-

II

FAWA1U.

I

\\ hat s Hi olani CareCnter at Khala \ui?

A The newly opened1 liolani Care Centerpresents a new era in seniorhealth care, providingassisted living, memorysupport and nursing.1-ii’olani Care Center on thecampus of Khala \ui.Oahu’N new benchmark insenior living.

\\hat makes 1-IkolaniCare Center different ?

Hi’olani Care Centerbalances the finest medicaland personal ca iv with thelatest technology. f—li’olani ‘5

Medical Director, Dr. RobertCries, is a graduate of theLniversitv of Hawaii’sCeriatric Medicine Fellowsprogram, one of the fourlargest fellowship programsin the nation. At Hkolani,you’ll find compassion,respect for each individual’sd igni tv and preferences,plus weilness programs formind, body and spirit. It’sthe finest choice for thosewho need e\tra siapportand gives peace ot mind tothe families who love them.

kJ \‘hat’s Fli’olani ‘sgJiding principle?

A Very simply: I liolaniCare Center wants ourresidents to live as well aspossible for the rest of theirlives, We’re committed tomaintaining a physicalen ironment and anattitude that fosters optimalliving for each resident.

0 Where do Hi olanresidents live?

I [i’olani Care Centeroffers 41 assisted livingapartments, 22 memor\support suites, and(iP nursing beds, mostlyprivate, which canall be personalized toreflect ‘home.’

CACC \ hat services areincluded at l—lkolani?

Hi’olani nursing staft is

available 2-I-hours evervdato support all the actix ities

of daily living large andsmall. Tempting gourmetmeals are prepared underthe supervision of [ii olani‘s full-time registereddietician. For assisted livingand memory supportresidents, there are weeklyhousekeeping and linen -

services, and daily brnursing residents. Aroundthe clock security and alertcystems pro\ ide safe andsecure living. Transportationi worrx -free withcomplimentary scheduledtrips to various medical andreligious facilities.

Chat a menities doHiolani Care Centerresidents enjoy?

Depending on theirabilities and preferences.HIolani residents enjoy awide variet\ of amenities.:\ssiCed li\ I ng residentsI iave access to a spectru in ot

keep residents in touchwith the greater Honolulucorn ni unity.

FJ Is there a minimumag requirement?

A Hi’oiani Care Center atKáhala u i is intended forresidents over 62.

0 f-low much does it costtve at Hi’olani?

fi Fees or assisted living,memory support andcomprehensive nursing arecomparable to other privatenursing centers. There areno entrance tees orresidency requirements. Calltoday about theintrod uctorv Mea Alohapricing program.

Is Hi’olani the rightplace for my loved one?

Only you can determinethat, and you’ll only knowhg visiting I liolani CareCenter yourself. To receivemore information, or toarrange a tour to ee oure\ceptiona I care- i lb thehpirit ot Ohana, call i--li’olaniCare Center today at (808)218-7052.

Knowledge.Compassion.Dignity.

The Spirit of Ohana Differencere nationaltarnilr( ‘id

0 1de\ h1. mc it

icti ities’like classes

Ii 11c ftc, 1 c.

lotlearning.OtliL rm iiti

i lud naits studio,salon and barhet shop.and common areas brc t tiinin’ h mnchoice enrich e ch d\at H olani hiletrequent e\cursions

-

Hi olani Care Center atKhala Nui is now open andwaiting to care for yourloved one with assistedliving, memory support andcorn p rehensi ye nursing.

Isn’t that what your lovedone deserves?

I (:::“ [_, “ .1.

(808) 218-7052www.kahalanui.com

I’1’

V

,I

1/

,/‘ J”CP

ili’olani Lire (‘enterC9 \Dlia Sheetllon,lcilu. [‘Ij’cii -i(,S21

HAWAIIMEDICAL

JOURNAL(US PS 23764O)

Published momhlv by theHawaii Medical Association

Incorporated in I 856 under the Monarch360 South Fleretania, Suite 200

Honolulu, Hawaii 9681 4 520Phone. (808) 536-7702: Fax (808) 528-2376

EditorsEditor: Norman Goldstein M [)

Contributing Editor: Russel ITStodd MD

Editorial BoardJohn Breinich MIS, Satoru Izutsu Phi),

Douglas C. Massey Mi), Myron F. Shirasu Nit),Frank F. Tahrah MD. Alfred D. Morris MD

journal StaffEditorial Assistant: Drake Chinen

OfficersPresident: Ittant Dr Rahman MD

President—Elect: Patricia Lartoie Blanchette Ml)Secretary: Thomas Kosasa MI)Treasurer: Paul DeMare ML)

Immediate Past President: Sherrel 1-lammar MD

County PresidentsHawaii : Jo—Antt Sarnhi Ml)

Honolulu: Scott McCaffrey MDMaw: Howard Barharosh 111)West Hawaii: Kevin Kunz M[)Kauai : Christopher Jordatt NI I)

Advertising RepresentativeRoth Commrtnications

2040 Alewa DriveHonolulu, Hawaii 96817

Photte (808) 595-4124Fax (11(08) 595-5087

The. Journal cannot he held responsihlt. for opinions expre.s:sedpapers. discas:s.ion, eommun.iearions or advertisements. The

adse.rtisinn p05ev of the llioraii Medical JOurnal is: eoverne.dhthe. rules of t.he Ci ttnei I on Drng.s of the Ame.riean MedicalA.s:srse.iation. ‘(‘he rieht is reserved to reje.ctmaterial :nhmitte.d foreditorial or ad e.rtis:ine columns, The. lJawaii 4’led”’aI Jou.rno.i(USPS 2376411) is puhlishe.d monthly by the. Hawaii Me.dicalAssoc:ation 115 SN 1)0121859411. 1381) South here.tania Street,S sic 11 1 e: I a II n 68 -s

iheassaster’rienil :ultltv’.v hanests to the. liesraii .t,,fedil’oflwtt ‘hen I) Sit S tt Ott Hi tt ltlt ‘1 vi

96814. Periodical postitge: pair) at ftonrtluln, Hawaii,Notttttettthe.r snhseriptiotts itre 5215. Copvrinltt 2005 hr the

ht,s itt \t dt ii S ow ti e I tite I 5 1 v

Contents

Editorial: Our Medical Students are Special People;‘s’orotait Goidsteio Ml) 176

A Medical Student’s Journey at the John A Burns School of Medicine

Kr/st/we L.M. Lee 178

Letters to the Editor 179

Efforts Toward Prevention in Hawaii: Resources for Providers to CounselPatients About Healthy LifestylesKeiiev M. Witltv MD .Shaoo P. Berry MD, Mar/so Lee, and Se/fl Yaotada MD, MPH.,,,.. 180

A case of hermaturia with rapidly progressive renal failureThot-Oliter Klein MD a,td Sit io-Feng S/terse/n (‘heng MD ....................................... 184

Residents’ Case Series: An 82 year-old man with chest discomhwtNec/into I), Rat’i MBBS, MPH, I-larry!. Bighaot Mi), You A. Devehaic MD,aitd Met’ao Wiiettot,c’a Mt) 188

Medical School Hotline: Medical Student Involvement in Research in thePre-Clinical YearsKeittoit Kramer PhD 1 90

Cancer Research Center Hotline: Hawaii’s Comprehensive Cancer Control ProgramCarolyn Gatos’ P/tD, IA’pg/n/a Press/er MD MBA, FACS,

and Weitdy 3m/too 135W, MAOM 192

HMJ Guidelines for Submission 94

Classified Notices 197

WeathervanePt’ it//I (told WD 198

reserved by the artist.

Cover art by Dietrich Varez. \IAlcano, Hawaii All rights

Kukui

Depictine Hawaiian candlronut,

175

EDITORIAL

Norman C i MD, FACPEditor, Hawaii Medical Journal

T T

iiJDTf’/ IT

Those of us who teach medical students at the John A.Burns School of Medicine know how truly special ourstudents are. With diverse backgrounds, educationalexperiences and dreams of their futures in medicine,we, the full-time and clinical faculty, are blessed to havethese excited, intelligent and compassionate studentteaching experiences.

One such student is Kristine Lee, who recently completed a Dermatology elective. In order to give hera diverse view of Dermatology priorities I arranged arotation through my office and the offices and clinicsof dermatologists Joseph McKinlay M.D., John BoyerM.D., and Douglas Johnson M.D., and plastic surgeonsRobert Peterson M.D. and Greg Caputy M.D. Kristinealso observed anesthesiologist and cosmetic tattooauthority Linda Dixon M.D.

Kristine was invited by the Interim Dean of the Schoolof Medicine to present her JABSOM experience at ameeting of the University of Hawaii Foundation onApril20, 2005. Her presentation to the Foundation appearsonpagel78. (

50 Years of Dedication to Hawaii’s Physicians!

Trr: mn

Secretar.: Jr. MD

Stephen thia ALP.

CAleb, H e•n PhD.

Ann Barbara Lee PhD.

• Professional 24 Hour Live Answering Service

• Relaying of Text Messages to Pagers and CeLl Phones

• All Calls Confirmed, Documented and Stored for 7 Years

• KIPAA Compliant

• Affordable Rates

• PaperLess Messaging

• Receptionist Services

• Subsidiary of Honolulu County Medical Society

• Discount for Hawaii Medical Association members

the chtierence ut a nnff answering service. Pall rrl for

intorina (ion,

‘ce H in/i/ia 1ana ,‘r

Physicians Exchange of Honolulu, Inc.1360 S. Beretania Street, #301

Honolulu, HI 96814

524-2575

Honolulu County Medical Society

cv:

. :ALfl .dhicv

ecvvg and prco

Its rnernbevs and

lisa The betterment

at fublic cad maintain Pa high

standards ci j.cj practice thrauab

peer review

President: D. Scott McCaffrey, M.D.

President-Elect: Iohn Rausch, M.D.

Immediate Past President: Ronald H. Kienitz, D. 0.

Scrtar: Roger T. Kimura, M.D.

Treasurer: Vince Yamashiroya, M.D.

Trsurer-ELeci: David Young, M.D.

5fri;5j Caunty Medical Saciety13.60.5, Beretan:ia St.

Hanalulu, HI 96814(808) 5366988

A MEDICAL STUDENT’S JOURNEY AT THE JOHN A.BURNS SCHOOL OF MEDICINEbY K[USTINE LM, LEE

My journey through medical school was one of discovery and womder. I am an explorer of the human body. mind and spirit. I knewsince the third grade that I wanted to he a physician. The climacticmoment came when I needed stitches in my finger. and my father.a local physician, sewed me up. Since that time. I have been on ajourney to accomplish this fiat. I attended the University of Idahounder scholarship. where I learned all of my basic science and eniharked on experimental genetic research, Of course at the time, theresearch was on zebra, not m sophisticated hipedal counterparts.During my senior year, I applied to attend the John A, Burns Schoolof Medicine and was accepted. I rememberthinking that my journeywas over, I had gotten into medical school and I was set up. I learnedin a hurry that I was wrong.

Thit ear of medical school, I carried around Stedman’smedical dictionary. You have to learn a new vocabulary and wayof communication to understand medical literature, or even whatthe nurses and doctors are talking to each other about. We alsostarted seeing patients the first week of school, We were like littleducks, following our attending physician around Queen’s hospital,trying to walk as fast as he did, and talking to patients who knewway more about medicine than us, The entire time, we relied onthe excellent staff and teachers to pull through and help us adjustto our new lives,

As second year rolled around, our confidence was being built. Wenow had a full year under our belts. We also had 50 new friendsand comrades all experiencing the dizzy whirl of life as a medicalstudent. The countless hours of studying until 3 in the morning atthe old Biomed building. The rush to see who would get that lastcopy of the latest cardiology hook. Typing up our learning issues inthe old library and resource center the fastest so that you wouldn’trun out of printing paper. Traveling to UC Irvine together to studyfor our hoard exams. The fun little games we made up to keepourselves sane.

Then the third year of medical school hit us like a ton of bricks,Su.ddeniy, we’re work.ing, 1 Of) h.ou.rs a week. directly wit.h pat.ie.ntsin the hovpitai a.n.d in c.].inics. We’re respon.sihi.e •for patients’ livesrow. I. rem.emhe.r delivering my fi.rst baby and te.arin.g up because.someon.e allowed me to share that most intimate ti.me in thei.r h.fe.I also reme.mher seeing su.rgery perft.wmed for th.e first time andhem a.wed by the. power rf me.dicine A.nd standing, next to youare your future colleagues. iearni.ng and ahsorhi..ng evervth.ing withyou. Propping cash other up in lectures when falling asleep seemsto he the only cptlon a.nd making: sure that everyone has somethi.ngto eat. It’s in this hectic time that you start truly Icr ruing how muchImpact a doctor has a patient. Most of t.he. time., it’s not just apill that will cu.re the. patie.n.t. It’s e.ducatin, th.e.m about. th.e.ir illness,gtfm,, tii kn a rhi i mrl commuor. mug s ith thLO I mds I

learned to accept that medicine is not perfect. and that each patient

is truly an individual that must he approached di’ffhrentl each time.We have had an excellent education and training here at JABSOM,Our teachers and patients have taught us that compassion, empathy,and the spirit of ohana is just as important as knowing how’ to sutureand prescribe blood pressure medications,

As fourth year of medical school rolls around, we’ve started toapply for residency’ positions. We had an electronic application, andsoon enough, we scattered to the wind. We flew to all corners of theUnited States interviewing with dozens of hospitals to find just theright program. Residency is the training you receive after medicalschool in your specific field of interest, I will he moving up to SanFrancisco and working at Kaiser to receive three additional years oftrainintz in internal medicine, This program focuses on outpatient,clinical training, I will have my MD, hut there is still so much learasing to do. I have responsibility for all the patients. making medicaldecisions and prescribing medicines, hut we have a guiding farceof physicians who oversee us.

After residency is finished, I intend on moving hack to Hawaii andjoining my father’s practice at Kuakini. It’s not just my father’spractice, hut our small family business, My’ mother is an LPN andan office manager. and they opened their clinic in the late 70’s afterdad finishedtraining in internal medicine atthe University of Hawaii,Everyday after school was spent in that office, and patients, or my“aunties and uncles” would often comment on my presence and

ask me when I was going to let dad have a break and take over, I’malmost positive that none of them had the gift of fortune telling andknew that it would actually happen some 25 years later, I’m goingto try and convince him not to retire too early, hut stay and sharehis pearls of wisdom with me. I am honored to receive my’ parents’legacy’ and look forward to helping all of our patients, those “aunties and uncles” who encoura’ed me and have trusted my family totake care of them, I am so grateful that I have had the opportunity toreceive my education in Honolulu, and that I will he able to returnto Hawaii and take care of our Kama’aina,

178

LETTERS TO THE EDITOR

‘Tort reform wouldimprove medical care”

The recem comments by Timoth I N IacMaster, attornc\ at law

disparacine the need for medicalma practice tort reform ‘‘( iaiher—tue Place:’ Star—Bulletin. April26 can he summari/ed. Basicalls, his message is: Doctors are

p em in] md ther make t s olmone compared to the generalpublic. He asks, “Why shouldpatients and their families havetheir constitutionally guaranteedrights to trial hyjury taken awayin order to enable cardiologiststo make more money!”

I—Ic misses the importance oltr\ inc to balance the cost of

continuing a medical practicein managed care situations, likeprepaid insurance companies andMedicare. that prevent costs frombeing passed on to the consLimer.

Phvsiciansarefacing acontinued

reduction of reimbursement fortheir services with increasingcost of medical malpracticeinsurance. Therefore. mau\ doctors are reducing their Medicareand high—risk patients. and thatis the truth of the matter.

We were not given the salariesof the plaintiff attorneys to compare with the physicians listed.Nevertheless, there are tvs ii

suggest ions thai come to mind.

Since ph\ siciamis are has inc toreduce their charges to patieni 0

provide medical service. ssouldit not he lair to ask attorne sto take loss er contingenc lees

rather than the cumomarv 3))

percent ) so that more moneycould be passed on to their deserving clients in the settlementof cases? Furthermore, if theattorneys in the United Statescould accept svhat is practicedin several other democraticcountries, laws could he passed

so that the plaintiticould ay all

the costs if the case was pros edto he ss ithout merit. This latter

condition would discourage the

abundant “nmsance sLnts thatare settled merel because it is

more espensive for the insurance

company to light the cases es enif they are not justi lied,

Malcolm R. lug ME)Kapiolani Medical Center

Editor’s Note:DiR Leire; to rile Es//for -lp

/kalrvl i/I rile Iioilo/ii/n .fnnI/u//er/i; LLII( 1 liii /kft’e. l /2.(Ji J1j(/(l\ tliv o. 2005

Re: The HonoluluProfessional Program

l)ear Norm,

\\ e have tecentl\ opened anoutpatient cheuuc;il depen—dencv ireatmeru gm brprofesso inal s. There are limitedaddiction treatment tacilitiein Honolulu and none that address the particular needs of theprofessional. Though chemicaldependency as a disease hassigns and symptoms commonto all, professionals tend to risea similar set of delences thatmake treatment together morebe ne Ii ci al

Vie otiera full railge of outpatienttreatment services. including initial evaluatioti. Intensis e Outpa—ieiit Treatnient. lani i I r tteatment

& aftercare as ss eli a treatmentof co-occurring disorders.

Gerald McKenna, MD is a Harvard trained addictionist andpsychiatrist with esperience invarious treatment settings, having worked in Boston, los Angeles and Haw an. Michael Foleyhas a master in social ss ork and adoctor of psychologx decree. inaddit ion to a docti r of Mi iii ‘a rv.He has established treatmentcenters in the t nited States and

the nited Kingdom. WilliamPerri, PhD is a psychologist whopros ides psychological testingfor our clients. John Keenan hasa Ps\ 1), PhI) is trained as :i nenn ps\ JR log i st and has e \tens 5 C

clinical e\perience in outpatient& residenttal chemical dependence treatment settings

T ee t her. our team ss ill pros idethe km id il prolessional treat ii tentou w ish for your probessiotmalpatients with addictive disorders.We provide convenient es eninghours in our ofhce on SouthKing Street in the First Interstate

BLnld;ng.

Please contact our stat) torfurther in formation. Vs e Ii H

forward to ssorking with you,

Sm ncerel s,

Gerald J . McKenna Ml)Medical Director

Michael F. Foley MSW, PsvD,

Progam DirectorMm

1314 South King Street,Ste. 962Honolulu, HI 96814Ph: (808) 536-7338

(808) 246-0663

179

Efforts Toward Prevention in Hawaii:Resources for Providers to Counsel PatientsAbout Healthy Lifestyles

4r1 — O,.” “‘L JJ r—

Author& Aft fiat ions:Hawaii/Pacific Basin Area

Health Education Center: JohnA, Burns School of Medicine,iK,M,W. SRB.. S,Y,)

University of Hawaii,Department of Family Medicineand Community Heaith (KMW,S.P,B,)

Correspondence fo:.Seiji Yamada MD, MPHEmail: seiji@hawaf.eduPhone: (808) 3583505Fax: (808) 6921258

AbstractAs part of the Healthy Hawaii Initiative professionaleducation campaign, 14 focus groups were conductedacross the state with primary care providers, staffand community leaders to determine what messagesabout healthy lifestyles work with patients in healthcare settings. Focus group members indicated thatculturally sensitive andpersonalbsed messages, positive reinforcement, and teamwork are most effectivein counseling patients.

IntroductionIn the US, tobacco use, poordiet and physical inactivityaccountforover 30% of all mortality. In their analysisof2000 mortality data Mokdad and colleagues bound thattobacco accounted for 435,000 deaths or 18. lCi; of totaldeaths, and poor diet and physical inactivity accountedfor 365,000 deaths or 15.2% of total deaths.’ Accordingto the January 2004 Progress Review of the nutritionand overweight objectives of the Healthy People 2010Project. the prevalence of obesity is increasing acrossall racial and age segments of the U.S. Additionally,there has been no appreciable increase in the intake of

fruits, vegetables, and whole grains, or diminution ofthe intake of high fat foods. Among the many barriersto decreasing obesity and poor nutrition, the reportidentified “[L lack of acceptance ofobesity as a diseaseby a large part of the public, healthcare providers, andthird-party payers,”2While tobacco continues to leadas the underlying cause of death, the prevalence ofsmoking among adults has declined from 25% in 1990to 22.5% in 2002. As the campaign against tobaccomatures, the Healthy People 2010 Progress Reviewrecommends customizing antismokmg messages toreach occupational and ethnic groups that continueto show relatively high prevalence of cigarette use.as well as collaboration between public and privateentities,4

To address these behaviors, the State of Hawaii isutilizing a portion of its share of the tobacco mastersettlement funds for a program titled “Start LivingHealthy,” the goal of which is to improve lifestylechoices by promoting simple and consistent lifestylemodification messages to all of the people of Hawaii2.The messages of the mass media social marketing

campaign are (I) Eating Better, (2) Getting Active,and (3) Living Tobacco Free, The State of HawaiiDepartment of Health also supports activities to promote these messages in schools and in communities.In order to achieve synergy among the social marketingcampaign, community activities, and the health caresystem, the Hawaii Department of Health has collaborated with the University of Hawaii John A. BurnsSchool of Medicine Area Health Education Center todevelop and deliver an educational campaign knownas Provider Training for Changing Habits (PiTCH).

Because of their credibility and authority regarding health issues and long-term relationships withtheir patients. health care providers play a centralrole in motivating patients to adopt positive lifestylebehaviors. However, in the U.S., during the I 990s. inclinical encounters with patients with obesity, diabetes,hyperlipidemia, or heart disease, fewer than 45% ofpatients received counseling regarding diet, and fewerthan 30% of patients received counseling regardingphysical activityi’ Fewer than a quarter of physiciansassess and counsel patients about tobacco use7, andonly 42% of obese adults in the U.S. report that healthcare professionals advised them to lose weights. Failure to perform such preventive counseling has beenattributed to time constraints, lack of reimbursementfor counseling services, and limited knowledge aboutnutrition andnutritional counseling among physicians9.However, in order to prevent the morbidity and mortality that arise from tobacco use, poor diet, and physicalinactivity, the adoption of healthy lifestyles must heencouraged at every possible opportunity.

To this end, a task fArce including representativesof academia, physicians, nurses, nutritionists, thepublic health community, local legislative membersand the private sector met regularly during 2003 toreview and adapt national guidelines for local needs,In order to assess the needs of the unique population ofHawaii, this group organized 14 focus groups of healthcare providers across the state to examine the role oflifestyle education in clinical practice in Hawaii, Participants were asked about harriers to and facilitatorsof providing patient education, and techniques thoselocal providers have found to he useful, This article

Sni’i Yamada MD. MPh’

00005 uED:CAL jouFir’iA.L, VOL 00,0255 2.005

180

describes the results of these locus groups and how they ser”.ed as

the basis for the de elopment of a curriculum to equip providerswith simple and easy-to-remember messages regarding smokingcessation, diet, and exercise.

MethodsThe task force developed a structured focus group discussion outlineand contracted with a private research firm to hold focus groupsacross the state. Institutional review hoard exemption was obtainedfrom the University of Hawaii Committee on Human Subjects.Participants were selected by convenience sampling. One—hundredsixteen participants (34 primary care ph sicians. 34 non—ph sicianhealthcare providers. 4t) medical olOce staff, and X communit”. lead

ers ere divided into fourteen locus groups according to occupationand practice location. The locus group discussions were conductedTom June 2003 to August 2003 on Oahu ( focus Sroups). the Big

Island of Hawaii (2 focus groups), Maui (2 focus groups). Kaua’ i

I focus group), and \Ioluka’ i (I focus group). Providers’ length

of practice. experience, and ethnic background varied. The setting

they practiced in included hospitals, community health centers.

private practices, and group organizations.The groups were led by an experienced focus group moderator

who utilized the focus group discussion outline developed by the

PiTCH Task Force. She encouraged individuals to share their

opinions in an open discussion format. Topics co ered in the focus

groups included: current health issues. current health practices. bar

riers to healthy lifestyles and behavioral change, solutions to healthissues, physical activit. nutrition, smoking. health education, and

partnersh ps between organizations and health care professionals.Each focus group meeting was two hours in duration. Task force

members observed the groups from behind a one—s’ ay mirror or

the hack of the room as dictated by the location. The focus groups

crc audio tape-recorded. and transcribed. Summary and transcriptswere provided by the research firm, and the task force applied a

hermeneutic method of interpretation, moving from part to wholeand back, to extract the most significant meanings from the focus

groups. Disagreements in interpretation or emphasis among the

authors crc resolved through discussion.

Results

Barriers to Patients Adopting Healthy LifestylesHealth care providersagree that thegeneral population ofthe StateotHas’. au —including adults, adolescents, and children — have unhealthylitest les such as poor diet, ph\ sical inactis its, and lack ofpres enta—ive care that contribute to chronic health problems such as heart

disease, diabetes, hypertension. hypercholesterulernia, asthma, andgout. Participants believe that “the lack of understanding of what

a healthy meal is and what actually is meant by regular exercise”poses a harrier for patients and that “we have to do screening andeducate [the puhlic[ for ph-” ention.

Fear of aining ss eight. pc pressure. and increased stress ssere

noted as obstacles to patients stopping sinokmv. Passis e entertain—inent, busy lif’estv Ic’, and ea’c of obtaining last food were identi—tied as barriers to hcalth lifcstles. The a ai lahilit of food ofpoor nutritional value in the schools was ident ii ied as part icu ladpiolilciiatic. Thesc kids from elementary through high school

— if they’re being ingrained to eat junk foods in school, and the ‘re

already eating junk food on the outside, especiall on ss eekends

— hoss are we going to train these people to change that diet ss hen

they become adults’?”Most of the participant health care pros iders reported asking their

patients about smoking history. However, fewer asked abotit diet

or exercise unless patients presented with medical problems such as

diabetes, hypereholesterolemia, or obesity. Due to time constraints,providers tend to discuss one aspect of prevention at a time. “In asituation where you know this patient is going to come hack againand again and again ou’ll have opportunities to address this one andthat one in their turn. So it’s not like you lorget the others because

you only have an opportunity today to address one.”A communE expressed opinion \vas that patiems generally do

not present for care unless they have some sort of problem. ‘‘l.’n—

fortunately we don’t see too many people that just come unless they

has e a pain or something.” Ness I”. diagnosed medical conditionsare seen as opportunities and motivalors for behavior change. “If

we identify a problem like diabetes or elevated cholesterol or blood

pressure. often I go with the approach [lifestyle changes I because

they don’t want to start on medication right away so the usual first

treatment is exercise, eating healthy”.

Physicians uniformly agreed that they had little time to counsel

patients, but were i’eceptive to learning simple approaches to en

couraging health lifestyles. Most participants did notrecogni e the

“5A’s” for smoking cessation (ask, advise, assess, assist, arrange’when queried about it, let alone name them. When told what the

5A’s stood for, however, man declared that they’ perform all the

suggested tasks —- that they just don’t think of them as the “5A’s.”Many participants cited the lack of reimbursement forcounseling

regarding lifestyles as abai’riertoperforming such counseling duringmedical encounters. There were many complaints that obesit\ has

not been a reimbursable diagnosis. A related problem identified by

the participants was that nutrition counseling was not reimbursed for

patients who are simply obese, while, in contrast, it is reimbursed

for patients with diabetes. A number of clinicians found it ironic

that they had to wait for overweight patients to develop diabetes

before being able to rekr them for nutrition counseling A number

of participants expressed dismay’ that pharmacologic aids br smok

ing cessation, nicotine replacement products and hupropion. aie notcovered b insurance. ‘‘Three years ago a woman caine in ss ho had

just spent I () da on a sentilator in our hospital. She had chronicrespirator disease and smoked and coi ldn ‘t get off of c icarettes.

She shossed ne the QEEST [Medicaidl bill where they paid for

close to 60.0()t) for her lCI care, and she said. ‘The ‘,son’t gis c

me a S 100 for the damn patches.”

Useful techniquesMany focus group participants described the need for a variety of

methods to reach patients and described different approaches formembers of different genders. cultures or ethnic groups that theyhad found successful.

III us’c 1 ,,i!,’. I Ii h’.ilk-nw’ IIi,’m uiiJ ‘a’.. “but knau. I lu r an

an in rhi-, “ - t,ni an finn n hat.’ .lkn Inn’ nd c/n , .,

!iiaviv’,,ji’.’ I’.’. /fl’’l in’ \nII thai ihc’. ,,iij il, Ii, faii ‘.,ln I il’.’ i/i,

‘.Ini ihhiw in a n,’nun, .‘.‘.‘. I un’ a d,ti’i’ iii i/)/)i’a’nJl. I an (ui a?

ia/k r’.’unl ii, “I.e t’. ta/k ah’.’ui i/Il’. a’. a l)I’nl)li11I “ flit/t in’. lIia/

181

lii hoic iheni (rune milk iinel ihevve list O juiuncLs. and then bloodpress ins is crei rn

SoilitiIliic.s /hoca sssiiiIu ehinijue esperiii/Ivr//iiiir’/ninhllereveil .Iapaiu 51 unite parnilis. Oav. / in i(i in it lo have you go ‘unsethat be the i/inc that (‘ii 1 ‘un in to see no the nec! lone von ni/I bedown ni s/irIi and sue/i a ,ieihi,” hometun,s it works,

“n1 hole to respect the culiuis’ nuniber one, You have to see whattheir support system is and where that support is going to conic /rom

its not/list i/ic panent I,iir who are i/ice yonrt to have their supportfrom. ‘ “br some ruliins s Uk’stcrn mcdi, inc is sort oi like ,i lastresort.

‘‘i/i, lu/lu/al Orii’t, /001/il l,,iv, veil i/s/i tour prop/c i//lit doe.i,’u ale jour times in rim/c d,iv.

Man prco iders emphasized building trust,

“There a,v iechniques. i/von will, ii creatuiy an atmosphere 0/trust.Absolute/v it takes time, but it also takes o certain amount of skill.

I knon I/ia! ill mnakc ins wI/i u/rn tab/c and i/li ( i cal this slots o/ins south ,i,id earls adulthood and so on, it setS a standard fin ‘chatyou can reveal in the eva/li m,’lnn So if lie done it then thee ,,iii too,

[hat ‘sine ste/c. In c/ni’ ci el/I I ilunk build/nit trill! is appropriate 1//Ill

/iiiderst,mn,lmy loin ,ou ,w,ile a irustoly eIil’ii’nllmnr’Ilt ‘iliciiin s,’li ca/I

take risk ,ii,c/ reveal i/un ys ,/iId discuss them 1/1(1! would be m is’,i/lvimportanl pal’! nJ am behmn’ior 111,01Cc i’urrieu/uni I would think.”

Positive reinforcement and lack of a judgmental attitude s\ crcdescribed frequently. 1 think they (providers) needs to look at theperson.. in a holistic way you’re not just going to say you needto lose weight but vvhat is it you enjoy?””.. if the patient just losta little bit of weight I’d sa ‘Wow, you’re really firming up hereand you lost a couple of pounds and you really look good.vs ould encourage them ss ith positive reinforcement.” “Go. c themkudos.

Most pros iders emphasized a team approach svherchv the ss orkcould be distributed and patients contacted b man members ofthe medical office. Many non—phe sician pros idcrs and office staffdon’t feel it is appropriate to counsel patients unless directed to doso by the physician. Therefore, patients will benefit maximally ifthe lead health care provider initiates a collaborative program and,expresses enthusiasm, and provides ongoing support forthe programor system introduced.

Useful resources

The focus groupsemphasized the need fortcamwork in theof lice andin the community to disseminae the Start Living l-lealthe message.I nterdi sci pl nary tcamw( rk — s’ol laborat ion among pros iders. localhospitals, the medical school, the health department, and the corn—munity - vs crc seen as having a positive impact upon encouraginghealthy lifestyles. .Solutions discussed included early education,team managers and team efforts initiated by the physicians andimplemented by other health professionals in the office setting.

Fools cited by providers as helpful include posters, brochures.health walks. pcdorsseters. health fairs. literature and videos as ailablefordistnbuiion to in-div duals and groups. Insurance reimbursementfor counseling, for necess;ire medications, for gym membershipwere all described as desirable Start Liv nig I leaf thy media spotson television and at the mos ie theaters vs crc cited as ps/’itiv e influences oii the lives of their patients. though the participants reflected

on their own, rather than on their patients’ reactions to these spots.Speci lie visual aids that participants viewed as effectis e includedthe poster depicting a baby smoking inside his mother’s uterus anda poster of a tobacco diseased lung, as well as bode mass indc\(BMI) charts.

li/sri have a B/v/I , hart in all no’ ri’n’ms, rmcl actually I don / thunk9brt of tim tinie I bring it up. I t/nnk because I have ii there, and I’malways late to see ins patients. thies’ h,ii’e tin/c’ to look cit the ii ct/I cinchlie/us’ tIPs out. And be tIm dine uvulA in, thee re like, “1/es what isthis tinny. rind hon csnni’ liii in i/u.s red section in.steorl oIl/nc greemiSe, -Inn ,ver heis-.’” Si, ihriis abnr’s li/a ,i slop liy/it. .5’oie permple,,/ii I even eel oii i/u ,hart i/mi i/nit s list ierv itrmrm,l, So ili,’i, lie brinya up, so / ‘ii say ,navb, oh, ‘i/i ‘O/a isl the li/il,.

F’inalle . dancing. such as hula. ballroom and line dancing, was anactis it recommended lw many pi’ov idcrs,

Rural areas were perceived to have fevver resources than urbanareas. especially where physical activity was concerned. Ruralcommunity members have less access to fresh foods, are less awareof healthy messages.. and have less educational materials availableto them. Rural pros iders identified pi’eventive services, healthscreenings, and health classes as unmet needs in rural areas. Alsopatients in lower socioeconomic classes had less access to fitnessequipment. On the other hand. whereas middle class individualshave access. they lack the time to use it.

The above ideas ss crc then i’c\ iessed e the PiTCH Task Force.together with the latest guidelines and research findings and incorporated into a brief curriculum for providers across the state.Brochures, posters, and pedometers have been delivered duringin-office visits by the PiTCH staff and at large group meetings ofproviders in Hawaii.

DiscussionAs a public health intervention, the Start Living Healths campaign is

dii’ecied toss ard the entire populace. with the intent of improvine thehealth status of all the people of Hays au. In contrast, physicians seetheir patients one at a time, and therefore think in terms of diseasestates and risk factors for morbidity and mortality. Many physiciansnoted that they are not comfortable discussing prevention on a firstvisit. but primary care providers who have a longitudinal relationshipwith theirpatients utilize this relationshipto promote the adoption ofhealthe lifestyles. 01’ necess itv. primary care providers personalizethe messages that thee give to their patients. and find that positivereinforcement and cultural adaptation of the message increase theirperceived success. In the office setting, teamwork was describedas necessary to succeed in prevention counseling, because of thelongstanding time demands of medical care and the lack of financialincentives to counsel patients. However it was noted he office staff.that the initiative must he taken by the health care pros ider, at vvhichtime staff feel empowered to participate.

Limitations of this study’ include the lack of a method to ensurethat the focus group participants are statistically representative ofthe population of pi’o\ iders iO 1-lass an. This is. liv’vs cv ci’. a qualitato. e stuth: its results can form the basis for subsequent quantitati\ estudies on counseling of pat/c/Its he ploy iders,

182

Gender and Cultural InfluencesThat middle-aged Japanese men are identified as being moreamenable than others to directive instructions by their providersimplies that different strategies might he of varying efficacy withdifferent populations. Further study should explore the possibilitythat different strategies work better with men vs. women or withdifferent ethnic groups.

Need for provider reimbursementIt was apparent that the providers wanted to help their patients adopthealthy lifestyles, However, they did not have the time to provideall of the counseling they could. Enhanced collaboration amongmembers of the healthcare team and better reimbursement fromthird-party payers would facilitate such efforts directed at healthpromotion and disease prevention. That obesity is increasinglyrecognized as a reimbursable condition is a great advance.

ConclusionsExamined in terms of actual causes of death, tobacco, poor diet, andphysical inactivity continue to be the majordeterminants of preventable death in the U.S. The obesity epidemic continues to worsen,as does world-wide consumption of nicotine. We can have no hopeof reversing these trends without a concerted effort that involvessociety as a whole. Messages that patients receive in the consultingroom, the waiting room and from the office staff must be consistentwith those that they receive from their families, friends, neighbors,and those that they receive from the mass media. These messagesmust be personal, culturally sensitive, appropriate and delivered withpositive reinforcement. In an effort to develop simple but useful

lifestyle modification messages that they can deliver to patients.we asked health providers what they need to know. Our task forcehas drawn on the focus group results reported here to develop thePiTCH curriculum. The task now is to disseminate the messagethat Hawaii’s health care providers can encourage their patients toadopt healthy lifestyles.

AcknowledgementsWe would like to thank the participants of the focus groups. the staff who arrangedand helped conduct the focus groups. and the members of the PiTCH task forcewho helped review the transcripts and develop the curriculum.

ReferencesMokdad AH, Marks JS. Stroup OF. Gerberding JE Actual causss ot death in the united States. 2000.JAMA 200429t:t23845. Erratum. JAMA. 2005:293(3i:293-4. Fiegal et al estimate the mortahtvattributable to Obesity to be much iOwer, Fiegal KM. Graubard El. Wiiliamson OF. Owl MR Escessdeaths assocmted with underveight. overweight, and obesity. JAMA. 2005:293:t86tt867.

2. us Oepartment ot Health & Human Services. Progress review: nutriSon and overwwght. 2004 Jan21. h5pj/wwwJeaithpeopRgov/data/2010grog/tocu&i9/default.htm

3. us DepartmentotHealth & Human Services, Progress review: tobaccouse, 2003 May14. hit :J/wam.htKyp.eo.pleovIrthiZ0I0progfoeua27Idefadll.btw

4. Ibid.5. Hawaii community Foundahon, Tobacco settlement spemal tund questions and answers, bllpJ/www.

ha.waiicommunjoundabon.orgdinsms/hcfiTS$FQ.AUpd.ateJansarv2003trtf Accessed8/29/04

6. Ma J, J, urizar GG. Alehegn T Staffort PS. Oet and physical activey counseling during ambulatorycare visits in the unted States, Preventive Medians, 2004 Oct 3914): 8t5’822.

7, Thorndtte AN. Riqoth NA. et ci. National patterns m the treatment ot smokers by physmans, JAMA.t998: 279: 604’8.

8. Galuska 0.. WrIl J.. Serdula M., & Ford E. Are Health care Proteawonals Advising Obese Patients toLose weight? JAMA. 199g. 282. 15761578,

9. Guzman SE. American Academy of Family Physmians Panel on Obesity. Practical advice tor tam/yphyaicranstohelpoverceightpatients. bJiw/iwww.aaf .or/Pr.aBuiltiobesHmonograh.gdi, accessed8/29/04.

10. Fiore MC. Bailey we, Cohen SJ. et al. Treating Tobacco use and Oependence. Chnical PrachceGuidehne, Rockville. MO: u.s. Oepartment of Health and Human Services. Public Health Service,2000.

Tons oltraining..Long Hours..

$bort on time.I’ve been there.

• Experienced working with physicians in realty.• Experienced working with physicians in hospitals... I’m an RN.• Experienced working with physicians at home... I’m married to one.

I understand.

The Physician’s Heal [slate Specialist.Con Hamilton, RN, RA, ABR, CRS

(808) 375-3959

RE/MAX Kai Lani 25 Kaneohe Bay Drive #109, Aikahi Shopping Center Kailua, HI 96734Each RE/MAX office independently owned and operated.

A case of hematuria with rapidlyprogressive renal failure

A0tnor Atf:aorDecaoer o nterna

Mertcne Ues:t oHawai.H: 10K SFS::

Tom-0ll•ver Klein MDDepartment of Internal Medicine,University of Hawaii1356 Lusitana Sf, 7th FlHonolulu, Hi 96813Fax 808: 586-7486Eoa: 1Dm osen

Case ReportA 76 \earoldiapanese man was admitted to the hospitalbecause of acute renal failure and hernaturia. Duringa routine physical exam 6 months prior to admissonthe patient was found to have microscopic hematuria.I-Ic ss as treated for presumed urinar tract infection.but his urine analvs is continued to sho proteinuria

100 mgdI . 50—IOU red blood cells /HPF. 4—10 hvalinecasts per low power tield (LPF) and 5-20 ‘a hue bloodcell! high power field (HPF).

One month priorto admission the patient representedto his primary care physician with a history of sevenkilogram unintentional weight loss over two monthsas well as bilateral leg swelling, increased fatigue anddecrease in exercise tolerance. Laboratory abnormalities included an elevated BUN and Creatinine of 23mg/dl and 1.9 mg/dl respectively, a hemoglobin of11.7 g!dl. ahematocrit of35.6 with normal indices, awhite count of I X.8 x l0/mm without a left shift anda thrombocvtosis of 737 x I 0d!mm. An urinanalvsisrevealed proteinuria I 100 mg!dl). significant blood‘a ith > 100 RBCHPF. 3-10 hyline castsiLPF.5-20WBCHPF arid man bacteria.

One week prior to admission the patient was referredto a nephrologist due to hematuria and progressiverenal failure with a BUN of 32 mg/dl and a creatinineof 2.3 mg/dl - His anemia had worsened (Hb 9.6 g!dl.hematocrit 28,7Uf) and his white count continued torise (23.2 x 103/mm) His serum iron level and totaliron binding capacity ‘acre both low (15 mcgdl. 164mcgdl respectivelv ‘a hi Ic the serum ferritin level ‘a aselevated 1050 mc mli Reticulocvtecount ‘a as normaland an dc’ ated Flapioizlobin was elevated. PS:\ ‘a as0.3 ng!ml.

Further evaluation sho’a ed a 24 hour creatinineclearance of 25 ml miii and a protein excretion of

2.Ut mg24 hours. Tests for hepatitis A. B. C. antiglomerular basement membrane antibodies. ANA,CS. C4 levels and a c-ANCA (Anti-Protcinase-3) of

1 .2 Units/mI were normal. His p-ANCA was stronglypositive with> 100 Units/nil (normal <9 U/mlL ESRwas elevated with 59 mm/hr. Serum electrophoresisshos ed hypoalbuminemia and a high alpha-I . gamma

traction with a normal beta fraction and no mc clonalbands. The urine elecimophoresis shoe cr1 proteinuria

with predominance of the albumin fraction. Becauseof rapidl progressive glomerulonephritis he was

admitted to the hospital.Further review of srstems revealed a chronic non—

producti e cough. He denied an Orver. chills, nightsweats. sinus or hearing probletiis. henioptvsis. nosebleeding. chest pain. palpitations. nausea. vomiting.constipation. diarrhea. niusculoskeletal pain, arthritis.d suria. rash or pruritus.

Past medical history included hypertension,COPD.hypercholesteremia and hperuricemia. The patienthad surgery for a spontaneous pneumothorax 2 yearsago. His medications included Allopurinol and Atorvastatin.

Physical exam on admission showed an alert oldergentleman in mild respiratory distress. His blood pressure was I 40!7OmmHg with a heart rate of 6/mm.Temperature was 39.3CC and his oxygen saturationwas 93L on room air. Several scars were noted onthe right chest from his prior surgery. There were nopetechiae. purpura or other rashes. Head. ear, noseand throat exam ‘a as normal. Auscultation ofthe chestrevealed a mild expirator\ wheeze ‘a ith a prolongedexpiratorv phase. Abdominal including a guaic stool.cardiac and neurologic exam sxere normal. There ‘a asmoderate bilateral pitting edema up to both kneespresent.

Chest X-Ray on admission showed a mild congestive pattern with cardiomegaly and small right pleuraleffusion.

The patient was admitted to the hospital and startedon ceftriaxone. Tuberculosis ‘a as considered and thepatient ‘a as placed on into respirator\ isolation. Subsequentlr his PPD. blood— and spinum cultures ‘a crcall negatin e including AFB. The patient continued to

hax e persistent fver up to 39.4 °C.Due to his acute renal t/nlure and positive p-ANCA

he undem’a ent a left kidne\ biopsy on hospital da

The kidneys appeared normal during the kidneybiopsy.

The patient was treated with Methylprednisolone750 mg IV daily for 3 doses followed by Prednison

80 mg per day that was initiated because of the highsuspicion for rapid progressis e glomeruloncphmitis

184

The biopsy subsequently shosed segmental necrotizing gloinerulonephntis (GN with focal necrotizing arteritis most consistent withpauci—immnnc glomerulonephritis. Immunofluorescence did notshow signilicant immune comple\ deposits. 5-6 out of IX glomerulihad glohal cellularcrescent tormation and moderate tubulointerstitialnecrosis with mononuclearinliltrateon lieht microscopv.The findingson election microscopy conlirmed the ones from light mircoscop\.O erall these findings are compatible oh the diagnosis of smallessl asculitis. There v as no report of necrotitingr granulomas.Because of the biops results and his posit. ix e p-ANCA the diag

nosis of microscopic polarterntis nodosa PAN was most likely.The l)itieit was also started on I O() mg Cvclophosphamide orall\The patient became afebrile after the first dose of steroids, lie v asstarted on Vitamin D and Calcium supplements to prevent steroidinduced osteoporosis. Trimethoprim—Sul famethoxazole was initiated for PCP prophylaxis as well as a small additional treatmentbenefit. His creatinine peaked at 3.5 rng/dl before returning to hispreadmission level. His WBC count also improved. His anemia remained stable and the patient was discharged on Cyclophospharnideand Prednisone, The patient expired one year later with a normalcreatinine due to unrelated respiratory failure,

DiscussionAsvmptoniatic microscopic heinatLiria has a broad differentialdiagnosis ranging from benign conditions such as vicorous exer—cisc. sexual activity, menstruation over urinar tract infections andnephrolithiasis to serious conditions such as glomerulonephritis orcancer. A repeat urinanalxsis is recommended to see if’the hematuria

is persistent and to guide further evaluation Afollow up in 6 monthsin case of isolated glomerular heniaturia is reasonable to check forthe development of proteinuria or renal insufficiency.

The combination of hematuria and protemnuria suggested a gb—merular site ot the bleeding and nonglomerularcauses like neoplasm.nephrolithiasis. cv sticdiseasc. papillar necrosis ormetaholic reasons

crc unlikely. The urinanalvsis suggested a nephritic svndm’om. Therapid progression of symptoms and accompanying renal failurerepresented a rapid progressive glomerulonephritis RPGN > whichis a clinical presentation of mans different glomerulonephritis.

There are three broad categories of nephritic syndrome. The firstis grouped tocether as immune—complex olomerulonephropathiesand includes immune mediated lg—A nephritis. membi’ano—prolifera—live ON and postinfectious ON. The history did not re cal a prioracute respiratory or abdominal infection which may suggest Ig-Anephropathy the most common form of glomerular hematnria. Although he presented with symptoms of pneumonia the time coursedoes not suggest postinfectious glomerulonephritis. On physicalexam and history there were also no signs suggesting secondarycauses such as systemic lupus ervthematosus (SLE) or other rheumatological diseases. Diagnostic workup for postinfectious ONwith Antistreptolysin 0 +‘- anti-deoxvribonuclease B and C3 wasnegative. SLE was unlikely with normal levels of C4 .ANA andC3 which in contrast to postinfectious ON remains low after 2—3months.

Memhranoprolifcrati cON associated with HCV and crvoglohu—ins were ruled out. The second category of nephritc syndrome are

the anti—basement glomernlonephropathies including Goodpasttn’e’s

Kahu Malama Nurses, Inc.Short and Long Term Relief Staffing

Temporary and Permanent Placement

21 Years Experience in Hospital StaffingLocally Owned and Managed by Nurses

1357 Kapiolani Blvd.. Suite 850

syndrome and localized anti-GBM disease which should be suspectedin patients with concomitant lung involvement as in this ease Anti—

glomerular basement antibodies were negative.The third category is erouped under ‘small es’el vasculitis or

pauci—immune disease (due to irtuallv no antibody deposition inthe nephron ( and consists of three major entities with \Vegenergranulomatosis. Churg—Straus’, syndrome and microscopic po1 —

angiitis, The\ are all closeE related and distinct from pol arteritisnodosa, Thetriad of symptoms include systemic necrotizing angiitis,

necrotizing inflammation of the respiratory tract and necrotizing

glomerulonephritis. The original description of the Churg-Strauss

syndrome included asthma, eosinophilia. granulomatous inflamma

lion, necrotizing systemic \ asculitis and necrotizing glomerulone—

phritis. To distinguish bet een the other t o entities p—A\CA for

microscopic polvangi tis and c-ANCA for Wegener granuloniatosisshould be ordered. Our patient had positive p—ANCA suggesti\ e ofmicroscopic P.-\N (ni-PAN . Even with this positive .ANCA con

stellation the diagnosis of rn—PAN is not definite. Nonetheless. the

treatment ofWG and m-PAN is the same2.in rn-PAN approximately

70% have ANCA. It is useful in supporting the diagnosis when the

clinical setting is suggestive of ni-PAN, Histopathology remains

the gold standard for diagnosis. A negative ANCA assay does not

exclude ANCA-assoeiated vasculitis (I0-50 may be negative )‘.

ANCA may also be used to monitor disease activity7,

In rnostcases.delinitediagnosis is rnadeh\ kidney biopsr .AI.adnebiopsy is es aluated in three different modalities: light microscopy.immunotluorescence and electron microscopy. Antibod deposits

can he found either subepithelial (membranous and postinfectious

GN). subendothelial (SEE) or in the mesangium ( Ig—A nephropa—

thy). A report of neerotizing granulomas would he more suggestive

of granulomatosis’.Since the Patient had pulmonary infiltrates on his initial presentation

in the hospital the question arises ifhe had systemic involvement ofthe lung. Microscopic polyangiitis is the most common cause of thepulmonarr —renal syndrome’. Sometimes a lung biopsy is perfbrmedto confirm this suspicion. but was not done in our case. The patient

improved with treatment although it was unclear vhether this was

related to treatment of his COPD or his underlying vasculitis.

EpidemiologyThere is little epidemiologic data for small vessel vasculitis because

of the rarity as well as the different classifications of the disease, Ina French study the estimated prevalence per 1 .000.000 adults was90.3 for all 4 vasculitides, 30.7 for PAN. 25. I foir microscopic PAN.23.7 for Wegenerand 0.7 forChurg-Strauss. The overall pre alence\\ as 2,°times higherfor Europeans compared ith non—European’.Results of pre inns studies suggested latitudinal differences. \ Oh

\Veenerheing more frequent in northern countries and microscopic—PAN prevailing in the south . Ethnic variations and difterences

between rural and urban areas niieht also pla\ a role. The esti

mated prevalence rate per I .000.000 for microscopic PAN as Of

in a northern area of Germany, whereas no cases were found in thesouthern part5.Conversely, Watts et al reported an annual incidenceof 8/1,000,000. The significantly higher pre alence observed forEuropeans ma infer a genetic susceptibility of Caucasians,

Pathophysiology

The ANCA associated vasculitides are an immune disorder withinflammatory and specific immune responses against neutrophilegranule proteins. ANCA’s are directly involved in the pathologicprocess by interaction with neutrophil and endothelial cells -. Thetheorr is that .ANCA induce a release of cvtokines from leuko—cvtes and thereby start an inllammator response s hich leads toa necroticing vasculitis. Other cellular responses involving ‘1’ and

13—cells are not as elI Linderstood. hut certainl take part in thepathogenetic process.

TreatmentTreatment ofANCA associated small-vessel vasculitis is dividedint(iacute. maintenance and relapse phase’. Current induction therapy ofmore severe cases as in our case starts often ith IV pulse steroids

(Meth Iprednisolone 7 mg/kg) to ameliorate symptoms, additionof Csclophosphainide 2nig/kg P0 (lail orO.5 gim7 IV per month

therapr s ith a subsequent switch to oral steroids tollo s. Thistherap leads to impro ement of t) percent of patients‘. Oral

Cyclophosphamide is more toxic due to accumulati\ e effects, butthe ad antage is less relapses during the treatment course2.

This patient had already a prognostic factor for poor renal outcome because he had renal failure on presentation7.The associated glomerulonephritis is progressive if not treated prcmptly. Forsevere life-threatening disease, plasmaphersis is another option,

Lntreated small vessel \ asculitis has a poor prognosis with 900

of the patients dying within two years. One third of the patientsdevelop relapse. hut two thirds of these patients respond to the same

initial treatment’’. Another therap option in less se crc diseaseconsists of Methotrexate772.Patients shoLild also he started onTrimethoprim— Sulfaniethoxazole for PCP prophylaxis since it hasbeen shown that six percent of Patients develop this disease duringthe immunosuppressive treatment with steroids and that preventingit is cost—effective—42.

Maintenance treatment should involve a quicker taper of steroidsthan in the past which as about one ear7 ‘‘. Once complete re

mission is achieved. cyclophosphamide is discontinued and either

threxate (which is an option only among those with a serum

creatinine concentration 2.0 mgidL 1 771imol’L I) orriathioprine is

initiated7 . Ifthere is a minor relapses during maintenance therap\.a trial of increasing dose of corticoLeroids and immunosuppressive

agents can be considered. Atiother option is treating the disease with

the initial induction regimen in patients with more severe disease

and in those who are no longer on immunosuppressive therapy75.

Other options which has e to be considered with further progressive

disease include maintenance dialysis and renal transplantation. Future

medical options might include RIG, leflunoinide. mvcophenolate

niofetil and 1’NF—alpha.

ConclusionThe ditOreniial diagnosis of hematuria can include benign disease

to life-threatening diseases such as microscopic PAN: thereforea systeniatic approach to the evaluation of hematuria needs to hetaken,

If the patient has clinical features suggesting glomerulonephritis.a nephrologist should he ins olved earlr in the course. Treatment (if

microscopic R\N ss tb cr totoxic therapr has nipros ed the outcome.

.S Hcnwturia with.... p 1Y.

1 8

Hozelden Sprinebrook helps those with alcoholism and other drug addictions find their was home. But first, we help

them find o woy hock to themselves. We’ve helped thousands down this road to recovery in on environment that’s safe,

supportise and ;sarm. And we can help sour clients tuo Our prosen approach to treating the whole person also helps

to mend those families torn apart by addiction We all know that rebuilding the person is the first step toward rebuilding

the tomilv. The hei they need, is just o short, norostop flight awos. For more informaon about how Hoelden

Springhrook’s portfolio of residentiol and outpanent sersices con help your clients,

_________

coil toll.free 8OO-33337i 2 or visit www.huzelden org springbrook.

Hozelden Springbrook. ‘Ac can help. It’s what we do

100% of our members said, “YES”, theywould refer a colleague to HAPI

In thftv tp r u ‘s v nduvt d in (P9 70(1’ md ‘00 , e a k ‘d our n ‘ herc it hm ould refer a vol u’ to HAPI In lItilt a e slIt o our member aid ‘

H P a to m ph7 a I’ protide relief tr sn th e m n ha ‘ed by n e i Ir , i v torn n nd to ake rtasn that mdiv I md a r said Lea ailab 0 Ha s d )vt(

I ,,s ‘iv , e sdv I, ti, H I It .‘d ii h’ ( I H do toy

0 s. “i ‘ HA Is m mbership has increased 4I’, I . .s i, ‘ or ‘ ‘0’ - “ °‘v’i’ s’ liv ii , i ‘ r o u a H A

no profit moti e 0 I S c’--’ s’ ,o o , r c’. s. ‘ I aH ‘1

‘PLRf ‘“ThIRD FOURTH FIFTH JSPECIALTYAR I YEAR ‘itAR

n c H API i0’ iii , I

.1 u I II r, c.5 “t‘ General Surgery $319 ‘ Z684 $3,324 $3,964

lv’ ““7. ‘1, Il Fbev’ Internal Medicne $106 $558 $878 $1,091 $1,30ii a Ii

Pediatncs $125 568 51 068 $1,32 $1,581

‘I’’ I’ is ins’s,, tf’,,t [1 \I’I iiJ ‘Is,. ,‘ t ‘ns’- ‘: iii,’ s’nv’i ‘ ,‘s, vi’I.” ,snk, ll,ivsv ‘iii \lvi,iL’s r-l’ir liv’ s.,’’rms’,’ s.v,,ili

r’ I I’i . , ‘ I I777 l3i’hssp ati eel “mite 71 [Isa’ lu HIh08-338- iqos s i%.hapihav ail.s.oin

vt’2005 Hsze]dvv Fossvdasov

HAZELDENSpringbrook

Resideniial Sers.ices in Newberg, Oregon

Outpatieni Services in Tigard, Oregon

r& RESIDENTS CASE SERIESJAMES I I.E. IRELAND MD. CONTRIbUTING EDITOR

RAWAJAMEDIC1

JRNA]L.

An 82 year-old man with chest discomfort

Neelima D. Ravi MBBS, MPH, Harry J. Bigham MD, Yuri A. Deychak MD,and Mevan Wijetunga MD

Case ReportAn i2 car old man with a histor of emphysema, hypertensionand prcs bus shrapnel injury in the hack, presented with a hand likesensation on the chest. His vital signs and physical examination were

unremarkable. He was ruled out for m ocardial infarction. Subsequentdipyridarnole myocardial perfusion scan revealed a small sized,reversible defect in the inferior wall of the left ventricle. Coronaryangiography revealed a complex of aneurysms in the proximal leftanterior descending artery with a fistulous connection to the pulmo

nary artery. The aneurysm complex consisted of multiple isolatedand interconnected chambers, with the largest chamber measuring16mm in diameter by intravascular ultrasound. (Figures U4) Therewas no evidence of significant obstructive atherosclerotic disease inany of the epicardial coronary arteries. Right heart catheterizationshowed pulmonary artery pressure of 55mmHg. No left to rightshunting was identified by a serial oxygen saturation study. Thework up for vaseulitis was negati\ e.

DiscussionA coronary artery’ fistula is an abnormal communication between anepicardial coronary artery and a cardiac chamber or major vessel.

The reported angiographic pres alence of this anomal’ ranges from(.). I to ().2U. Coronary arter aneurysm is defined as an arterial

segment with adiametergreaterthan 1.5 times the adjacentsegment.The angiographic prevalence of isolated coronary artery aneurysmsis in the range of I The combination of Coronary arteryfistula and aneurysm is rare.4

Coronary artery fistulae are usualls congenital. hut may rarely.

he post traumatic,5The majority of patients remain asymptomatic.

The natural history is variable, with long periods of stability in

some and sudden onset or gradual progression in others. Symptomsusually begin when the patients are more than 50 years of age andare usually the result of a coronary’ steal ( mvocardial ischemia. arrhvthmia. sudden death), volume overload congestive heart failureor isolated right heart failure oran infection (bacterial endocarditisAs\ mptomatic tistulae ma also be managed consery ativel ss tb

beta blockers or calcium channel antagonists. Fistula closure b\surgery or percutaneous catheter based technique is recommendedfor s mptomatic patients and as lnptomatic patients who are con—sidcrcd at high risk for future complications.

Coronar arter aneurysms ma has e a congenital etiology.The common acuired causes include athcroscle rosis. Kass asaki

disease and other vasculitidcs. The natural h istor is unclear.Thronihoembolism from the aneurysm may cause symptoms ol

unstable angina. Diagnosis is often incidental and made duringcoronary atigiograph. Management of coronary artery aneur Sm

often depends on coexisting obstructive coronary artery diseaserather than the sole presence of the aneurysm,5Antiplatelet therapy

and anticoagulation are ofteii considered in medical management.

Surgical options include coronary artery bypass grafting usually inconjunction with ligation, and resection of the aneurysm with end

to end anastomosis of the affected coronary artery.

ConclusionIn our patient, considering the age. presence of co—morbidities andlack of flow limiting coronary artery disease, surgical options ss crc

not pursued. The decision to place a covered stent was deIa ed untilconservatis e management was attempted. .-\nti—platelet therapy ss ithaspirin and clopidogrel along with treatment of angina ss ith a beta—blocker was begun. At 3 months follow up the patient remainedasvmptomatic.

References1 Vavuranakls M. Bush CA. Boudoulas H. Coronary artery hstu;as r scuds: Incidence. angiographic

charactenstcs. natural history. Cathet Cardiovasc Diagn. 1995: 3.5:116-1202. Yamanaka 0. Hobbs RE. Coronary artery anomal:en ini 126,595 oshenln. uncergoing coronary aOen

ngraphs Cathel Cardiovasc Diagn 1990:21 28-40.3 Syed M. Leach M Coronary artery aneurysm A review. Ping Cardiovasc 0/s. 1997. 4077-844 Hnose H. Amano A. Yoshida S. er al. Coronary artery aneurysm associated wrth fintula ir adults

Cotective review and a case report Ann Thorac Cardiovasc Surg. 1999,5 258-2645. Maitre B Jouveshomme S. Isnard R. Ricuet M, Pains A. Demnne JP. TraumatIc coronary-purmonary

artery fistula, 23 years after a stab wound Ann Thorac Surg. 2000:70:1399-1400.6. AtrnacaY,AltinT, OzdolC, PamlrG, Caglar N. Oral 0. Coronary.pulmonaryarteryfistslaassoc:atnc wnh

right heart failure: Successful closure of fistula with a graft stent. Angiology. 2002: 53:613-610.7. Hackett 0, Halhdie-Smlth KA. Spontaneous closure of coronary artery flstula. Br Heart J 1984,

52:477-479.8. Dorros 0. Th.ota V. Ramireddy K. Joseph. G. Catheter-based techniquestorclosureotcoronarytistuiae.

Catheter Cardiovasc !nterv. 1999: 46:143-150.9. Osgalp Z. Pamir G, Aipman A, Omurlu K. Crc.:. C. Oral 0. Coronary artery aneurysms, report

cases and review of the literature. Angiology. 1996; 47:1.97-201,1.0.. Firstenbera MS. Azoury F. Lytle BW. Thomas JO. Interposition vein graft tor nisntcoronaryarn.eurvvrn

repsi: Ann Thorac Burg. 2000:70 1397.1308

Ccrres0crrde.bce to.i1evarW.eiungaMDDivs.cn of Caroio;o.ovVdasn’rato” Hosoital Cen.te110 Irvnig S:reet NW.Was”lncton. DC 2001.0E”iai: rnevarlw7etungarvova000c.om

188

Figure 1.— Left coi ry angiography: Anterior view of the left coronaryartery showing muLe e saccular aneurysms (SA) on the proximal leftanterior descending artery (LAD). C= Left Judkins coronary catheter.LCx=left circumflex artery.

Figure 2.— Left coronary angiography: Right anterior oblique 200 viewwith cranial Nt of 20° showing multiple saccular aneurysms (SA) on theproximal left anterior descending artery (LAD). LCx=left circumflex artery.Dl =first diagonal branch of the left anterior descending artery.

Figure 3.— Left coro9ay a9giography: Right anterior oblique 30°viewshowing multipe saccuar areurysms (SAl on the proximal left anteriordescending artery LAD with contrast flowing into the pulmonary artery(PA). AR =aortic root LSV=eft sinus of Valsalva,

Figure 4.— Intravascular ultrasound (IVUS) image of proximal leftanterior descenong artery SA=saccular aneurysm, 0= cross sectionof the IVUS catheter.

189

MEDICAL SCHOOL HOTLINE

Medical Student Involvement in Research in the Pre-clinical Years

Kenton Kramer PhDOffice of Medical Education

John A Burns School of Medicine

Medical student participation in research activities is encouragedduring the pre-clinical years at the John A Burns School of Medicine (JABSOM). Studies have shown that participation in researchactivities early in their careers are more likely to become physician-scientists.-2JABSOM has experienced a dramatic increase inresearch grants and contracts awarded to the school since Dr. EdwinCadman’s appointment as Dean in 1999. As a result, students havebeen provided opportunities to learn actively about and to pursueresearch activities with local researchers.

Among the tirst year medical students in the Class of 2008, only6 students hold advanced degrees (5 Masters’ level and I PharmD).Thus many students have not participated in active research beforeentering medical school. Acourse entitled “Student Research Project”(BIOM 594) was developed to address this need.

The goal of the Student Research Project is to expose MD students to research experiences appropriate to their future roles andcareer paths as clinicians, physician-scientists, and educators. Thedevelopment of research skills of a prictical and general nature arethe objectives of this program rather than research specializationrequired of those who pursue a biomedical PhD degree. Nine weeksbetween Enits 3 and 4 (the second yean are reserved for researchactivities. Many students, on their initiative, choose to begin theirresearch during their first year of medical school.

After the implementation of PBL (Problem Based Learning) in1989. student involvement in research took two forms. First, medicalstudents interested in research could sign upforaone—credit researchelective and work under a research mentor. Thus a student couldlearn in depth about research from a faculty member. The studentwould be exposed to research concepts as ssell as the laboratory.Anelective handbook pros ided a list of.JABSOM faculty members andtheir areas of interest and e\pertise Second, during their preceptorship. students complete a communit\ protect in con junction with aprimary care preceptor. Together. the student and preceptor workedto deselop a project of value to either the preceptor’s practice orcommunits. Examples of pmec0 from the Class of 2003 meluded.Heath Chung and Stanle\ Tseng .,\lF) studs mo 7Iic Rie Bocm/ferd/h-at/on iiia Patient’s Seleerion u/a Physician ‘and Glenn Garo

ss ith Kamal \lasaki. Ml) and David Johnson. PhD on “The HealthStatus of Filipinos in Hoiiolulu Thdav

In 1999. headed h Bill Johnson. a group of proactive first yearmedical students proposed a change in JABSOM’s research require

ment. These students felt that every medic.al student should he aware

of the role of research in medicine and have an opportunity to participate in a structLired research program. Their proposal included I

a Student Research website that lists current research opportunitiesavailable to students.Faculty and community researchers submittedelectronicall\ a general description of their research for students toreviesv, Students interested in organizing an elective or arranginga summer research project could browse this website, The websitewas initially des eloped by Dr. Steven Seifried and supported bya Nll—IINCRR grant. The website is still active and can be foundat http:’/brin.hawaii .edu!researchopps/, 2) a ten-hour “ResearchExposure Short-Course”. This short-course was a series of talksinterspersed throughout Units I through 5 and introduced studentsto basic research concepts and 3) students svishing to pursue anin-depth research experience could enroll in a Research MentorElective. The MD Program Committee adopted this proposal in1999.

This concept has been modified throughout the succeeding years.

The current format of the Student Research Project is for each studentto identify an active researcher to stipervise their work, develop aresearch plan. and participate in a pmject in clinical medicine, basicsciences. or community medicine. The learning objectives are: Ito develop a basic understanding of research by working svith aresearch faculty member. 2 to develop an understanding of ethicsin research. including the role of the Institutional Review BoardIRB and 3 to des elop a general understanding of research design

and data analssis.l’able I lists suggested topics for the student todiscuss svith their research mentor. Students at the completion of aproject are encouraged to present their finding at local and national

Presentaton of findincs (e.g.. papers, presentations and posters)

Table 1 — Suggested Toptcs For Students To Dtscuss Wtth ThetrResearch Mentor

Croosna a meaninctui and feasibe research queston

Quanttanve ve’sus qual’tatve researcn rca. deouctive v. ndu-ctive reasonns

Tnecrydnver bujothess formation arc the ro:ecf the teratare revew

Resea’ch ethos. IRB procedures and oversgh:

Reseacr cescr arc ogc e g. hvoothess cenerahon and test.nc: e.xperlnienta quasexperrienra desgns: corceas of scr’ca’rce. correatcn. and causatv crc

Research cesgr ssaes -e.g rehaO y va cru. e’cr arc has

Research nst’umerds and sfatstcs

Data collecion

Understanding daso statstcs

Data interpretation, and recoding

lao

meetings. Funds to defray the cost of travel are available from theDean’s Office for those who have their papers accepted for presentation at local or national meetings.

Reseais’h highlights j(vm the Class of2007 are:

Jonathan Reitzenstein mentors. Ares Brown, Phi) and Martin Janus,Phi) (Department of Human Nutrition, food and Animal Seienees,Unn’ersitv olHa wan), The Annproliferatn’e b/feet of Poi (Coloeasiaesulenia) on Colonie Adenocarcinoma Cells in ½tro:

Marci i’eralto--- mnentor Jenniff’r Ko, Mi) ( Lawnda/e Christian healthCentet C Incago), Blood Lead Sereening and Childhood Jnunnnizationin North i,awndale;

Joes Kahatsu —mentozfiuculrv of the Department ofGeriatric Medicine(John A Burns School of Medieine), EAxis Deviation Prediets 8- )2’arineidenee Coronary Heart Dii ease in Elder/v .lapanese AmericanMen: The Honolulu Heart Program;

AdaniBracha—,nentoz Hvo—Chun Yoon, Mi)(KaiserMoanalua Mcdi—eal Center and JABSOM), Coronary Calcium Scorinp with EleerronBeam and Multidetector CT: intersean Ci? Comparing interseant’arialion C/sing i)vo Scoring Algorithms;

students to shadow a geriatrician as well as explore research interestsin geriatrics.

Since Dean Cadman’s arrival in 1996, there has been a dramaticincrease in the research grants and contacts awarded to the School,In turn there has been an emphasis on encouraging medical studentsto participate actively in research activities. Research by students inthe preclinical years at JABSOM is student-centered and dependson the initiative and creativeness of the students to seek out researchopportunities. The success of the Student Research Project, however,is related directly to the many individuals who unselfishly opentheir laboratories to students. Their continued support is essentialto developing the future physician-scientists for the State.

ReferencesGonzales, A. Westtall, J and Barley. G. 1998. Promohng medical student mvolvement fl pnmary careresearch, Fam Med 30l21:1 13-116.

2. Solomon. S. Tom, S. PichertJ, Wasserman, Dand PowersA. 2003. tmpactotmedical student researchin the development of physician-scientists. J tnvestig Med 51(3)149-156,

3. Hnose-Wong. S 2004, Addressing Native Hawaiian Health at the John A Burns School of Medicme,Hawaii Med J 63(2)52-53.

a, Naguwa. G. Kramer, K. Fukuda, M and Kasuya. R 2004. Students Teaching Students: CommumtHealth’s Scnool Health Education Program ISHEP). Hawek Med J 63(3):89-90.

Teals Nakaniura—onentom: ffscultv of the Department of GeriatrieMedieine (.lohn A Burtis ,Seitool of ,‘VIedieine), (‘aregiver.’, for Dcmu’nted Patienra: Do They Have a [Jig/icr Risk for Mortality andDepression?

a tot hong mm iltol hat tilts oft/it Sm hool 1* alth I din anon Pm o, tam(SfJEP), Medical Students ‘Dual Roles as Both Classmates atid ‘ihachers to High School Siudent,s in Medical Education.

Lmtsyj,he Si-fEB pro yratn and the Class pt 2008, headed by Di: GwenNaguwaz

Misha Kassel and (‘assie Lee: Effect of Small Groups on Learningand Application to Health Decision Making,

Cindy Ta and A-fare Kaneshiro, Conununity Health Prograin: influencing iirst Year Medical Student Future Career Decisions.

Kyle C/sun Assessing the Correlation Between Standardized TestingScores and Performance on Lesson-Based Evaluations in HawaiiHigh School Students.

Gina Fujikatni and Lauren Okamoto, i’he School Health Educa—tto,t Pm ot,, am As sit smn 1dapriv t (omniunsi anon Si, ati its in

the Classroom as a Model for Developing Effective Doctor-Patientomnmunications.

Tise 101/owing students also presented their ravearch iii i/it’ JABSOMBiomedical Scie,tces Symposium held on April28, 2005: Kyle (‘hun,Gina Fu/ikami unit Lauren Okamoto, Misha Kassel and (‘ass/c Lee,Jot’s Kohatsu. Lea/i Nakamnura, Cindy iii and Marc Kaneshiro, andVictoria Wi.ng. La’ie Chuti was awti.tythd a prize fOr the best presurn.tadon by a medical stt.mden.t.

The Student Research Project also offers opportunities for facultymembers interested in promoting student research. Forexample, The3rttVC Hawaiian Center of Excellence has developed a program totrain and retain medical students interested in research on NativeHawaiian health issues.’ SHEP gives students the opportunity forcommunity service while providing a structured research program.The Geriatric Department at JABSOM provides opportunities for

Aloha Laboratories, Inc

fl

restits c•is

A CAP accredited laboratoryQUality and’ Service

David M. Amberger, M.D.Best Do:ct.:..rs. Ia A1fl.:ric.

Laboratory Director

Phone (808) 8424600Fax (808) 8484663uits4alo’be abs corn

www.aibhaia’bs.com

191

I1)3 CANCER RESEARCH CENTER HOTLINE IAIh4IJJECAt

Hawaii’s Comprehensive Cancer Control Program

Carolyn Gotay PhD, Director, Prevention and Control Program, CRCH& Hawaii Vice Chair and Chair-Elect, Hawaii Comprehensive Cancer Control Coalition;

Virginia Piessler MD, MBA, FACS, Vice-President, Hawaii Pacific Health& Chair, Hawaii Comprehensive Cancer Control Coalition;

Wendy Nihoa BSW, MAOM, Coordinator, Hawaii Comprehensive Cancer Control Program,Hawaii State Department of Health

In a typical week, nearly 100 Have air residents will learn that thehave invasive cancer, a total of about 5.000 new cases each year,On average, 1,700 residents will die from cancer each year. secondon to heart disease as a cause of death. These numbers are likelyto rise, given the aging of our population. However, the good newsis that over the past decade, cancer mortality rates in Hawaii andin the US as a whole have continued to decline.1

Still, much more progress is possible. both in preventing cancerand extending the length and qualit of cancer survivors’ livesthrough a comprehensive cancer control process. According tothe Centers for Disease Control (CDC. which has spearheadednational efforts in this area. “comprehensis e canecr control (CCC)is an emerging model that integrates and coordinates a range ofactis ities to maximize the impaci of limited resources and achievedesired cancer prevention and control outcomes. A key componentto the success of this approach is establishing partnerships betxs eenpublic and prix ate sector stakeholders whose common mission is toreduce the burden of cancer.

To this end. the Have au Comprehensive CancerControl Coalitionwas established, bringing together a diversit of individuals andorganizations to createacoordinated plan to address cancer issues inour state. Coalition members include representatives from hospitals.health organizations, and health plans throughout the state, researchand educational organizations, the state legislature, governmentalagencies, and community organizations. Individuals include professional health care providers, researchers, and community memberstrained in numerous disciplines and — perhaps most importantly— mans individuals who are themselves cancer survivors.

The theme of the Hawaii Cancer Plan is “No More Cancer,” avision shared by all members. Below. s\ e summarize the Coalition’sactivities thus far, guiding principles, goals and priorities, currentprogress. and future prospects.

Coalition Activities

lhfi.en 0, m/ier 21)02 ,jndiannarv 2011,), ;1/’’re i/i,,,, /00/, ,v/eaitci’semend, d a ecra’s 0//our I/u -iliia,ed me i-tin ‘ pol/ cored iii the -tan-ruai ( am/i,u Si u 0 In Cumuli R1 I ii ( n/c I I I/i a,, iii liii

IL [‘am !cli,iul i’IIieali/i The mb/cc //ri-n/ i/ic-cc mcednrs u’a.s a dice/npa roiii f, em clu/cm’eI/elnru-c iance) -am//mi! in Hiaiaii ,a,d lie b/eiiii/vCall i/ic cm/ui i,-,’,llc. 1ulll(ul ii- - au,! ‘frill,’ itt, yo) 1l’aie n-v iil/5

ic/eiuui/b ,i, auth 22 e//-enuJ as pro cr/I’s 1’ ‘r ii nc 0 5 cars. Li hieii’,ut, -.s ‘div, ins, 4 furl/er Ice/eeC vie ce/ic ied tier uunplenn-ulfaf Ianc/hIm it 21)04-2005.

• Quarter/v uleetul/its m 9 i/ce Caaiiuaum canOn/k’ to discus,c It late/tiepIca/re .s and new developments in cancer prem’entuon and cantm’m ml, ei,cclto iwo/ce additional meunhcem’c 1111(1 organizatiOns.

• The Hawaii Cancer Plan 2004-2009” document was publm’s/cedand rolled (lilt at a series a/press con/erences throughout the state iii

Fall 2004. This document is awn/able/ram the J)eparunent a/Health

(see contact m/ormation) and svcii coon he available online.

• .) team /roni Han’ai attended the first CCC Leadership Institutein December 200/ to/aster planiiinit f/cr CCC el/arts. In September2004. /5 Coalition leader.s anendec/ the second CCC Leaders/li/i

In s0ncie. Tln,c was one 0,1 jOur reucccal mcii utes held across I/ce L S.aicil Hawaii n’a,c one cif /4 1-1 es/em .stute,s in attendance. The aimsof the Iucsiinae cc-eli’ fcc eichance tile’ c//i’m/c me/less hf s [clii’ C na/un cci

iii -ui’ine.s hi’ nsci’dicc tiii’ anc’lcc/e’e.s ia/c Ircumn/t mn ac’ea.s such asl/e/’c’/opllli/ llcIle/’(ltl/S’ resc mi/cm c. lii, 11(11,1 u’ehiitcoiislupcacndrc’ 501115 (‘5.

cidc’aciicv, (hid ec’aluanon.

• lice Department of Health cc-u.s success/ui in cacnpetncg far ci

CCC piaucninit ç’rant (2002—2003) imuu/ a CDC CCC impiementatumic

usiiit / 2004—2L09 Ia pr cm’idc’ sic/c/cart far Caahtcan acti’iues Hacm’anis au/c 0/ 49 stales, tile Di.s tm-i 0/ C’cclcc,nbcu.S tribes and tribal ariau/1/clilal/.s , 11111/ 6 C .5. :1 ssaciaied Pmicm/ic - Is/acids -teli c/arIes tiicit siiiius.sill (D( .s elppraxinmate/v .5 /2 cncl/iccn in Congressional appus prairIe ills

iii fiscal year 2004/ar this ilciliicr//e.

Guiding PrinciplesCoalition members identified certain principles that need to underliecomprehensive cancer control activities in Hawaii. These principlesreflect considerations that are specific to cancer control issues inour state. The principles are:

• Decision-making will he driven by the best available c/ata.

• Data a-ill he used to identity dispcuriiies iii the cancer burden an/all

1/,uceaO ,‘esidentc and plans ni/i hi ‘u/cue/c tim reduce those dusparuic

• (‘,ic,m’i/icatncuu ana,ceileoie’ratic’n chic is sc-n!ia/t’’ aeiin il//i/ f/Ic rmfllis

////c pftull ,mla acsuo’mu inijcic -/nm-nfancn. I/v ue’om’,nv’ lint, li/cr li/elm

ciii I/c (/1,1/c 10 lcd/I, C li/c eli/c cr iiuuidirui in /laaad 1/1,11/ c on/cl li,

‘lee iilll///IN/ii-ii // ne ill//V eon/n//n e/ all” umuln’u/nee/ cl/or! 5.

• 1/c/c/leaf la/I of 0(111 -a/-ti/c-ar! All e/ /cs/re. Feel/i/c cilcitCi (11/1/ /cc5l -

tie c’s ‘miii iii- the fiiumm/m/clfiol/ Or ml! circe/c vics ,n/d actIons lii- uie iii

• (,ium r eli/Cf its icnpmuit cml 1/Ic- leap/c am’cl peipu:atuocn of I/a,, ci

emli sac/a! /Uctlcc /55 11,-s - tic lola i cl/lu cuitlv seek l’qlla/ ma m ess tier cullpeople in Hawaii,

192

• Cultural competency by health professionals and hen/i/i sv’tems inHawaii is a key ingredient in the success 0/this plan.

• The plan actively supports the recommendations and strareitiesfound in other statewide plans that address cancer-related issues (e.g..the Statewide Thbacco Prevention and Control Plan, the Governor13/ne Ribbon Panel Report).

• l:vcrvone in Hawaii wi/I be touched at some time /0 cuicel:(0/il ci eoiiti’ol is the responsibility of everyone in lianaii — it, ironiutions, organi:ations, individual cini:ens. /amthes. /noinc.% sd. (i/idn/nnianit!e,s

• i/ic amer p/an n/Il be a rood map to reduce the (a/leer burden.Priorities will oe set with,n the p/an to m to,, i/ic i/eatrot needs anc/

inn 0 achievable, realistic stisitei/ies and roth 05.

• More wart/nv/i/Ic and e//’ctil’e cancer e/7 it are current/v under-way in I-mica/i and t/rouvliout the nation. i/ic state lancer plan ivi//identi/’ cyistiliC cf/orns snol st/i’d nOt to ihiplicale thou’ c//mis. butrat/ic,: n’lie,’e iipp/’( priate, to build, en/ia/n e. ainl espand n them/orthe benefit oj all citi:ens in Hawaii.

Goals and PrioritiesThe eight priority “take action strategies were deri ed from fourmore general goals which are pursued by groups we has e named Action—Teams orA—Teams . These are the foci of Coalition initiatis esduring the current year. The goals and strategies are as iN low:

• P,’ei’entum Goal: Prevent cancer/rn/n oi’curri,ie. especial/v i/us ‘uedu sit/n/i (1/id he/uiu’o,’ change trateu,’(e,StraieL’v I: Establish ,nantli,iin’v /i/ivs(cal cduu’aiini /in/u ‘,e,s in allschools in flawaii.,Strateuy2: Adopt, adapt, andi/np/enuenr/mrol’ide be/uii’ior change Intel’—vention,s targeting increased consunipuoii 0//inns (i/id vegetables.Strateev± Engage in e/jorts to create ,io,’,n,s that posnive/v support.s inoke-free behaviorStrateçv 4: Impleitient “HeaP/i Foods” polieie.s iii sc/mo/s.

• Early Delecuon Goal: Detect cancer it, its earliest stage.s andas surecoordination with cancer itianagement services.Sirtitegv5: Conductpatient andpublic education about i/Ic importanceof cancer screening with the emphasis that sereetuiuu sines livesStrategy 6: Develop and conduct health care provider trainings on

sereeinny’ guideline.s and the need to talk wit/i patient.s about theguidelines.

• Data/Surveillance Goal: Improve aiid maintain a lng/i qualitysurveillance system on all aspects of cancer to assure in/m u’,,icd dccinon-making.Strategy 7: Develop a pls’ess to share and disseminate /n/o,’niationregarding uses of health data.

• Cast’Insuramtee Goal: Address cost and payment i’oi e/’royc issues

br1’ancer-re/ated services.Stu’ati-r 5: Conduct a studs’ to co/Icr 1 Han’an-.spi/ic in/omnultionon licali!, care plan reimbtirsement, rare in the uninsured ainI under-ins um’ed, r sI barriers that I/inn (are 0/1(1 ocr ess 1” (are, aini is latcd

Progress So Farfunds recently be ame available through the CDC grant to supportsnial —scale projects that f’urther A—Team goals ..-\ Reiluest for Proposals ssas released, and each A—Team ss as gis en the opportunity tosLihmit a proposal. The proposals are currentl in ten ens, hut someimportant work is likei to e merge Ironi this effort.

Examples of accomplishments by the A-Teams and other Coalition members include:

• i/ic signing of Memoranda of Faders naiidni between severaloruyrinigations that collect cancer-related data, mi-sn/mug iii increased

sharing 0/data.

• The passage off/RE 321-45: ( ancel’ Exaniniatioiis. This bill Iii h—PaIns the need/or the health Deparmmnern to o’om’A nit/i ithiergous’i’,iIliClit c112(’ilcieS. health care pro videcs. health nl.s i//el’s. (I/id ntlie,’s toimprove the overall rates 0/ si -/‘eenolg, rash diagiiois, ((11(1 tm’eit/nemit

iii (‘(mccl:

• ihe (lereso/)mnemlt n/a hm,’iutegic (‘o,n,nn/ucatia/i.s 1’/an to establish

a IfCf CP v1nste. ri volvo b,’ochui’e lcumrl’ent/v available ho,,, I/IC

Departmenio/Heaim/n. video a/ic//c mcliiipuihlic-.seci’ice an/imi/ice,ne,its.

c/lkl(ithiCI’ C//ill-is in /acilitatecnnnntniic’aiions ut/i/i/n the C oalinon andbetuy’e/, the (‘oaiitinil (1/1(1 the pub/k’.

• The develop/ne//i (1/li conipi-ehensi s’ Ei’alnatioii Phu,. to dete,’mi,ie

how well the (‘nalitini, is ,neeming its goals.

Future PlansThis Plan is nierelvthebeginning As science and practical experiencegrow, new challenges, innovative tools, and more effective strategieswill emerge based on the changing needs of our states’ residems.The Hawaii Comprehensive Cancer Control Plan is intended to bea living. dynamic road map used by organizations, communities.and individuals to create. implement. and sustain activities to reduceHanvaii ‘s cancerburden. Clearly, with 99 priorities identitied. there ismuch work remaining.We invite all readers’ tojoin us in our ongoingefforts to further reducethe impact of cancer inHawaii.

For futher assistancecontactthe Hawaii Comprehensive CancerControl Program at (808)692-7480: hcqc’mgyji.health.state.hi.us.

For more informationon the Cancer ReseachCenterof Hawaii, pleasevisit w,wsp.crgh.Hrg.

References1. Hawaii Cancer Facts &

Fi4ures 2003-2004. Honoulu: American Cancer Society,H.awaii-Puc/ic Inc. 2003.

2 Hawa,, cancer Plan 2004-2000.. Honolulu: Hawaii SlateDo.oaOrnent of Health, 2004.

Craig Nakamura (PB)Commercial Properties Of Honolulu

591-8755Peter M. Lee (R)

Marcus & Associates. Inc.839-7446

Kuakini Physicians Tower

For Sale (Leasehold)Medical Office Condo

Units available from 652 to 1,527 sq. ft.

Prices starting at $1 26.500Design your ideal office space

orLease a finished office spaceLease Rents from $2.40 psf

+ utilities and parking

193

Hawaii Medical Journal (Guidelines for Submission)

ManuscriptsSubmit scientific articles. essa\ s. letters and other manuscripts toI!aoaii Medical ,Iournnl. 136(1 South I3eretania Street, Suite 200.Honolulu. Ha ai i 14.

Manuscripts are re ie ed by the editor. the peer review panel.and other experts in the particular specialties. Please he aware that\our article ill be edited to comply ith the AMA style. correctedfor grammar. and recommendations could be made by the peerreviewer.

Please submit five copies on -l/2 x Il paper. It is recommended the article he submitted on a floppy disk or CD withthe manuscript. Please indicate what software you are using(Micosoft Word or Word Perfect). Submit only articles thathave not been submitted elsewhere.

• Use Times font in 10 point size,

• Please do not underline and do not use full caps.

• Use double spaces between lines. Do not use I - 1/2 spacing.

• Number pages consecutively beginning with the title page.

• Graphs. tables and figures must be sized by the author,up to 7-1/2 inches in width. Please make graphs separatefrom text.

A cover should contain the name of the author with whom HMJwill correspond. include an address, phone number, fax numberand pager if needed. along with a statement that the manuscripthas been seen and approved by all authors.

Title and Authors’ NamesPlease keep the title short. specific and catchy if possible. If thetitle submitted is too long, it will be edited. List first name, middleinitial and last name of each author with highest academic degrees:name of department and institution to which the work should heattributed: name and address ofauthorto whom requests for reprintswill he addressed, or statement that reprints are not available: thesource of support in the form of grants. equipment. drues. or allof these.

Abstract (see Synopsis-Abstract)The second page of the manuscript should include an abstract nolonger than 60 ords that highlights for the reader the essence ofthe authors work, It should focus on facts rather than descriptionsand should emphasize the importance ot’thc findings and briefly listthe approach used br uathering data and the conclusions drawn.

StyleUse J.-IM-f st\ Ic or consult the AMA Manual of Style. Use theobjectis e case, such as “the team determined or “the study involved,” not I or \s c. and avoid medical jargon. Use generic drugnames unless citing a brand name relevant to your findings. Do notuse abbreviations in the title and limit their use in the text.

TextHM.J recommends that articles he divided into sections with headings:

Introduction. — -The purpose of the article and rationale for thestud\. Do not re ew the subject extensively.

Methods. — Describe the patients or experimental animals clearl\.Identify the methods, apparatus. and procedures in suf’tIc ient detailto allos other ph\ sicians to reproduce the results.

Results. -—- Present the results in logical sequence in the tables,illustrations, and tables. Do not repeat all of the data in the text.summarize impoi’tant observations.

Discussion. Emphasize the new and important aspects of the studyand conclusions taken from them. Do not repeat data in Resultssection. State new hypotheses when warranted, but clearly labelthem as such. Recommendations may be included.

Illustrations, Tables, Graphs and FiguresTables and graphs must be prepared in Mircosoft Word or Excel.Numerical data should accompany graphs.

Each figure or illustration should have a label pasted on the backindicating the figure number, name of authors, and the top of thefigure. Do not write on the back, or scratch or mar them with paper-clips.

Illustrations must he clear, distinct, and unmounted. Please limitthe number of illustrations.

Figures should be done on a computer or professionally drawnand photographed.

Type legends for illustrations starting on a separate page witharabic numbers corresponding to the illustrations. When symbols.arrows, numbers or letters are used to identify parts of the illustration. identify and explain each one clearly in the legend. Explaininternal scale and identify method of shining in the photographs.

ReferencesAll reflrences must he cited in the text and should he arranged mthe order in which they are cited — not alphabetically. Please usethe JAMA st\ Ic fir the references:

1. Joes J Necro!Izng Canada esophaabs J46t4. 198224-:219O2’9i2 S:vfl L BochemsTh, 2rd ed Safl F’acsc Caa WH F’eer’ar Co 93 559-596. Nc: CA

K ‘“v’ n iue r—.”a 6fl !fle Uncea S:a:es Senv P ed “tuefiza Vacc!”es. arc Syarea:. Oadc. Cu

Acade’mc P’ess I: 1976 297-358

AcknowledgmentsAcknowledge onl\ persons who have made substantial contributionsto the stud\ Authors are responsible firohtaining written permissionfi’om es ervone acknowledged b name: readers might belies e thoseacknoss ledged ai’e endorsing the stnd and conclusions.

ReprintsAuthors may order article reprints for a fee; however, a cop\ ofthe Joti,’,ial \ ill he sent to each author from which photo-copiesma\ be made.

Synopsis-AbstractIn this age ofclcctronic data retrieval, awell—wrinen synopsis—abstracthas become increasingl important in directing readers to articlesof potential clinical and i’esearch value. The synopsis-abstract summarizes the main points of an article: (I> the purpose of the study.(2) the h isi pi o cdurcs toIlos ed () thc m nn findings and (4)

(‘ontiluies on/u. 196

FIVEWAYSTODIEONTHEGOLF

COURSE:I. Hit by a golf ball.

2. Run over by a golf cart.

3. Whacked by a golf club.

4. Struck by lightning.

5. Forgot your hat.

cerson an hco.r us the US. citesfrom mejanorno, the deadc testfarm of skin cancer. 1± you

a lot of tUne in the cc:::..

:Ueco Stee cc cc the cc‘run. (hover u U/ear c fn

Seek: shade. And use sunscreen.

more

inicrcnat.ion on home

caote-ct : mU franc

kJ)

OERICAN ACA1EY OF OHMATooGY

LEEJ]

sects I d Vt’ HH /7(155 (tarn scc/ Or’1i,1s/ tO!

a FnaiIJrilcu7(’ SW! /1(15:

195

the principal conclusions. Expressions such as “X is described.”“Y is discussed,” “Z is also reviewed” should be avoided in favorof a concise (limited to 135 or I 5() words in AMA’s ournals)statement. A few specific guidelines to consider in preparing asynopsis-abstract tollov:

• DC) not begin the abstract with repetition of the title.

• Omit P values.

• Cite no references.

• Aoid abbreviations.

• Use the salt or ester of a drug at first mention.

References to WebsitesRoth AE. Report on the design and testing of an applicant

proposing matching algorithm, and comparison with the existingNMRPalgorithm design review ofthe National Resident MatchingProgram home pae 1. December 6. 19%.A ailablepitt.edtjalrothpba’c. lhtnJ. Accessed August I - 1997.

2. Ameican Medical Association—Medical Student Section. Ameri

can Medical Association-Medical Student Section resolutions for

the 1995 interim meeting Texas Medical Association Web sitel.Available at: hllpi//wsv\y.hcm.ied1i/Lrng.-1ms!i95res.htm#H.

Accessed August I. 1997.

• If an isotope is mentioned, when first used spell out the nameof the element and then. Ofl line, give the isotope number.

• Avoid the use of trademarks or manufacturers’ names unlessthey are essential to the study.

• Include major terms in the abstract. since the abstract can betext searched in many data retrieal systems. This will enablethe article to he retrieved when relevant.

References to BooksComplete Data.—A complete reftrence to a hook includes (Iauthors’ surnames and initials: (2) surname and initials of editoror translator, or both, if any: (3) title of book and subtitle, if any:(4) number of editions aller the first; (5) place of publication; (6)name of publisher; (7) year of publication; (8) volume number, ifthere is more than one volume; and (9) page numbers, if specificpages are cited.

I .Strver L. Biochemisr,-v. 2nd ed. San Francisco. Calif: WH Freeman Co; l98I:559-596.

2.Kavet J. Trends in the utilization of influenza vaccine: an examination of the implementation of public policy in the UnitedStates. In: Selb R ed. In/]uena: l7riis. liccines, and Srratet’v.Orlando. Fla: Academic Press mc: I 976:297-308.

Figure Sample

For assistance with tables, figures, charts, and graphs you may

contact Drake Chinen. IIMJ Editorial Assistant, at (808 536-

7702 or (808) 383-6627.

Table Sample

Table 1. Age Structure of the Study Population

Ebeye CHCAge Study Popula- % Ebeye Census

tion

3039 302 43% 1227 45.5%

40-49 206 30% 843 312%

50-59 110 16% 391 145%

60-74 52 7,5% 193 7.2%

75 22 3.1% 40 1.5%

Total 692 2694

Comparison of age structure of study population with age structure ot residents of Ebeyeas recorded n 1999 Census.

100

80

60cD0Cl)‘a)Ct

20

0

r Female

Male

Figure 1.— Incidence of Invasive Colorectal Cancer. Hawaii 1996-2000 (Age-adjusted to the US 2000 Population)

“Heinaturia with... “,jrom p. /86

There are still questions which remain unsolved including the role of renal transplantin patients with severe small vessel vasculitis or new therapeutic drug regimens whichmight he less tOXiC.

References1, Grossfeld GD, Lftwin MS. Wolf JS Jr. et aL Evaluation of asymptomahc microscopic hematuha in adults: the Amehcan Urological

Association best practice policy, II. Patient evaluation, cyJology, voided markers, imaging, cytoscopy, nephrOlogy evaluation, andtoiow-up, Urology 2001:57:604-610.

2. Gros..s WL, Schmitt WH, Csernok E, ANCA and associated diseases: immunodiaanostic and pathogenetic aspects. Olin Exp Immunol1993:91:t-12.

3. Ksllenberg 0GM, Brouwer E. Weenino JJ, Cohes Temaert JW, Anti-neutr hil cytopiasmic sntibodies: current diagnostic andpathophymologic potential. Kidney 1st 1994:46:1-15,

4, JennetteJC, Falk RJ,Anti-neutrophicyloplasmicautoantibohe.s:dmcoverv, specdlcdy. disesseassooationsand pathogemcpotential,Adv Pathol Lab Med 1995:8:363-78,

5, Pettersson BE. Sundehn B, Hegl Z. Incidence and outcome of paucivmmune necrotizmg and crescentic glomerulonephnhs in adults,Clm Nephroi 1995:43:141-149,

6, Hoffman GS. Specks U, Antineutrophi cytoplasmic antibodies, Arthritis Rheum4t it998), pp. 1521—1537,7, Grard T, Mahr, A, Noel LH et at,, Are anhneutrophil cytopiasmic antibodies a marker predictive of relapse in Wegener’s granuloma

tosis? A prospective study, Rheumatology (Oxf/ 40 (2001), pp, 147—151.8. Jennette JO, Falk RJ. Andrasay K, et aI. Nomenclature of systemm vascuitidea: proposal of an mtternahonal consensus conference,

Arthriha Rheum 1994:37:1 87-t 92,9, Nachman PH, Hogan SL, Jennette JC. Falk RJ. Treatment response and relapse in antineutrophil cytoplasmic autoantibody-assocu

ated mcroscopc polyangbhs and glomerulonephritis. JAm Soc Nephrol 1996:7:33-39,to, Nice JL. Bottinger EP, Saurina GR, ci al, The syndrome of lung hemorrhage and nephnhs is usually an ANCA-aasooated conddion,

Arch Intern Med 1996:156:440-445,11, Mahr A. Guilevin L. Poissonnet M. Ayme S. Preealence.s of polyarterms nodosa, microscopic polyanghta, Wegener’s gra

nulomatosis, and Churg-Strauss syndrome in a French urban multiethnic population m 2000: a capture-recapture estimate.Arthritis Rheum. 2004 Feb 15:51I1(:92-9.

12. Koidingsnes W, Nossent H. Epidemiology of Wegener’s granulomatosis in northern Norway. Arthritis Rheum 2000:43:2481—7,13. Watts RA. Gonzalez-Gay MA, Lane SE, Garcia-Porrua C, Bentham 0, Scoff 0G. Geoepidemiology of systemicvascuitis: comparison

of the mcidence sr two regions of Europe. Ann Rheum Dis 2001:60:170—2,14, Cotch MF, Hoffman GS. Yerg DE. Kaufman Gl, Targonaki P Kaslom RA. The epidemiology of Wegener’s granulomatosia: estimates

of the five-year penod prevalence, annual mortality, and geographc disease distribution from population-based data sources, ArthritisRheum 1996:39:87—92,

15. Reinhold-Keller B, Zeidler A. Gutfleisch J. Peter HH. Rasps HH. Gross WL. Giant cell arteritis a more prevalent in urban thanin rural populations: results of an epidemiological study of primary systemic vasculitides m Germany. Rheumatology (OafOrd)2000:39:1398—402,

16. Watts RA. Lane SE. Bentham G. Scoff 0G. Epidemiology of systemsr vasculitia: a ten-year study in the United Kingdom. ArthritisRheum 2000:43:414—9.

17. Savage CD, Harper L. Holland M. New hndings in pathogsnssis of anhneutrophil cytoplasm antibody-associated vasculitis. CurrOpin Rheurnatol 4(2002). pp. 15—22.

18. Bacon PA. Therapy of vasculitis. J Rheumatol 1994:21:788-790.19. Savage COS. Winearls 0G. Evans DJ. Rees AJ, Lockwood CM. Microscopic polyarteritis: presentation, pathology and prognosis.

QJM 1985:220:467-483.20. Groot KD. Adu 0. Savage CD. The value of pulse cyclophosphamide inANCA-associated vasculifis: mefa-analysis and crihcal review,

Nephrol Dial Transplant 2001: 16:2018.21. Hogan SL, Nachman PH, Wilkman AS, Jennelte JO. Falk RJ. Glomerular Dmease Collaboratae Network. Prognostic markers in

patients wth antineutrophil cytoplasmic autoantibody-asaociated mIcroscopic poiyangiti.s and glomerulonephritis. JAm Soc Nephrol1996:7:23-32.

22. Sneller MC, Hoffman GS. Talar-Willams C. Kerr GS, Hallahan CW, Fauci AS. An analyam of forty-two Wegener’a granulomatosispatients treated with methotresate and prednisone. Arthritis Rheum 1995:38:608-613.

23. de Groot K, Reinhold-Keller B. Tatms B. et al, Therapy for the maintenance of remismon in mxty-f lee patients with generalizedWegeners granulomatosis: methotrexate versus tnmethoprim!sulfamefhoaazole. Arthnhs Rheum 1996:39:2052-2061.

24, Ognibene FP, Shelhamer JH, Hoffman GS. et al, Pneumocyshs carini pneumonia: A major complication of immunosuppressivetherapy m patients wdh Wegener’s granulomatosis. Am J Respn Crit Care Med 1995: 151:795,

25. Chung JB, Armstrong K. Schwartz JS. Albert D. Cost-effectiveness of prophylaxis against Pneumocystis carini pneumonia in patientsw’ith Wegner’s granulomatosi.s undergoing immunosuppressive therapy. Arthritis Rheum 2000:43:1841,

26. Hoffman GS, Kerr GS, Leavitt BY. ci al, Wegener’s granulomatoai.s: An analysis of 158 patients. Ann Intern Med 1992: 116:488,27. Guillevin L. Lhote F. Treatment of polyarteritis nodosa and microscopic poiyangitis. Arthritis Rheum 1998:41:2100,28. Langford CA. Treatment of ANCA-associated vasculiti:s, N Engi J Med 2003: 349:3,29.Savige J, Davies 0, Falk RJ, at al, Antineutroph.il cytoplasmic antibodies and associated diseases: A review of the clinical and labora

tory features. Kidney lnl 2000: 57:846,

Classified Notices

To place a classified notice:HMA members—As a benefit of membership. HMA

members may place a complimentary one-time classified ad in HMJ as space is available.

Nonmembers,—Rates are $150 a Word with aminimum of 20 words or $30. Not commissionable,

For more information call (808) 536-7702.

Office Space & Support Services

ALA MOANA BLDG— PHYSICIAN WANTED to sharespace and support services. Interest in physical rehab.preferred. We have unique time-share arrangements startingat one halt-day per meek. Run your practice with no fixedoverhead. Contact Dr. Speers, REHABILITATION ASSOCIATES. 955-7244.

CT Consulting

STARTING A NEW PRACTICE? — CT CONSULTING. INC., provides business insight to effectively contractmith healthplans. establish billing guidelines, interview staffand coordinate other business functions. With 15+ years ofexperience in the healthcare industry, CT Consulting addsbusiness savvy to your practice. Contact Catherine at (8081330-7738, e-mail: cjcoo$gitin@ttawah.yr,000i.

Physician Wanted

PRIMARY CARE PHYSICIAN — HALF-TIME, UniversityHealth Services Manoa, call Lily Ning MD at (808) 956-8965for information,

Physician Wanted

EXPERIENCED PHYSICIAN NEEDED — PART-TIME,in a family practice clinic, mill be working with an NP. SendCV to (808) 689-7115.

Honolulu Practice Available

ACTIVE ONGOING — INTERNAL MEDICINE PRACTICE,in urban Honolulu available as physician plans to retire.Contact: (808) 951-9931

Surfer’s Medica’ Association: Conference in Biarritz, FranceThe first European meeting of the SMA wig be held from September30 to October 9,2005.

The conference would be of interest to physicians and allied hea.lthcare professionals whotreat surfers as patients and/or who are surfers themselves.

The conference program will include presentations by aH attendees to update the statusof the healthcare/surfi’ng interfac’e pius networking with international colleagues. Additional details are available on the SMA website (www.damoon.net) in the events section,

The conference registration fee of $2,200 USD includes one oceanfront room (based ondouble occupancy) for ten nights, three meals per day and ground transport each day toselected surf spots,

To enroll, make check payable to SMA:BlARRfl and mail to 1330 Ala Moana Blvd., #2101,Honolulu, HI 96814, Questions may be directed to the conference chairperson,Dr. Bob Spe ers at gpeers@lava.ret.

THE WEATHERVANERGSSELF [$TODD SIP. CONT RI PUTING EDITOR

+ DISCUSSING DYSLEXIA 40 YEARS AGO. CHARLIE BROWN SAIL).“CAN YOU RULE OUT STUI’IDI fl?It is a wide. eas and fertile field to pioss. Naturalls. tircnts want to providethe best opportunil\ bir their children to learn, so whenes er a pied pipercomes along w oh a magic tool to aid “dy ‘Ic s a. parents are ready Io huS55, or 511 ‘to/ni Sc,oitii-iti Svnilromc, also called Irlen syndrome, s thelatest diaenosis requirl no a magic p tion, Psychologist Helen lrlen clannsthat children w Oh the syndrome arc sensitis e to light, which can interferewith their ability to read. s\ rite and concentrate. The Irlen method involvesplastic colored filtering lenses inserted over reading materials. The methodalso may include colored contacts or eyeglasses. part of a package sold byMs. Irlen. Testing is done at irlen Centers with a bill of about $500, notlikely to be covered hr insurance. The American Academy o/Pediairics andthe American .Scadi’,uv ()j’hthalinologv have called the research methodsunsound, lacking scientitic basis, and call the findings open to question.Moreover, they stated that the process of selecting the right lens color ishighly subjective and ss ithout scientific rigor. The media, ready conduitsfor flim-flam. and caring ‘.cry little about scientific integrity, have devotedtime on NBC news. 60 minutes and Peteriennings and the News, to providea podium for the latest snake oil.

+ AND THAT’S WFIAF I LIKE ABOUT THE SOUTH.In Montgomery, Alabama. Cheryl Rogers tiled a lawsuit claiming that herhusband’s use of Vioxx led to his death due to heart disease, It was foundthat the sample containers of Vioxx supposedly taken by the deceased weredated after his death, and a prescription for the drug had never been filled.Merck’s attorneys filed a motion to dismiss the complaint, claiming therewas no evidence that Rogers es er took the drug, hut Judge John Rochesterrefused the motion. ‘Fhe Associated Press did a review of campaign financereports and (bund that six PAC’s had contributed $35,000 to the Judge’scampaign fund. The entire $35,000 was traced to the plaintiff’s attorneys.the Beasley Allen law firm, and an additional $25,000 from five other PACswas also funded entirel’s hr Beaslev Allen. for a total of $60,000. JudgeRochester said donations dont influence him. “If it had any influence. Iss ould violate my oath of office.” Of course! 1-low silly to even suggestthat a judge could he corrupt.

+ MED-QUEST PROBABLY KNOWS WHA1 YOU ATE FOR LUNCH!Holy HIPAA Hasvan’s doctors need to knosv that the Med—Quest Division(MQD1 of the stale Department ot Human Sen ices has contracted withACT Hcriiaç’c, In,’, in Richmond. Virginia. to get deep into our medicalpractice. ACS gathers infarmation about the patients prescriptions, andss ill tell the doctor about the potential (or falls and other adverse reactions.In simple terms, the prtect manager (a Pharm.Di with a busy computerprogram atACS Heritage si’s thousand miles away, is poking through medical and prescript ion in format ion, to advise the physician. Supposedly. thiwill prcvide opportunities to impros e outcomes and avoid unnecessarycosts, It ss ill also shock doctors to learn that they- are being watched hr acomputer pmgram tar, tar ass ar . and many will w onder what other aspectsof their prlctice are being “Pied upon.

+ RE CAREFUL At THE FA’,R END OF TI-IF GENE POOL.I ,ook no ahead n the ear 2t 23, the In itcd K ngdoin ha’s ruled that eh il —

di’en born in 2ttt(5w ill has e a right at age 1$. to learn the hological taiher’’name. nec upation. i-el ig ion. and ittier dat a. What th is means is that spermdonors si ill lose their right to anony inits, Similar regulations already eSistin Sweden, Sw itrerland. Norsi ay and the Netherlands, where recruitingdonors is becoming pi’ollcrnatic. (‘n’os International in Denmark, theworlds largest distributor of (rn/en sperm. has a stable of 2f 0 carefullyscreened, mostlr blond and blue-eyed Scandinavians. Some of these menhave sired 2t i or 3(1 children. Many ot these studs have refused to donatesperm toeountries that reqii’e disclosure. Whateverhappened tothat simpleworld I was horn mto.’

+ AMATEURS BUIIF THE ARK. PROFESSIONALS BUtLT THETtTAN tC.With great f’anf’are and at a cost of $12 billion, the latest in airborne giantshas test flown in I rin.s Fhis behemoth the \irhu’, \‘X0 is desined to

carry as many as S’3 human beings. stacked in two decks ss th 53S below.3 5 tipper lesel and 20 crew, .-\ tull hooking will require one houi’ to loadbefore take—, itt’. and pi’obahl hours to unload passengers and luggage -

C:itei’ing and cleamung ss ill he a major challenge to as oid tui’n—arounddelay s. Special loading and dock i rig ramps will he required. and i’unw ayand taxi ss ar s w ill has e to he beefed up to handle the massive footprint i’i

the landing geam-. Other airport ti’at’fic will need to he delayed and clearedaway for the A3$U to land. taxi and take off. Many large airports—— Atlanta.Den’i er, Seattle. Las Vegas are ‘ct using to accommodate the monstei’. -\

first major challenge will he testing of’ emergency unloading Accordingto regulations. the Plane must be evacuated in 90 seconds (! (in case of acatastrophic c’s cut. The aircraft stands 30 feet high. and in an emergencythe crew must gel frightened passengers to jump out in an orderly manner— all 350 souls w ithiri I ½ minutes. The Airhus A330 is one piece of thegreat new millennium that holds little appeal for me.

+ GOOD HEALTH IS JUST THE SLOWEST POSSIBLE WAY To DtE.An article just published in the Archive,v ojlnterna/ Medicine revealed that97C of Americans fail when measured against four basic healthy life stylefactors. Non-smoking, maintaining healthy weight. regular exercise andfive or more servings of frtnts and vegetables each day, were the behaviorfactors surveyed for I 50.000 Americans. Lead researcher, epidemiologistMathew Reeves at Michigan State University. gathered data from the Centers for Disease Control and Prevention, and was “shocked” that a mere3ff enjored this-- basic lifestyle pattern. According to age. people 35 to 44fared the worst, while those over 65 did the best. The annual medical billin the U.S. is $1.5 trillion, the hulk spent on heart disease. diabetes andcancer. What an incredible cost saving would occur if that 3th- could hechanged 1(1 2fiU.

+ IT’S BREAK TIME, ANYBODY WANT A HOT DOG? HOW ABOUtA ROLL?A police officer in Pamnesville. Ohio, was fired for having sex in his policecruiser. Lie appealed the decision to an arbitrator. It was t’ound that the of Ii cerwas on his ‘‘break’’ and that Ii is radio had remained on in the es cut of’ anyemergenc\ cal I. The arbitrator ruled in his tas or, notinc that Clint EastssoodDirty Harry (took time to finish his hotdog svhi Ic he was ohseryi nit a hank

i’obhem’r . and then w cut into act ion. ‘l’he of ticer was reinstated.

+ BE CAREFUL WHEN TURNING THE OTHER CHEEK!In Gsvi nett (‘ounty . Ge irma. a I 0 year old seas arrested on a weaponscharge. and brought ni for booking. ‘l’he jailer svas suspicious. performeda pat doss ii aiid 0 mund nothing, so he decided to d,i a strip search. ‘l’o 115surprise, he t,iund a pistol tucked between the man’s buttocks! \Vow! Talkabout a concealed 55 eapi in. and svhat about the risk of damage to body partswhen lounging on the sofa’.’

Al)DEN [),‘\•:• P l neal correct ness ru 1 amok — Canadian prisons no foni’er al loss

guards at ma’s i mu nm—sccurit\ pin ‘sons to ‘sear pm’oter’ti ye vests becauseit sends a ‘‘e,’ntrontational signal’’ to prisoners.

•: The American S,icmet of Aesthetic Plastic Sorcery reported that(,t)t it) butt lifts s’s crc performed in the F’S. last year. Botton is I

+ An offer from ‘‘LII’. Essence.’’ is that or S I 5.95 ron can purchase acandle that si oclls like .ls’sus.

•:• L.iff’ after death ace ,rding to Forbes magazine, Elve- Presley estateeamed $40 million in 2003, sOnIc Charles Schulz earned $32 million.

+ Ii only takes one Dell PC person to change a light bulb, hut first hemust install the lighthulh adapter card, which is extra.

+ (‘i-os’s a pig ss tIm a centipede. and you get bacon and legs.

ALOHA AND KEEP THE FAITH — RTSS

C.’ontents of thii o,iiiilr do nor necerr’oro’s re//n-i the opinion or j.o sit/on of thelion ott I/pot/n , no! S itt is too A flu tnt Ui Ct / lion to ion IA or to

‘00101CC 1 i’s SIC/i i/i i/lOt 0/1/ic Writer.

Name

U MD/DO SeOaNy

o Other

.. . .

M1

rot/H..

Last fiVe/Her. St sSN toe CMt (tsr

Saturday Mount P cfic Quality H alth F und tic

Sunday

R[ ‘t

DMA Memte 1 5225 osclodcs I -Set 0 Hio ‘ono lice Medco I/HIrers

Noii--Mr-hrr 0 5225 does rsot ir i/cr OH Porto Ike Med col Soil DOs er Deket

El 575 M-edrssk Studerrt/ieorderrt

U Please ro odor rn-c for one of 75 ova/chIc me/root Os/entire des-k scholarshps

o wLt ottenO ALec/ce No-me

E r [1

5550 S•:-sSSo-r-

-

Hawaii Modical Association

k

I

.ij