on the Internet: web-based archived curriculum, 63(10):287 BLANCHETTE P. Guest editor [Editorial], 63(9):257 BOLDT DW. Teaching suturing in a workshop setting: a comparison of several models, 63(9):258 BURGESS LPA. Distance learning on the Internet: web-based archived curriculum, 63(1 0):287 CASTONGUAYB.Problemsolvinginhealthcare:thecenter for health outcomes, 63(12):365 CHAN OTM. cockroach as a host for Trichinella and Entero­bius vermicularis: implications for public health, 63(3):74 CHAN PS. Physicians and complementary-alternative medi­cine: training, attitudes, and practices in Hawaii, 63(6):176 CHEN TH. Diabetes mellitus prevalence in out-patient Marshallese adults on Ebeye Island, Republic of the Marshall Islands, 63(2):45 CHENG SF. Acute renal failure resulting from intravenous immunoglobulin therapy, 63(9):266 CHEUNG LWK. cancer Biomedical Informatics Grid (caBIG): pioneering an expansive network of information and tools for collaborative cancer research [Cancer research center hotline], 63(9):273 CHING C. ePoi: electronic pathways to online information facilitating access to Hawaii's online library resources [Medi­cal school hotline], 63(5): !57 CHING CSH. Index to Hawaii Medical Journal volume 63, 2004, 63(12):375 CHINN PL. Implementation of Hawaii's prepaid health care act: root cause of a health care monopoly. 2003 [classical article], 63( 4 ): I 08 CHITPATIMA ST. internationallandmine telehealth sympo­sium between Hawaii and Thailand using an Internet2 and

multi-protocal videoconferencing bridge, 63(1 0):294 CHOI J. Severe hemorrhagic complication of talc pleurodesis for idiopathic pleural effusion, 63(7):208 CHUNG MH. Insulin-secreting cystosarcoma phyllodes of the breast: a case report and literature review [Residents' case series], 63(7):211 CHUNG R. Patient characteristics, health status, and health­related behaviors associated with obesity, 63(5):150 COONEY RV. University of Guam I Cancer Research Cen­ter of Hawaii pmtnership [Cancer research center hotline], 63(1):21 CUENCO MMA. Index to Hawaii Medical Journal volume 63,2004, 63(12):375 DALE PW. Surgical notes from ancient Tonga, 63(4): 129 DODD A. Diabetes mellitus prevalence in out-patient Mar­shallese adults on Ebeye Island. Republic of the Marshall Islands, 63(2):45 DONLONTA. Your family history can save your life [Cancer research center hotline]. 63(8):245 ERON LJ. virtual hospital: treating acute infections in the home by telemedicine, 63(10):291 ETKIN NL. Polypharmacy, complementary and alterna­tive medicines (CAM), and cancer [Cancer research center hotline], 63(11):349 FINGER DR. Catastrophic antiphospholipid syndrome; a "catastrophic" case of systemic lupus erythematosus, 63(12):362 FORRESTER MB. Occurrence of neural tube defects and down syndrome among siblings, 63(4):127 ---Rates for specific birth defects among Native Hawaiians compared to whites, Hawaii 1986-2000, 63(8):238 FRANKE AA. Overweight and obesity, a worsening health problem particularly in children [Cancer research center hotline], 63(3):91 FRASER SL. Chyluria due to lymphatic filariasis: case report and review, 63(7):206 --- Hemophagocytic lymphohistiocytosis: a rare cause of pancytopenia, 63(9):262 FUKUDAM. Students teaching students: community health's School Health Education Program (SHEP) [Medical school hotline]. 63(3):89 FUKUHARA D. Walking in peace. 2004 [classical article], 63(6):173 GALLAGHER TE. Augmentation of Special-needs Ser­vices and Information to Students and Teachers "ASSIST" - a telehealth innovation providing school-based medical interventions, 63(10):300 GARSHNEK V. Distance learning on the Internet: web-based archived curriculum, 63(1 0):287 GEESEY YL. Effects of upcountry Maui water additives on health, 63(9):264 GIBBS B. Hemorrhagic fever with renal syndrome, 63(9):260 GLAMB RW. Unusual botfly skin infestation, 63(3):80 GOLDSTEIN N. Doctors are most likely to be involved in auto accidents [Editorial], 63(1 ):4

Publish your paper [Editorial], 63(2):32 --- EMTALA/COBRA [Editorial], 63(3):64 ---Implementation of Hawaii's prepaid health care act: root cause of a health care monopoly [Editorial]. 63( 4): 104 ---Robert A. Nordyke, MD July 14, 1919- August 23, 1997 [Editorial], 63(5):144

Oral antibiotics and breast cancer [Editorial], 63(6): 172 --- Sir William Osler [Editorial], 63(7):200 --- Oslerisms [Editorial]. 63(8):228 ---ubiquitous contact dermatitis from mango, poison ivy. and other "poison" plants: a humorous and interesting review. 1968 [Classical mticle], 63(8):231 ---American College of Physicians annual meeting- Hawaii Chapter: what's new on the horizon? [Editorial], 63(9):257

Telemedicine [Editorial], 63(10):284 --- What's old and still on the horizon history of the ACP­Hawaii [Editorial], 63( ll ):328 --- Journalism on the slopes of Haleakala [Editorial], 63(11):328

Peer review panel [Editorial], 63(12):360 ---Translating services in Hawaii [Editorial], 63( 12):360 GON SM. Laboratory professionals: the "behind the scene" partner in healthcare [Medical school hotline], 63(4):133

GOODHUE WW JR. Traditional Chinese medicine: applica­tions to hemt disease and stroke [Editorial], 63(1):6

HCMS 78th annual meeting and installation of officers [Editorial], 63(2):36 ---voice of one .. the strength of many [Editorial], 63(3):67 ---Public speaking made easy [Book review]. 63(4):105 ---Fragments from Hawaii's medical history/NHCOE's 2004 calendar [Editorial], 63(5): 145 GOODMAN MT. Ethnic disparities in colorectal cancer incidence and mortality in Hawaii [Cancer res arch center hotline], 63(2):54 GRESS FM. Hemophagocytic lymphohistiocytosis: a rare cause of pancytopenia, 63(9):262 GRONLEY K. Patient characteristics, health status, and health-related behaviors associated with obesity, 63(5):150 HALM BM. Overweight and obesity, a worsening health problem particularly in children [Cancer research center hotline], 63(3):91 HAMMAR SL. Aloha HMA members [President's mess­sage], 63(3):66 HARDMAN JM. Clinical Laboratories ofHawaii presents an eclectic potpourri [Medical student papers], 63(3):73 --- cockroach as a host for Trichinella and Enterobius ver­micularis: implications for public health, 63(3):74 --- Ophthalmomyiasis in Hawaii, 63(3):78

Unusual botfly skin infestation, 63(3):80 --- Fatal postoperative arrhythmia in a man with a remote history of methamphetamine and cocaine use: a case report, 63(3):82 --- Pathology and medical education [Medical school hat­line], 63(11):348 HAWAII MEDICAL ASSOCIATION AUXILIARY. Ger­rit Parmele Judd MD 1803-1873 [Na kauka o Hawaii], 63(2): 34 ---Thomas Charles Byde Rooke MD 1806-1858 [Na kauka o Hawaii], 63(4):106 HERNANDEZ BY. Ethnic disparities in colorectal cancer incidence and mortality in Hawaii [Cancer resarch center hotline], 63(2):54 HERR M. Insulin-secreting cystosarcoma phyllodes of the breast: a case report and literature review [Residents' case series], 63(7):211 HIRAOKA E. successful treatment of end stage of heart failure associated with complete right bundle branch block with biventricular pacemaker placement, 63(5):155 HIROSE-WONG SM. Addressing Native Hawaiian health at the John A. Burns School of Medicine [Medical school hotline], 63(2):52 HIROTA B. Severe hemorrhagic complication of talc pleurodesis for idiopathic pleural effusion, 63(7):208 HO R. AANCART comes to Hawaii [Cancer research center hotlinej, 63(6):189 HOFFMANN TN. novel approach to tele-echocardiography across the Pacific, 63(10):310 HONG R. successful treatment of end stage of heart failure associated with complete right bundle branch block with biventriculm· pacemaker placement, 63(5): !55 HOWARD LR. [re: physician assisted suicide!. 63(3):68 HUDSON DH. internationallandmine telehealth symposium between Hawaii and Thailand using an Internet2 and multi­protocal videoconferencing bridge, 63( I 0):294 IINUMA G. Effects of upcountry Maui water additives on health, 63(9):264 INOUYE DS. Fatal postoperative arrhythmia in a man with a remote history of methamphetamine and cocaine use: a case report, 63(3):82 IRIMAJIRI S. Severe hemorrhagic complication of talc pleurodesis for idiopathic pleural effusion, 63(7):208 ITANO J. Oncology nurses ... who are we? [Cancer research center hotline], 63(4):135 IZUTSU S. John A. Burns School of Medicine class of2008. profile [Medical school hotline], 63(9):271 JACOBSJ. Multimedia solutions in a problem-based learning curriculum [Medical school hotline], 63(12):369 JENKINS KA. Effects of upcountry Maui water additives on health, 63(9):264 KA'OPUALSI. Reducing cancer disparities for and with Na­tive Hawaiians [Cancer research center hotline], 63(7):216 KAAHAAINA D. community-based asthma management -HAWAII MEDICALJOURNAL, VOL 63, DECEMBER 2004

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program: effects on resource utilization and quality of life, 63(4):121 KAHOKA EHN. Ophthalmomyiasis in Hawaii, 63(3):78 KAKAZU KK. cancer Biomedical Informatics Grid (caB! G): pioneering an expansive network of information and tools for collaborative cancer research [Cancer research center hotline], 63(9):273 KARAS S. Ophthalmomyiasis in Hawaii, 63(3):78 KARCH S. Acute coronary syndrome and crystal metham­phetamine use: a case series, 63( I ):8 KASUYA R. JABSOM's post-graduate evaluation: the intern residency program director [Medical school hotline], 63(7):214 KASUYART. role of curriculum review at the John A. Burns School of Medicine [Medical school hotline], 63(1):18 KELLEY CR. If restaurant's were run like doctors' offices [Commentary], 63(3):72 KELLEY RR. America's health care mess [Commentary], 63(3):69 KIM C. Water flouridation information found on the World Wide Web, 63(6):185 KING P. virtual hospital: treating acute infections in the home by telemedicine, 63(10):291 KING RS. Hemophagocytic lymphohistiocytosis: a rare cause of pancytopenia, 63(9):262 KITAGAWA K. Mango: Hawaii's forbidden fruit, 63(8):236 KRAMER K. Students teaching students: community health's School Health Education Program (SHEP) [Medical school hotline], 63(3):89 KRAMER KJ. Experiencing life as a rural health professional [Medical school hotline], 63(6):187 KUSUYAR. Students teaching students: community health's School Health Education Program (SHEP) [Medical school hotline ], 63(3):89 LACZEK JT. Hemorrhagic fever with renal syndrome, 63(9):260 LAM L. Comparing need between health occupation and health education schools: which schools benefit most from the School Health Education Program, 63(9):268 LAW S. Esophageal cancer surgery: lessons from I ,200 resections, 63(7):203 LEE A. Severity of chronic kidney disease did not influence bleeding during treatment of acute coronary syndromes, 63(11):333 LEE EKW. cockroach as a host forTrichinella and Enterobius vermicularis: implications for public health, 63(3):74 LEE JD. [re: Hawaii Medical Journal], 63(1):5 LEE R. Comparing need between health occupation and health education schools: which schools benefit most from the School Health Education Program, 63(9):268 LIM JT. Chyluria due to lymphatic filariasis: case report and review, 63(7):206 LINDBERG M. JABSOM's post-graduate evaluation: the intern residency program director [Medical school hotline], 63(7):214 LINDSAY J. Acute coronary syndrome and crystal metham­phetamine use: a case series, 63(1 ):8 LINDSEY JL. Shriners Hospitals for Children, Honolulu's experience with telemedicine: program implementation, maintenance, growth, and lessons learned, 63(10):296 LORENZO PS. In search of novel molecular targets in cancer: the diacyglycerol pathways [Cancer research center hotline], 63(10):318 LOZANOFF S. JABSOM willed body donation program, a unique medical educational experience [Medical school hotlinej, 63(8):243 LUM JJ. Management of patients with chronic kidney disease presenting with acute coronary syndrome, 63(11):330 --- Severity of chronic kidney disease did not influence bleeding during treatment of acute coronary syndromes, 63(11):333 --- Gender differences in therapy for patients admitted for unstable angina and myocm·dial infarction with underlying chronic kidney disease, 63(11 ):337

Bleeding risk in patients with underlying chronic kidney disease admitted for acute coronary syndromes, 63( II ):344 MADISON JR. Management of patients with chronic kidney disease presenting with acute coronary syndrome,

63(11):330 --- Severity of chronic kidney disease did not influence bleeding during treatment of acute coronary syndromes, 63(11):333 --- Gender differences in therapy for patients admitted for unstable angina and myocardial infarction with underlying chronic kidney disease, 63(11):337 ---Bleeding risk in patients with underlying chronic kidney disease admitted for acute coronary syndromes, 63(11):344 MARINEAU M. virtual hospital: treating acute infections in the home by telemedicine, 63(10):291 MCAULIFFE J. Experiencing life as a rural health profes­sional [Medical school hotline], 63(6):187 MCCLATCHEY W. Ethnopharmacology and study of medical plants in the Pacific Islands [Cancer research center hotline], 63(5):159 MERZ RD. Occurrence of neural tube defects and down syndrome among siblings, 63(4): 127

Rates for specific birth defects among Native Hawaiians compared to whites, Hawaii 1986-2000, 63(8):238 MOORE NK. Hawaii/Pacific Basin Area Health Education Center (AHEC) is using technology to make the Pacific smaller, 63(10):285 MORRIS AD. I'm third: an American boy of depression years [Book review], 63(5):146 ---Cross-cultural medicine [Book review], 63(12):361 MOSER SM. Commentary. 2004 [classical article], 63(5):147 MUNIR JA. novel approach to tele-echocardiography across the Pacific, 63(10):310 --- Case report: a common presentation of a rare disease - hepatosplenic T-celllymphoma, 63(1 1):341 NAGAO CFK. Ophthalmomyiasis in Hawaii, 63(3):78 NAGUWA G. role of curriculum review at the John A. Burus School of Medicine [Medical school hotline], 63(1):18 NAGUWA GS. Students teaching students: community health's School Health Education Program (SHEP) [Medical school hotline], 63(3):89 NATHANSON R. Hawaii physicians' support for assisted dying is growing, 63(2):33 NAVIN JJ. Clinical Laboratories ofHawaii presents an eclectic potpourri [Medical student papers], 63(3):73 --- cockroach as a host for Trichinella and Enterobius ver­micularis: implications for public health, 63(3):74 --- Ophthalmomyiasis in Hawaii, 63(3):78 ---Unusual botfly skin infestation, 63(3):80 --- Fatal postoperative arrhythmia in a man with a remote history of methamphetamine and cocaine use: a case report, 63(3):82 NGUYEN MM. Severe hemorrhagic complication of talc pleurodesis for idiopathic pleural effusion, 63(7):208 NIP I. Comparing need between health occupation and health education schools: which schools benefit most from the School Health Education Program, 63(9):268 NTSHIKI M. John A. Bums School ofMedicine class of2008, profile [Medical school hotline], 63(9):271 OMORIJ. Multimedia solutions in a problem-based learning curriculum [Medical school hotline], 63(12):369 ONO CM. Shriners Hospitals for Children, Honolulu's experience with telemedicine: program implementation, maintenance, growth, and lessons learned, 63(10):296 ONO JC. Unusual botfly skin infestation, 63(3):80 PANG LW. Effects of upcountry Maui water additives on health, 63(9):264 PEABODY JW. Maternal predictors of infant health outcomes among Hawaiians, 63(2):40 PERSON DA. Insulin-secreting cystosarcoma phyllodes of the breast: a case report and literature review [Resident's case series], 63(7):211 POLISH R. Case report: a common presentation of a rare disease- hepatosplenic T-celllymphoma, 63(11):341 PRESTON G. Case report: a common presentation of a rare disease- hepatosplenic T-celllymphoma, 63(11):341 PRESTON GG. Hemophagocytic lymphohistiocytosis: a rare cause of pancytopenia, 63(9):262 ROBERTS JR. Catastrophic antiphospholipid syndrome; a "catastrophic" case of systemic lupus erythematosus, 63(12):362 ROHNER AL. Effects of upcountry Maui water additives

on health, 63(9):264 SAKAI DH. role of curriculum review at the John A. Bums School of Medicine [Medical school hotline], 63(1):18 SEIFRIED SE. ePoi: electronic pathways to online informa­tion facilitating access to Hawaii's online library resources [Medical school hotline], 63(5): 157 --- Distance learning on the Internet: web-based archived curriculum, 63(10):287 SETO TB. Management of patients with chronic kidney dis­ease presenting with acute coronary syndrome, 63(11):330 --- Severity of chronic kidney disease did not influence bleeding during treatment of acute coronary syndromes, 63(11):333 --- Gender differences in therapy for patients admitted for unstable angina and myocardial infarction with underlying chronic kidney disease, 63(11):337 --- Bleeding risk in patients with underlying chronic kidney disease admitted for acute coronary syndromes, 63(11):344 SHAHA SH. Problem solving in health care: the center for health outcomes, 63(12):365 SHIGEMASA SR. University of Guam I Cancer Research Center of Hawaii partnership [Cancer research center hat­line], 63(1):21 SHIMW. Problem solving in health care: the center for health outcomes, 63(12):365 SHOULTZ J. Experiencing life as a rural health professional [Medical school hotline], 63(6):187 SOE T. Diabetes mellitus prevalence in out-patient Mar­shallese adults on Ebeye Island, Republic of the Marsball Islands, 63(2):45 SOH EK. international landmine telehealth symposium between Hawaii and Thailand using an Intemet2 and multi­protocal videoconferencing bridge, 63(10):294

novel approach to tele-echocardiography across the Pacific, 63(10):310 SONSON JM. Gender differences in therapy for patients admitted for unstable angina and myocardial infarction with underlying chronic kidney disease, 63(11):337 SPIES C. Management of patients with chronic kidney disease presenting with acute coronary syndrome, 63(11):330 --- Severity of chronic kidney disease did not influence bleeding during treatment of acute coronary syndromes, 63(11):333 --- Gender differences in therapy for patients admitted for unstable angina and myocardial infarction with underlying chronic kidney disease, 63(11):337 ---Bleeding risk in patients with underlying chronic kidney disease admitted for acute coronary syndromes, 63(11):344 STEWART JP. novel approach to tele-echocardiography across the Pacific, 63(10):310 STITHAM MD. [re: Prepaid Health Care Act], 63(6): 175 STOOD RT. weathervane, 63(1):26 --- weathervane, 63(2):58 --- weathervane, 63(3):98 --- weathervane, 63(4):138 --- weathervane, 63(5): 166 --- weathervane, 63(7):222 --- weathervane, 63(6): 194

weathervane, 63(8):250 --- weathervane, 63(9):278 --- HMA Annual Meeting 2004: multi-tasking in medical professions at the !48th annual meeting ofthe Hawaii Medical Association, 63(10):314 --- weathervane, 63(10):322

weathervane, 63(11 ):354 --- weathervane, 63(12):382 SUMIDA KNM. 5-azacitidine: an alternative treatment of myelodysplastic syndromes in patient with refractory responses to hematopoietic growth factor: a case report and review of literatures, 63(1 ): 14 SUWANAWIBOONB.5-azacitidine:analtemativetreatment of myelodysplastic syndromes in patient with refractory responses to hematopoietic growth factor: a case report and review of literatures, 63(1):14 TAIRADA. Patient characteristics, health status, and health­related behaviors associated with obesity, 63(5):150 TANSY. Commentary, 63(6):175 TANJI V. ePoi: electronic pathways to online information facilitating access to Hawaii's online library resources [Medi--HAWAII MEDICAL JOURNAL, VOL 63, DECEMBER 2004

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cal school hotline], 63(5):157 TAVARES DK III. Effects of upcountry Maui water additives on health, 63(9):264 TODD WA. Maternal predictors of infant health outcomes among Hawaiians, 63(2):40 TOKESHI J. Severe hemorrhagic complication of talc pleurodesis for idiopathic pleural effusion, 63(7):208 TOKUHARA KG. Teaching suturing in a workshop setting: a comparison of several models, 63(9):258 VAREZ D. Auku'u, 63(1):3 --- Hula kane, 63(2):31

Kala, 63(3):63 --- Pele dispersing the hala, 63(4):103 --- Mele po, 63(5): 143 --- Menehune, 63(6): 171

Hulu ula, 63(7): 199 --- Ku'i poi, 63(8):227 --- Kukini, 63(9):255 --- 'Opae e, 63(1 0):283

Maika'i, 63(11):327 ---rainbow football, 63(12):359 VEEHALA DP. Hawaii/Pacific Basic Area Health Educa­tion Center (AHEC) is using technology to make the Pacific smaller, 63(10):285 VINCENT OS. intemationallandmine telehealthsymposium between Hawaii and Thailand using an Internet2 and multi­protocal videoconferencing bridge, 63(10):294 VOLOCH K. community-based asthma management program: effects on resource utilization and quality of life, 63(4):121 WAJANAPONSAN N. Acute renal failure resulting from intravenous immunoglobulin therapy, 63(9):266 WASHBURN A. community-based asthma management program: effects on resource utilization and quality of life, 63(4):121 WEEDER RS. Medicine, meditation, and Osler's aequa­nimitas, 63(7):20 I WERMAGER P. ePoi: electronic pathways to online informa­tion facilitating access to Hawaii's online library resources [Medical school hotline], 63(5):157 WJJETUNGA M. Acute coronary syndrome and crystal methamphetamine use: a case series, 63( l ):8 WILCOXBA. Integrating ecohealth in the School of Medicine [Medical school hotline], 63(10):316 WILKENS L. cancer Biomedical Informatics Grid (caBIG): pioneering an expansive network of information and tools for collaborative cancer research [Cancer research center hotline], 63(9):273 WILLIAMS L. Melanoma and Hawaii's youth, 63(3):87 WITHY K. Hawaii/Pacific Basin Area Health Education Center (AHEC) is using technology to make the Pacific smaller, 63(10):285 WONG DKW. Are immune responses pivotal to cancer patient's long term survival? Two clinical case-study reports on the effects of morinda citrifolia (noni), 63(6): 182 WONG J. Esophageal cancer surgery: lessons from l ,200 resections, 63(7):203 WONG MM. Physicians and complementary-alternative medicine: training, attitudes, and practices in Hawaii, 63(6):176 YAMADA KS. Bleeding risk in patients with underlying chronic kidney disease admitted for acute coronary syn­dromes, 63(11 ):344 YAMADA S. Diabetes mellitus prevalence in out-patient Marshallese adults on Ebeye Island, Republic of the Marshall Islands, 63(2):45 YAMAMOTO LG. Water ftouridation information found on the World Wide Web, 63(6):185 ---Teaching suturing in a workshop setting: a comparison of several models, 63(9):258 YONEHARA C. virtual hospital: treating acute infections in the home by telemedicine, 63( 10):291

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Nothing Is So Firmly Believed As That Which We Least Know. What optometrists don't know, will hurt people. The American Society of Cataract and Refractive Surgery, (ASCRS) has closed its annual meeting and scientific program to optometrists. Exceptions will be provided for those optometrists who work directly under the supervision of ophthalmologists. Like everyone else in medical practice, theASCRS wants to keep knives and lasers out of the hands of non-medical people. Legislatures (e.g. Hawaii) are prone to follow the dollars and the lobbying rather than exercising logic and protecting the public. More than ever, Hawaii eye surgeons must carry the label eye-MDs, to emphasize the enormous difference to our patients.

If You Think You Understand Everything That Is Going On, You Are Hopelessly Confused. Sometimes it seems that our world is more imperfect than we could imagine. In Texas, two patients brought law suits against their HMOs. A woman had extensive pelvic surgery, including bladder and rectal repair and hysterec­tomy, and was sent home one day after surgery, as directed by the health plan. Her surgeon had recommended a longer stay, butthat was denied! She developed complications and had to return to the hospital. In the second case, the HMO formulary substituted the primary care doctor's fora cheaper pain reliever. The patient developed GI bleeding from an ulcer, nearly died from a heart attack, and spent five days in the critical care unit. In Texas, a patients' rights act makes health plans liable for damages caused by HMOs' negligent decisions. However, the HMO defendant attorneys trumped the Texas law by moving the case to a federal court where ERISA (Employee Retirement Income Security Act of 1974) takes precedent. ERISA allows one to sue the plan, but only for denied benefits, and not for damages. The US Court of Appeals supported the litigants, stating "ERISA should not be interpreted to pre-empt state malpractice laws." The nine balding and hoary-haired group in Washington D.C. unanimously overruled the appel­late court and essentially gave the HMOs license to make any error and not have to pay. Thanks a lot. Rehnquist and company.

Ever Since Adam, Fools Have Been In The Majority. Doctors behaving rudely? Yes, it happens, and all too often. At Tulane Uni­versity Health Sciences Center a system has been introduced called "code pink." When a doctor is yelling and berating a nurse or other staff person, code pink is called and suddenly a group of people are standing behind the staff person. The doctor abruptly realizes he/she is behaving badly and calms down. In a national survey of 1600 hospital executives, one-third of the CEOs reported disruptive physician behavior at their facilities. Not rarely, a doctor will insult a patient or a colleague, scream at nurses, ignore pages, throw a pen or a chart, or strike a wall, or even swear at staff. Because of the difficulty keeping staff people, and the fear of litigation, hospitals are becoming less tolerant of such behavior. Policies are being developed, disciplinary actions are increasing, and some hospitals may require the bad-ass doctor to get counseling.

It Is A Sin To Believe Evil Of Others, But It Is Seldom A Mistake. Coming out at election time in candid support of John Kerry, six past presidents of the American Academy of Pediatrics and noted author T. Berry Brazelton, M.D. prepared a collaborative statement entitled, "Our Children Deserve Better." Briefly, the joint declaration condemns President George Bush for his failure to attend to the health of America's children. Noting specifically that 27 million children were without health insurance at some point in 2002-03, and alleging that the administration shows little commitment to maternal and child health services. The protest notes a lack of attention to pre-natal care, inattention to preventive health services such as immunizations, and little help with acute and chronic illnesses such as asthma. To add credence, the statement was signed by 36 leading pediatricians, including chairs and professors of pediatric medicine and past presidents of other prominent medical associations. The message includes a statement "we embrace John Kerry's straightforward goal that every American deserves the same affordable health care that is available to every member of Congress and government official." So say we all. That proposal has been offered many times within and outside of medical organizations, and Congress has consistently ignored it.

I'll Buy The Election, But I Can't Afford A Landslide . .Joseph P. Kennedy Moving into the critical November election, one has to wonder about the matter of Alzheimer's patients' votes. Tests ofliteracy in the south for blacks (How do you spell chrysanthemum?) and poll taxes have long been ruled out, but as longevity increases some legitimate difficulties arise, largely about cognitive potential. Such considerations as how to assess capacity to vote, and what kind of assistance is fair and logical, and how to work out a uniform policy for different venues. A charge nurse in an extended care facility could control a dozen votes, more or less. But, as they say in Chicago, vote early and often, and don't vote for, always vote against.

When Your Ship Comes In, The Tax Man Is Waiting On The Dock. Oprah (You remember her; big land owner on Maui.) gave away a new Pontiac G6 to all 276 people in her studio audience September 13th. But, there ain't no free lunch, and no free car either, because the car represents added income of about $28,500. This means that a married person with two children and an income of $18,000 will lose over $4,000 in refundable tax benefits and have a tax due of$1, 170, plus a state tax. A couple filing jointly with income of$56,000 will owe an extra $6,000 in taxes, and a well-to-do person with income of $143,500 will have additional taxes of $12,000. Of course, the car can be sold, but there is no escaping the tax burden of once having owned it. If Pontiac should pick up the sales tax and various income taxes due, there is still a tax on the value of any "free" tax payments, which is called a gross up. With the IRS, it's called Gotcha!

Alcohol - The Only Enemy Man Has Learned To Love. The airlines offer wine for travelers, but there is rarely a choice. Even in first class, the label might be "Chateau Fleet Street" and the discriminating palate can be offended. Now, American Airlines (first and business class) and Jet Blue (any class) will allow you to BYOB (bring your own wine), will chill it for you if they have room, and they will serve it without a cork­age fee. They even let you take leftovers with you. At this date, United, US Airways and Southwest only serve the wine they sell.

Fashion By Any Other Name Is .Just As Ridiculous. In an effort to provide a stylish image for men, Riviera Concepts Inc., is distributing the fragrance of the Hummer. Yes, the scents of big powerful autos such as Jaguar, Ferrari and now Hummer are part of the $920 mil­lion men spend annually on smelling good. In Hummer's case, the aroma is not actually the smell of grease and belchfire exhaust, but is a complex of green leaves, thyme, and peppercorns blended with the smell of leather, sandalwood, patchouli and tonka beans. Supposedly, the scent creates the "essence of outdoors." Hey, why not! Dump the girlie-man Old Spice and go for the Hummer; it sells for a mere $52 for 4.2 ounces.

Send In The Clowns - Don't Bother, They're Here. A senior high school student in Crawford, New York, wanted to round out his extracurricular activity for his college application. He saw an ad for the school's Civil War Club, joined up, and participated in a weekend mock battle replicating the battle of Chancellorsville. An ever-alert school security guard spotted the student's parked car, saw a uniform and a fake musket, and notified the police. The student was arrested on a weapon's charge, and the school suspended him for five days pending an expulsion hearing for violation of its zero tolerance weapons policy. You've got to feel safer with people like these protecting us.

ADDENDA •!• A 22year old woman developed a brain abscess (strep viridans) four

weeks after a tongue piercing which caused oral infection. •!• Life span of the eagle, 40 years; the parrot 120 years. •!• Never date a mushroom, even if he is a fun guy.

Aloha and keep the faith - rts•

Contents of this column do not necessarily reflect the opinion or position of the Hawaii Ophthalmological Society and the Hawaii Medical Association. Editorial comment is strictly that of the writer.

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