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JOURNAJ.December 1998 Volume 57, No. 12 ISSN: 001 7-8594

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Our heartfelt thanks to all Health Plan Hawali Physicians

For all the times you’ve:

a’ Provided members with consistently high-quality care

Worked with us to improve quality of life for high-risk members

Stayed up late reviewing clinical practice guidelines

e Helped us resolve our members’ most challenging care concerns(6/98 to 6/01)

Flown in from the Neighbor Islands to participate in quality management meetings

Helped us provide evidence of improved outcomes for members

‘ Achieved consistently high levels of patient satisfaction

Increased immunization rates for Hawaii’s keiki

?i Documented according to NCQA requirements

tt Gone beyond the call to demonstrate truly excellent standards of care

Mahalo! We couldn’t have done it without you!

—,--- accNational Committee for Quality Assurance

HAWAIIMEDICAL

JOURNAL(USPS 237-640)

Editorial

Contents

Published monthly by theHawaii Medical Association

Incorporated in 1856 under the Monarchy1360 South Beretania, Second Floor

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

EditorsEditor: Norman Goldstein MD

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

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

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

Alfred D. Morris MD

Journal StaffManaging Editor: Becky KendroEditorial Assistant: Carol Uyeda

OfficersPresident: Patricia L. Chinn MD

President-Elect: James Lumeng MDSecretary: Philip Hellreich MD

Treasurer: Charles R. Kelley MDPast President: Leonard R. Howard MD

County PresidentsHawaii: Timothy Oldfather MD

Honolulu: Cynthia Goto MDMaui: Jon Betwee MD

West Hawaii: Ali Bairos MDKauai: Thatcher Magoun MD

Advertising RepresentativeRoth Communications

960 Prospect Street, Suite 11Honolulu, Hawaii 96822

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

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

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

Nonmember subscriptions are $25. Copyright 1998 by theHawaii Medical Association. Printed in the U.S.

Norman Goldstein MD 725

AnnouncementRobert T. Wong MD Lecture Series 725

President’s MessagePatricia L. Chinn MD 726

Commentary: What’s New in Medical Communication?Norman Goldstein MD 729

Harry L Arnold Jr. MD, Case of the MonthGradual Loss of IgG Antibodies AgainstGB Virus C/Hepatitis G Virus in a Patient with AIDSVivek R. Nerurkar PhD, Pong K. Chua BS, Cecilia M. Shikuma MD,Wan-Mohajza Dashwood BS, Chris LP. Mime RN, Cora L. Woodward BS,Glenn Kobayashi BS, Jon E. Peterson PhD and Richard Yanagihara MD 733

Interferon Alpha-2b in the Treatment of Chronic Hepatitis C:Early ExperienceNathaniel Ching MD, James Luineng MD, Ronald Pang MD, Glenn Pang MD,Fung Wa Or MPH, Natascha Ching MD and Clara Ching PhD 735

The Effects of ArginMax, A Natural Dietary Supplementfor Enhancement of Male Sexual FunctionThomas Ito MD; Kaye Kawahara MD; Anurag Das MD, FACS;and Warren Strudwick MD 741

Diagnosis and Management of Female Urinary IncontinenceKevin C. Shandera MD 746

News and NotesHenry N. YokoyamaMD 750

Classified Notices 752

Index 1998Marlene M. Ah Heong and Carolyn S.H. Ching of the Hawaii Medical Library 753

HAWAII MEDICAL JOURNAL, VOL 57, DECEMBER 1998723

WeathervaneRussell T. Stodd MD 758

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

Wa ‘a Kaulua

Depicting the two Hawaiian migratory voyaging canoes under full sail at sea.

Join us in the questfor continued

medical excellence.

Jom your Straub colleagues as we strive forcontinuing medical excellence.

Straub Clinic & Hospital, Inc. is accredited bythe Hawaii Medical Association to sponsorcontinuing medical education for physicians.

Straub designates this educational activityfor a maximum of one credit hour inCategory 1 of the Physician’s RecognitionAward of the American Medical Association.Each physician should claim only thosehours of credit that he/she actually spent inthe educational activity.

StmubWhen it really mattersVisit Straubs homepage at httpi/www.straabhealthcom

You are invited to attend...

— Friday Noon Conference —

Luncheon

Prevention of SuddenCardiac Death

Peter J. Kudenchuk, MD, FACC, FACPDecember 4, 1998, 12:30 — 1:30 p.m.

Doctors Dining RoomLearning Objectives

At the conclusion, participants should be able to:• Understand the natural history of patients with high

risk heart disease.• Recognize recent clinical trials that have focused

on antiarrhythmic prophylaxis of high risk cardiacpatients.

• Evaluate the role of implantable devices in theprevention of sudden cardiac death.

We would like to acknowledge the generous Educational Grantfrom Wyeth-Ayerst Laboratories


Hypercoagulable State inBudd-Chiari Syndrome

Dipika Mohanty, MDDecember 11, 1998, 12:30 — 1:30 p.m.


At the conclusion, particIpants should be able to:• Understand the clinical course of the Budd-Chiari

Syndrome.• Review the management of the Budd-Chiari Syndrome.

Summarize the clinical characteristics of the casestudies.

— Tumor Board Conference —

Thyroid Cancer IncidenceReuben Guerrero, MD

December 14, 1998, 12:30 — 1:30 p.m.Doctors Dining RoomLearning Objectives

At the conclusion, particIpants should be able to:• Understand the difference in the incidence of thyroid

cancer among different ethnic groups.• Recognize the different type and incidence thereof.• Describe diagnosis and treatment of thyroid cancer.


Luncheon

Viscosupplementation inOsteoarthritis

Timothy Olderr, MDDecember 18, 1998, 12:30 — 1:30 p.m.


At the conclusion, partIcIpants should be able to:• Gain knowledge of pathophysiology of synovial fluid

in health and disease.• Summarize the Straub experience.• Understand the role of viscosupplementation.

We would like to acknowledge the generous Educational Grantfrom Wyeth-Ayerst Laboratories

Please call Fran SmIth at 522.4471 for more InformatIon.

Editorial

Norman Goldstein MDEditor, Hawaii Medical Journal

As the Hawaii Medical Journal enters its 58th year of continuouspeer-reviewed publication, Hawaii physicians, other healthcareproviders, the Editorial Board and Publications Committee havereason to be proud of a job well done for yet another year.

Reviewers are the foundation of our Journal. The only other peerreviewed medical journal in the United States is the New EnglandJournal ofMedicine, now in its 86th year. Because of the necessityfor anonymity in their task, peer reviewers receive no publishedaccolades for their efforts but they all deserve our gratitude for thehigh quality manuscripts printed herein.

This year we had excellent Special Issues dealing with ClinicalToxicology and the Hawaii Poison Control Center in March andApril. September featured Traumatic Brain Injury, and the finalspecial issue of the year was in November, featuring LaparoscopyPart I.

Regular columns continue to be very popular. Henry Yokoyama’ sNews and Notes and Russ Stodd’s Weathervane are the monthlyofferings most physicians appreciate. The medical school’s HotLine, Military Medicine, and the newly instituted Harry L. ArnoldCase Report ofthe Month in honor ofour former Editor (1941-1985)features interesting reports of medical cases in Hawaii.

A major emphasis in the Editorial section during 1997/98 wasdoctor-assisted death with dignity, due to the Governor’s impaneling of a Blue Ribbon Committee which met monthly beginning inDecember 1996. The final report was submitted to the Governor onMay 11, 1998. The majority opinion stated: “Because we in Hawaiilive in a pluralistic society with many religious and cultural perspectives, it is important that no one perspective be allowed to impose itsbeliefs and mores on another.”

Another year of thanks is extended to Carol Uyeda, EditorialAssistant; Becky Kendro, Managing Editor; our Editorial Assistants, Drake Will MD, Ann Catts MD, and Al Morris MD; andadvertising representative Michael Roth. Our cover by DietrichVarez continue to be the most artistic of all medical journals—takea moment to scan others the next time you are in the Hawaii MedicalLibrary.

Thanks also to the membership of the Hawaii Medical Association for continued support and encouragement, which enablesinterested doctors of Hawaii to experience for themselves theeditorial freedom extended to me. It is a lot of work, but veryenjoyable, educational and satisfying for everyone involved.

Mahalo and Aloha, Carol Uyeda

After serving as an Editorial Assistant for almost 4 years, CarolUyeda has left the Hawaii Medical Association. On December 18,she departs Hawaii for a new career in Phoenix.

As our Editorial Assistant on the Journal, she worked very closelywith Becky Kendro. our managing editor, and Michael Roth, ouradvertising representative, to get and retain new advertisers. We are“in the black,” thanks to this troika.

Carol wore many hats at the Hawaii Medical Association. Sheproduced the invaluable HMA Directory, the Hawaii Medical Newsand, undoubtedly, many other in-house projects about which even Iwas not aware.

She was always there for me - via phone, fax, and e-mail. She hadto “push” our regular column writers to get their materials inpromptly in order to meet production deadlines.

She worked diplomatically with our authors, informing authors oftheir acceptance promptly, and also handled the rejected manuscripts with friendly, courteous correspondence.

We wish you well in Arizona, Carol. Mahalo nui ba.Welcome aboard, Drake Chinen.

Announcement

Robert T Wong, MD Lecture SeriesAnnounces Speakers for 1999

Harvey F. Lodish PhD. is the first of 1999’s distinguished speakers in the Robert T. Wong MD Lecture Series at the John A. BurnsSchool of Medicine.

Dr Lodish is a Member of the Whitehead Institute for BiomedicalResearch and a Professor of Biology at the Massachusetts Instituteof Technology. He is a member of the National Academy ofSciences, one of the highest honors given to scientists in the U.S. Hislaboratory has concentrated on the biogenesis, structure, and function of secreted and plasma membrane glycoproteins.

His public lecture will beheld on Thursday, January 2 1,1999 at4:30 p.m. at the University of Hawaii at Manoa. His topic will be“Developmental and Cancer Biology: Importance of TGR-b.”Reception to follow lecture. He will also be participating in PediatricGrand Rounds, Thursday, January 21,1999, at Kapiolani MedicalCenter for Women and Children, from 8 to 9 a.m. His Topic will be“Erythropoietin, the Erythropoietin Receptor and the Controlof Red Cell Production.”

He will be speaking during lunch with graduate students onThursday, January21, from 12 to 2p.m. at the University of Hawaiiat Manoa (UHM), Biomedical Science Building (BioMed).

He will also be participating in Medical Grand Rounds, Friday,January 22,1999, at Queen’s Medical Center, Kam auditorium andhis topic will be “Regulation of Fatty Acid and Glucose Transport.” From 11:30 to 1 p.m., at Unit 5 (MS II) and Unit 2 (MS 1)Colloquia, UHM Biomed B-103. The topic will be “Regulation ofFatty Acid and Glucose Transport.”

The Series’ second lecturer will be Susumu Tonegawa, PhD.Dr Tonegawa received the Nobel Prize for in Physiology or Medicine in 1987 for his discovery of “the genetic principle for generationof antibody diversity.” He will be presenting his lecture on March12, 1999.

Started in 1985, the Robert T. Wong, MD Lecture Series brings toHawaii gifted individuals who have made major contributions tomedicine and science.

For additional information, please contact Julie Woo, 956-5087.

HAWAII MEDICAL JOURNAL,

725VOL 57, DECEMBER 1998

President’s Message

Patricia L. Chinn MDPresident, Hawaii Medial Association

Today, as individual physicians and as an organization, we arefacing difficult times and must make difficult decisions. We can nolonger shy away from controversial issues. Today, there are thingswe can no longer afford to do, and things we can no longer afford notto do. As a professional organization we must advocate for physicians, but first and foremost, we must serve and protect our patients.

On October 2, 1998, the HMSA held a special membershipmeeting for the purpose of changing its Constitution and Bylaws.These proposed amendments serve to disenfranchise the membersof this mutual benefit society, a move of great concern because of theenormous influence exerted by this health plan behemoth. Becausethe HMA is dedicated to patient advocacy, your Executive Committee decided on two actions: 1) to oppose these amendments; and 2)to notify our membership of the significance of this meeting.Furthermore, the HMA joined forces with the Hawaii Coalition forHealth and the Hawaii Federation of Physicians and Dentists to takea unified position, as all three organizations opposed these changeswhich would affect HMSA’s 600,000 members on the basis ofpatient advocacy.

Unfortunately our efforts failed. The deck was stacked against us.There was only a minimal 10 day advance public notice for the

Surgical Pathology

Dermatopathology

Cytobgy

Frozen Sections

Intraoperative Consultations

Daid M. Amberger, M.D.

meeting. The meeting was scheduled for a busy Monday morning,the eve of the general election. After the meeting, HMSA’ s spokesman admitted that: 1) the HMSA contacted only certain employergroups and; 2) an exceptionally large number of paid HMSAemployees, “as many as 200 staff members might have attended toassist in the meeting” (Honolulu Star Bulletin 11/3/98). Attemptswere made to discredit the HMA and the Coalition by declaring thatour efforts were motivated by political self-interest a time honored tactic ofdrawing attention away from the issues when the issueshave little merit. Indeed, if any organization could be accused ofself-interest, it was not us.

We are appreciative of the large amount of feedback we receivedfrom membership, most in support of our actions. However, we didreceive criticism from three physicians, one who serves on theHMSA Board ofDirectors and another who is conflicted because heis a board member of a corporation involved in a joint venture withHMSA. These isolated comments were far outweighed by thenumerous letters, faxes, and phone calls we received encouraging usto continue opposition to the amendments.

It is important to say here that this year the HMA will continue totackle tough and controversial issues, and we will continue to takea proactive position in areas ofpatient advocacy. For, if we fail to do

so, we will lose our raison d’etre and the trust our patients place inus to work for their best interests.

I would encourage every member who is interested, to get involved with this and other issues, by coming to the ExecutiveCommittee meetings held weekly or the Council meetings heldmonthly. Your officers and commissioners are volunteers and“regular” doctors just like you. What you as an individual membercan derive as a benefit of membership is directly related to whatefforts you contribute toward our association. HMA’ s ultimatesuccess is truly a result of the collective efforts of individualmembers. At minimum, please call or fax your comments to us.

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HAWAII MEDICAL JOURNAL, VOL 57, DECEMBER 199S

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Members of the HMA Committee on Physicians’ Health are available by phone to colleagues and theirfamily members who feel they need help with their situation. We assist physicians who become unableto practice medicine with reasonable skill and ignore the safety of their patients. Chemical, mental,emotional and physical impairment are considered by the Committee. The Committee will assist withina confidential system to restore the physician to a state where he or she will be able to practice medicine.

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1360 South Beretania Street, Second FloorHonolulu, HI 96814

(808) 536-7702, ext 2234 or ext 2230fax (808) 528-2376

(808) 566-1403(808) 956-7457(808) 236-8497pager 541-6922(808) 254-5385pager 231-1333(808) 522-3220(808) 523-6966(808) 246-0663(808) 871-7502(808) 521-3851

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Commentary

What’s New in Medical Communication?

Norman Goldstein MD, FACP, NNClinical Professor, Medicine (Dermatology)

John A. Bums School of MedicineUniversity of Hawaii

Advances are happening fast in the medical communicationsfield. Some we now take for granted; others we’ve only heard about;and there are those we cannot even conceive of as possible, yet thesenew modes are either already in operation or soon will be!

Ten years ago, I wrote an article published in the Hawaii MedicalJournal, Is a “Fax” in Your Future?’ In it, I suggested that physiciansconsider a facsimile unit for their office, laboratory or perhaps eventhe home.

In the December 3, 1987 issue of Pacific Business News, aheadline stated “it’s hard to find an office that lacks a fax.” Thatreport referred to nonmedical offices. A year later, there were veryfew solo medical and small group practices in Hawaii that had faxunits. Only one major medical clinic, Straub, in Honolulu had a fax.The Hawaii Medical Library was then planning to install one.Today, the fax is almost as common as the telephone.

We have come a long way since Rockwell International Corporation first developed facsimile technology in the late 1960’s: fromthe thermal paper (that turned brown so quickly) to the modern plainpaper units. Today faxes are faster, with sharper print, and costeffective. Most still print with black ink, but the color fax is alsoavailable.

Medical Communication is so vast a field of interest that it couldeasily warrant a textbook. Soon the subject will be a Special Issueof the Hawaii Medical Journal, but in this paper, we review howmedical communication has progressed within the past decade.

The medical office I clinic I home I carTelephones — very few offices now have only one telephone line.

The phone companies in Hawaii can provide various types ofrotating lines, including in-office communications, paging systems,call waiting, caller identification, conference call capabilities, andeven two-way video telephones. Styles and colors ofphone units areunlimited.

Telephone message machines are useful, but can be frustrating;a simple recording indicating office hours, out to lunch, or to call Dr.X who is covering for you, can certainly be helpful. A moreextensive recording indicating the virtues and services of youroffice has many advantages too, when done professionally. Voicemail, requiring a directory ofevery employee, nurse, and additionalpersonnel, is time-consuming, often culminating in a recordingindicating “I am either on the phone or out of the office. Please leavea message.”

Car phones used to be expensive to purchase or lease, and theyrequired special installation. Now, hands-free car phones withpush-button rapid dialing are more affordable and far safer whendriving than previous alternatives.

Cellular telephones are lighter, smaller, and so affordable thatmany physicians carry a “cell” phone in addition to their pager. It’spractical and safe for a spouse and children to carry their own cellphones.

Pagers are ubiquitous with dozens of varieties available fromnumerous answering services in Hawaii. Digital, vibratory, alphanumeric and voice pagers cater to individual needs. Island-wide,statewide, and worldwide paging is available in Hawaii.

The Startel Telephone Answering System used by the PhysiciansExchange of Honolulu has such a variety of features that I can onlyindicate a few here. After office hours, the Exchange picks up callsmade to the office. Urgent calls are relayed by voice pager. Every callis answered and a message entered into the computer and time-stamped, as well as all processes made to relay the call. The nextmorning, all completed messages are faxed to the office. (Fig. 1).Messages are retained for seven years. In addition, all calls answeredand made from the Exchange are automatically recorded into theirvoice recording system. These taped recordings are also retained forseven years. The Exchange also acts as a communications center(Fig. 2) and contact for burglary and fire alarm systems in homes andoffices. The Exchange is a subsidiary of the Honolulu CountyMedical Society. A brief tour of the Exchange is a real “eye-opener”as to what is available in pager service, and I recommend that everyphysician visit their offices on Beretania Street.

Desktop equipment is user-friendly now with many special features depending on office/clinic/hospital needs. Magnetic tapesremain favorites and are economical. Equipment companies caninstall wiring, from exam rooms and consultation rooms, directly tothe Secretary/Transcriber.

Portable dictation equipment has become even more portable. Asmall hand-held, pocket-sized unit can easily record an hour-longdictation or a lecture.

Computer programs are available in foreign language formats.This will undoubtedly become more popular as pricing is reduced.Hawaii will be the perfect testing laboratory to develop these multilingual programs.

Some dictation equipment companies, notably Dictaphone, are setup to enable the physician to dictate directly to the Secretary viaphone from home, car, office, and the cell phone. It works very well,and saves time.

Voice-activated computers: For those who cannot or prefer notto type, the wonder of all office computer devices is the voice-activated dictating device. Several years ago, a demonstration ofvoice-activated computers was held in Honolulu. At that time, I wasvery unimpressed. The system required a great deal of training,advanced computer knowledge and, most importantly, it meantspeaking y s-l-o-w-l-y as the unit learned your speech patternsand dialect.

Today the DragonDictate/NaturallySpeaking equipment enablesusers to speak to the computer in a natural way and at a normal pacewith no need to pause between words. It has an active vocabulary of30,000 words and up to 200,000 words in backup disc dictionaries.This manuscript is being entered and typed by my voice-activatedcomputer, then finalized by a (highly overqualified) transcriber.

Tapes and Disks: the dinosaurs of recorded sound, the “78”, “45”and LP records are still around, valued by collectors, but magneticaudio tapes have all but replaced them. Continuing Medical Educa

HAWAII MEDICAL JOURNAL. VOL 57, DECEMBER 1998729

Fig 1.— Sampleoffaxrecordof phonecalls madetotheoffice. Messages receivedbythePhysicians Exchangeoperatorsandsenttophysician at7:15AM next

tion programs on tape are available for all medical specialties. Athome, in the office, and in the car, they continue to provide up-to-date medical information. The same can be said for videotapes,which provide patient information in offices and hospitals. TheCompact Disc (the ubiquitous “CD”) is now usurping the audio andvideo tape market, though tapes will probably remain a majoreducational/instructional medium for another generation. The CDROM’s varied uses in medicine, entertainment and communicationin general are easy-to-use, easy to mail, and economical. Now,interactive CD’s and Laser Discs are happening.

Another use for the compact disc includes storage of basicmedical records which must be retained for the life of the patient.Storage space for standard files is increasingly expensive for records,photos, and X-rays, which can now be transferred to CD’s. It’s notcost-effective at this time, but as the technology improves, undoubtedly charts and records will be retained on CD’s.

The Medical LibraryAny dissertation on medical communication must include the

Library. Here are a few statistics: the Hawaii Medical Libraryreceives more than 18,000 books and journals in an average year.Twenty-nine thousand books and journals were loaned in 1996.

Between July 1996 and June 1997, more than 124,000 “searches”were done on the Library’s web site. The Web continues to expandexponentially as a major method of information transfer. Infonnation skills are taught by the reference library staff, providing a formalclass setting which includes the Internet, MEDLINE and otherdatabase searches. For those who cannot spare the time to go to theLibrary, the H.M.L. reference staff will provide reprints via the mailor by fax for a modest fee.

The Library is also home to the Consumer Health InformationService (CHIS). This new service provides health informationresources to enable consumers, (patients and families) to makeinformed health care decisions. Call the Library and ask for theCHIS brochure for distribution to your patients. Then stop in to seethe improved facilities at the Hawaii Medical Library — the Forefront of Medical Communication in Hawaii.

Medical Communications in Our HospitalsIn preparation for this manuscript segment, I contacted the hospi

tal Directors of Communications and Computer Directors. Theyinundated me with materials on what’s happening today in thecommunications field in our Hawaii hospitals.

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730

At Kapiolani Medical Center, for example, they have a newtelecommunication system, “catapulting them into the 21St Century!” From voice mail to simplified four-digit dialing to programmable speed calls to ringer choice, etc., etc. for their more than 800phones and 275 fax machines and modems.2Telecommunicationsare here, not just at Tripler Army Medical Center,3 but the entire world. Two-way video consultation programs doubled in the U.S. from 38in 1995 to 69 in 1996. Interactive clinical consultations of all types showed a 300% increasefrom 6,134 to 19,380. According to TelemedicineToday magazine, this has increased even morein 1997.

The World Wide Web has opened up medicalcommunications in our hospitals, clinics, offices and homes — as well as those ofour patients.Space here does not permit further explanationof the explosion in medical communicationsthrough the Web at this time. Look for theSpecial Issue of the Hawaii Medical Journal formore information in 1999.

ConclusionCommunication, in medicine and in general,

is at its heart between people. From papyrus topaper, from audio and video to CDs and LaserDisks, we as physicians must always rememberthat eye to eye verbal communication is still, and

There’s No Excusefor Domestic Violence

always will be. the best and most consoling means ofbonding with our patients, our friends.

References1. Goldstein, N. Is a “Fax” in Your Future? Hawaii Med J 1988; 47:238.239.2. Kapiolani Health News. August12. 1997. 3:1.3. Delplain C.B.. Lindborg CE., Norton S.A., Hastings J.E. Tripler Pioneers Telemedlcine

Across the Pacific, Hawaii Med J. 1993; 52:338-339.4. Survey of U.S. Telemedicine Reveals Tripling of Activity in 1996. Association of

Telemedicine Service Providers; joint press release October 7, 1997.

Editor’s Note:This manuscript first appeared in the April 1998 Pro

ceedings of the Straub Foundation’s “What’s New inMedicine in Hawaii”. As you will read, there are manynew treatments, procedures, specialties and medical services available in Hawaii now.

Forty-two manuscripts were contained in the Proceedings, and while most of the papers were written by Straubphysicians, several came from other leaders in the country.The papers are uniformly well written, especially for themedical generalist.

Bo Eklof, MD, PhD. medical director of the StraubFoundation and Editor of the Proceedings made a note

worthy effort in detailing what’s new and promising in the Hawaiimedical community. Limited copies of the Proceedings may still beavailable at the Foundation office (524-6755) and at the HawaiiMedical Library.

Reprinted with permission.


Fig 2.— Physicians Exchange Communication Center. At peak hours, seven operatorsarekeptbusy. TheCenterislocated intheHawaii Medical Association Buildingon Beretania Street.

PHYSICIANS’EXCHANGE

OF HONOLULU, INC.

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Gradual Loss of lgG Antibodies Against GBVirus C/Hepatitis G Virus in a Patient With AIDS

Vivek R. Nerurkar, PhD*, Pong K. Chua, BS*,Cecilia M Shikuma, MD**, Wan-Mohaiza Dashwood, BS,

Chris l.P. Mime, RN, Cora L. Woodward, BS*, GlennKobayashi, BS***, Jon E. Peterson, PhD****

and Richard Yanagihara MD*

GB virus C/hepatitis G virus (GB V-C/HG V) is a positive-sense,single-stranded RNA virus belonging to the family Flaviviridae andis distantly related to hepatitis C virus (HC 13 GB V-C/HG V can betransmitted by the parenteral and the sexual route1 4 AmongThdividuals infected with human immunodeficiency virus type 1(HI-i) by the sexual route, we and others have demonstrated a highprevalence of GB V-C/HG V infection.58Recently, Woolley and colleagues reported that AIDS patients co-hfected with GB V-C/HG Vhad a significantly lower mean CD4 cell count than AIDS patientswithout GB V-C/HG V infection,9suggesting that GB V-C/HG V antibody may be lost with progression to AIDS. To our knowledge nodata are available on the loss of antibody agathst GBV-C/HGV inAIDS patients. We now report on an HI V-infected patient whoexhibited gradual loss of IgG antibodies against GB V-C/HG V, aswell as HCI.4 with progression of HIV disease.

Case ReportA 35-year-old Caucasian woman, presumed to have been infected

by injection drug use (IDU) with HIV subtype B in 1994, was firstseen in October 1995 in our Women’s Clinic, which providesmedical and psychosocial services to HIV-infected women. At theinitial visit, CD4 and CD8 counts were 197 and 435 X 106 cells/L,

Retrovirology Research Laboratory and**Hawaii AIDS Research Consortium,Pacific Biomedical Research Center,University of Hawaii at Manoa,Honolulu, Hawaii,***Hawaii State Department of Health,Honolulu, Hawaii, and****Orfl.. Clinical Diagnostics,Raritan, New Jersey

Grant support: U.S. Public HealthService grant GI2RRJAI-03061from the Research Centers inMinority Institutions ProgramNational Institutes of Health.

Reprint requests to:Vivek R. Nerurkar, Ph.D.Retrovirology Research LaboratoryLeahi Hospital, Atherton Bldg.Second Floor3675 Kilauea AvenueHonolulu, Hawaii 96816

respectively. Plasma was negative for GBV-CIHGV and HCVRNA, as determined by reverse transcription-polymerase chainreaction (RT-PCR) using oligonucleotide primers spanning 377-bpand 257-bp of the 5’-untranslated region of GBV-C/HGV and HCV,respectively.8 However, plasma was positive for IgG antibodiesagainst GBV-C/HGV and HCV, as measured by enzyme-linkedimmunosorbent assay (ELISA), with optical density (OD) readingsof 1.14 and 2.60, respectively. Hepatitis B virus surface antigen andcore antibody were also detected, and liver enzyme levels wereabnormal: alanine aminotransferase, 71 lUlL; aspartate transaminase, 118 lU/L; gamma glutamyl transferase, 73 lU/L; and alkalinephosphatase, 294 lUlL. Low-grade squamous intraepithelial lesion(SIL) found on initial visit progressed to high-grade SIL in April1997, and human papillomavirus 18 was detected by PCR incervicovaginal lavage cells.

In April 1996, she was diagnosed with Mycobacterium aviumcomplex and esophageal candidiasis, and in August 1996, HIV RNAburden was 230,290 copies/mL (Amplicor HIV-1 Monitor Test,Roche Diagnostic System, Somerville, NJ) with CD4 and CD8counts of 48 and 145 X 106 cellslL, respectively. In October 1996,highly active antiretroviral therapy (HAART) was started with theaddition ofIndinavir to D4T and 3TC. The patient was noncompliantto HAART and in February 1997, cytomegalovirus-associatedretinitis was diagnosed in her right eye. A month later, HIV RNAburden was 152,967 copies/mL with CD4 count of 26 X 106 cellslL.In April 1997, with increasing compliance to HAART, her HIVplasma viral RNA decreased to 27,334 copies/mL, with CD4 andCD8 counts of 160 and 217 X 106 cells/L, respectively. HIV RNAviral load was 230,000 copies/mL in September 1997. In October1997, non-Hodgkin’s lymphoma and HIV-associated myelopathywere diagnosed with a CD4 count of 22 X 106 cells/L, after whichher health deteriorated rapidly, and she died in January 1998. Atautopsy, blood and peritoneal fluid were collected.

Plasma collected over a 27-month period were tested in triplicateby ELISA for IgG antibodies against GBV-C/HGV (Ortho HGVCHOe2 ELISA Test System, Ortho Clinical Diagnostics, Raritan,NJ), HCV (Ortho HCV Version 3.0 ELISA Test System, OrthoClinical Diagnostics) and HTV (Genetic Systems H1V-1/2 EIA,Genetic Systems Corp., Redmond, WA). In addition, plasma wereassayed for reactivity to HIV proteins by Western blot analysis(HIV-1 Western Blot Kit, Cambridge Biotech Corp., Rockville,MD). To assure comparability, all plasma specimens were tested bythe above-mentioned assays at the same time. As seen in Fig. 1, thepatient lost IgG antibodies against GBV-CIHGV and HCV (positivecutoff value, OD 0.6) between 18 to 20 months after the initial visit,and the OD readings were 0.07 and 0.03, respectively, in the plasmasample collected at autopsy.

DiscussionAs a result of 11W-I-induced severe immunosuppression, de

pressed humoral and cellular immunity has been documented tospecific parasitic,10-12bacteriaV314 and virafl” 15-16 agents. Significantly lower levels of IgG, 1gM and IgA antibodies to Giardialamblia were demonstrated in AIDS patients with acute giardiasis.12Loss of humoral immune response to Pneumocystis carinii in AIDSpatients when compared to other immunosuppressed patients orimmunocompetent controls has been documented.’3’‘ Moreover,


progressive loss of IgG antibodies against Chiamydia pneumoniae

has been demonstrated in middle to advanced stages of HIV-1

infection.’4In a study of 95 HIV- I-infected individuals (45 asymptomatic and

40 with AIDS), Radkowski and coworkers” demonstrated lower

antibody titers to hepatitis B surface antigen, rubella virus and

cytomegalovirus in AIDS patients when compared to

asymptomatically infected individuals. Similarly, a population-

based study of measles and measles immunization in HIV- 1-in

fected children demonstrated loss of anti-measles antibody over

time in older children and a statistically significant correlation

between lower CD4 counts and measles-mumps-rubella vaccine

nonresponsiveness.’6Finally, time-dependent HCV seroreversion

has been reported in a cohort of HIV- I-infected IDU. ‘

Loss of seroreactivity to specific HIV- 1 epitopes has also been

reported. Up to a 100-fold greater affinity to HIV- 1-specific p24 and

p17 proteins has been found in asymptomatic HIV-1-infected indi

viduals than in AIDS patients,’8suggesting that those who develop

AIDS either lose or fail to develop high-affinity antibodies early in

the infection. These data also demonstrate that the presence of low-

affinity antibody and the progressive reduction in titer of specific

antibodies are better predictors of disease onset than CD4 cell count.

Moreover, antibodies against HIV-l p24 is undetectable in 45% of

individuals by the time of AIDS diagnosis.’9 Although the patient

reported here did not exhibit a dramatic drop in IgG antibodies to

HIV- 1 as measured by ELISA, during the last 3 months before death,

there was a gradual loss of reactivity to HIV- 1 gag-encoded pro

teins, as determined by Western blot analysis (Fig. 1).In conclusion, as seen in other opportunistic infections associated

with AIDS, AIDS patients co-infected with GBV-CJHGV may

similarly lose anti-GBV-C/HGV antibodies during progression to

AIDS.

References1 LinnenJ, WagesJJ, Zhang-KeckZ, eta!. Molecularctoningand disease association of hepatitis G virus:

a transfusion-transmissible agent. Science 1996; 271:505-508.2. Simons JN, Pilot-Matias TJ, Leary TP, et at. Identification of two flavivirus-like genomes in the GB

hepatitis agent. Proc Nail Acad Sc! USA 1 995;92:3401 -3405.3. SimonsJN, LearyTP, Dawson GJ, Pilot-Matias TJ, Muerhoff AS, SchlauderGG, Desai SM, Mushahwar

1K. Isolation of novel virus-like sequences associated with human hepatitis. Nat Med 1995; 1:564-9.4. Stark K, Bienzle U, Hess G, Engel AM, Hegenscheid B, Schiuter V. Detection of the hepattis G virus

genome among injecting drug users, homosexual and bisexual men, and blood donors. JInfectDis1996:174:1320-3.

5. Bonacini M, Qian 0, Govindarajan S, Valinluck B. Prevalence of hepatitis G virus RNA in the sera ofpatients with HIV infection. J Acquir Immune DeL/c Syndr Hum Retrovirol 1998; 19:40-43.

6. lbanez A, Gimenez-Barcons M, Tajahuerce A, et at. Prevalence and genotypes of GB virus C/hepatitisG virus (GBV-CIHGV) and hepatitis C virus among patients infected with human immunodeficiencyvirus: evidence of GBV-CIHGV sexual transmission. J Med Wail 1998; 55:293-299.

7. Scallan MF, Clutterbuck D, Jarvis LM, Scott GR, Simmonds P. Sexual transmission of GB virus Clhepatitis G virus. J Med Wrol 1998; 55:203-208.

8. NerurkarVR, Chua PK, Hoffmann PR, Dashwood WM, Shikuma CM, Yanagihara R. High prevalenceof GB virus C/hepatitis C virus infection among homosexual men infected with human immunodeti.ciency virus type 1: evidence for sexual transmission. JMed Virol 1998; 56:123127.

9. Woolley I, Valdez H, Walker C, Landay A, Zdunek D, Hess G, Lederrnan MM. High prevalence ofhepatitis G virus RNA and antibody to probable viral envelope protein but not both in AIDS patients’plasma. AIDS 1998; 12:530-531.

10. Carrega G, Canessa A, Argenfa P, Cruciani M, Bassefti 0. T cell blastogenic responses to Toxoplasmagondi trophozoites among HIV.infected patients. AIDS Res Hum Retroviruses 1995; 11:741-746.

11. Radkowski M, Laskus T, Kopicz-Kaminska EW, Mian M, Szymanska B, Babiuch L, Slusarczyk 1.Evaluation of humoral immune response in patients with asymptomatic and syrrrptomatic HIV infection.Analysis of titers of anti-Hbs, antibodies against cytomegalovirus, herpes simplex virus type I, rubellavirus and toxoplasma gondii. PolArch Med Wewn 1993; 90:112-118.

12. Janoff EN, Smith PD, Blaser MJ. Acute antibody responses to Giardia lamblia are depressed in patientswith AIDS. JlnfectDis 1998; 157:798-804.

13. Elvin K, Bjorkman A, Heudin N, Edksson BM, Bartholt L, Linder E. Seroreactivity to Pneumocystiscailnii in patients with AIDS versus other immunosuppressed patients. ScandJlnfectDis 1994; 26:33-40.

14. Viscott Comandini U, Massetti AP, Marchese R, Zaccarelli M, Vullo V, Delia S. Chlamydia pneumoniaeseroprevalence among HIV-1 -infected and uninfected people wfth known HIV risk factor. AIDS 1996;10:1543-1547.

15. Chamot E, Hirschel B, WintschJ, RobertCF, Gabriel V DeglonJJ, YerlyS, PerrinL. Loss of antibodiesagainst hepatitis C virus in HIV-seropositive intravenous drug users. AIDS 1990; 4:1275.1277.

16. Patumbo P, Hoyt L, Demasio K, Oteske J, Connor E. Population-based study of measles and measlesimmunization in human immunodeficiency virus-infected children. Pediatr Infect Dis J 1992; 11:1008-1014.

17. Piter LL, Niell HB, Langdon SB, Ballz S, Clark ST, Edwards CC, Woods DR. Evidence for depressedhumoral immunity to Pneumocystis cadnii in homosexual males, commercial plasma donors, andpatients with acquired immunodeficiency syndrome. J CL/n Microbio! 1987; 25:991 -995.

18. Chargelegue D, Stanley CM, O’Toote CM, CoMn BT, Steward MW. The affinity of tg(3 antibodies to gagp24 and p17 in HIV.1-infected patients correlates with disease progression. Cl/n Exp !mrnunol 1995;99:175-181.

19. Lau RK, Hill A, Jenkins P, et 51. Eight year prospective study of HIV infection in a cohort of homosexualmen—clinical progression, immunological and virological markers. mt jSAIDS 1992; 3:261-266.

Fig. 1.— LongitudinalanalysisoflgGantibodyresponsetoGBV-CMGV,HCVand HIV, asmeasuredbyEUSAandWesternblotinanAlDSpatient.Reactivity to HIV proteins is indicated: positive, +; negative -;indeterminate,± ELlSAcutoffswere 000.6 (4)forGBV-CIHGVand HCV, and OD 0.2 (—f) for HIV.

GBV-CIHGVANAHCV RNA

•oAHIv

HIV Westernblot analysis

p17p24p31gp4lp51p55p669p120gpleo

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734

Interferon Alpha-2b in the Treatment ofChronic Hepatitis C: Early Experience

Nathaniel P.H. Ching MD * James Lumeng MD **, Ronald Pang MD **, Glenn Pang MD**Fung Wa Or MPH***, Natascha W.H. Ching MD, and Clara Ching PhD

The antiviral and immunomodula tory effects of interferon wereassessed in the treatment of chronic Hepatitis C in multi-ethnicpatients to prevent viral replication and chronic liver damage. Threemillion units of recombinant interferon alpha-2b were administeredthree times a week for 48 weeks to a group of 9 active Hepatitis Cpatients. A clinical response was defined as normalization of serumALT values. Serum was frozen and stored for Hepatitis C viralassays. Four patients normalized their liver functions. When virallevels were measured only two patients had unmeasurable levels ofHCV RNA after treatment. Therapeutic results were observed andmuch work needs to be done to improve therapy because a seriousepidemic is predicted for the future.

IntroductionThe Federal Drug Adminstration approved Interferon alpha-2b

for the treatment of chronic Hepatitis C in February 1991. TheHepatitis C antigen was identified in 1989 and an antibody testdeveloped soon thereafter; prior to this, Hepatitis C was referred toas Non-A Non-B Hepatitis. Interferon has been shown currently tobe the most effective therapy in approximately 30 to 40% of chronicHepatitis C patients1-3because of its antiviral and immunomodulatoryeffects. The reports leading to FDA approval looked promising sointerferon therapy was utilized for our patients soon after FDAapproval and forms the basis for this report of our early experiences.Our group was referred the Hepatitis C Virus (HCV) cases fortreatment because of our experience in a research project to treatchronic Hepatitis B patients.4

Chronic Hepatitis B is a major public health problem in Hawaiibecause of the large immigrant population from Asia and the PacificBasin. Exposure to Hepatitis B virus (HBV) often results in chronicHepatitis that can significantly increase the risk of developingcirrhosis and hepatocellular carcinoma. Hepatitis C can develop intothese same fatal complications. The recent NIH Consensus Conference on Hepatitis C notes that 4 million people in the United Statesare currently infected with HCV with about 30,000 new cases a yearwith the numbers to double or triple in the next 20 to 30 years.5It willbe a major public health problem until an effective therapy andvaccine can be developed.

Materials and MethodsPatient Population

Patients testing positive for the first generation HCV antibody test(Ortho Diagnostics, New Jersey) and negative for Hepatitis Bantigens or antibodies were referred for evaluation for treatment.Patients with elevated liver function tests, primarily ALT >=1 .5Xhigh normal level for over 6 months, were then selected for treatmentaccording to the FDA approved protocol. Patients were excluded ifthey showed evidence of cirrhosis as reflected in their alkalinephosphatase levels. Informed consent was obtained.

Interferon TherapyChronic active Hepatitis C patients were treated with recombinant

interferon alpha-2b (Intron-A, Schering-Plough Corporation,Kenilworth, NJ). Three million units were administered subcutaneously 3 times per week for 48 weeks. If there was no clinical reponse,another 48 week course was offered . Patients received their injections in the Ambulatory Oncology Clinic or chose to voluntarilyself-administer their medication after training by the OncologyNursing Staff. The dose was reduced to 1-2 million units whenplatelets were <100,000 or granulocytes were <1000.

Evaluation During TherapyPatients were evaluated during therapy for hematological and

biochemical profiles. Blood was collected for complete blood andplatelet counts and liver function tests (LFrs) including serumalanine and aspartate aminotransferase and gamma glutamyltranspeptidase activities (ALT, AST, GGPT) prior to therapy, after2 weeks, monthly during therapy and 2-3 months post therapy. Liverfunction tests were performed by Immunoassay (EIA) (AbbottLaboratories, Abbott Park, IL). All evaluations were performed bythe same Clinical Laboratory. A clincal response was defined asnormalization of ALT levels.

*Depaents of Surgery and ***MedicineJohn A Bums School of Medicineat St. Francis Medical CenterUniversity of Hawaii andDepartment of MedicineSt. Francis Medical CenterHonolulu, Hawaii

Supported in part by a grant from theHawaii Department of Health,Hawaii Medical Association andCancer Federation, Inc.

Address correspondence andrequests for reprints to:Nathaniel Ching, M.D.1360 S Beretania Sf, Suite 400Honolulu, Hawaii 96814

HAWAN MEDICAL JOURNAL, VOL 57, DECEMBER 1998735

Hepatitis C Virus (HCV) AssayAliquots of serial serum samples from each patient were drawn at

baseline, 2-3 month intervals during therapy, the end of therapy and

2-3 months following therapy and stored at -70 C for analysis when

more specific viral tests were available. The first generation test for

HCV antibody was performed in the clinical laboratory. Sera drawn

during therapy were frozen for later batch analysis for HCV-RNA

by reverse transcription-polymerase reaction (RT-PCR) by Lawrence

Lumeng MD, Department of Gastroenterology, Indiana University

School of Medicine. RT-PCR analysis for the 256BP and 157BP

regions confirmed the diagnosis of HCV but it was only semi-

quantitative.Branched HCV RNA analysis was performed by Reference

Laboratory Alliance (Pittsburgh, PA).6HCV-RNA is quantifiable at

levels >3.5X10E÷5 Eq/ml butis notFDAclearedfordiagnostic use

and may not constitute the sole basis for patient diagnosis. HCV

RNA in a patient’s sample is captured and hybridized to several

target probes corresponding to the conserved 5’ nontranslated

region of HCV. Amplification of signal from the hybridizations is

achieved by addition of branched DNA molecules which can bind

multiple copies of enzyme emitted and measured by a luminometer.

Concentrations of viral target in individual specimens were deter

mined by comparison with a standard curve.HCV genotype determination was performed on the baseline

samples by RT-PCR at Reference Laboratory Alliance (Pittsburgh,

PA). The 1NNO-LIPA (line probe assay) is a reverse hybridization

for the differentiation of the various HCV genotypes. DNA repre

senting a sequence from the 5’ nontranslated region was amplified

using biotinylated primers. Amplified DNA was hybridized to

specific oligonucleotide-probes immobilized on membrane strips.

Hybridizations were visualized by reaction of alkaline phosphatase,

bound to amplified DNA, with chromogenic substrate. The pattern

of reactivity of a simplified fragment with one or more lines upon the

test strip allows recognition of five major HCV genotypes (Geno

type 1-5) and 6 subtypes (la, lb. 2a, 2b, 3a,3b).

Statistical AnalysisResults are expressed as arithmetic mean ± SD except where

noted. Data was analyzed with the Sigma Stat program (Jandel

Scientific, San Rafael, CA). Continuous variables were analyzed by

linear regression or Analysis of Variation (ANOVA) techniques.

The IBM 55SX -PS2 computer was used for the analysis.

ResultsStudy Population

Eleven patients were referred for evaluation for treatment; one

patient did not qualify because of associated Hepatitis B involve

ment and evidence of cirrhosis. One of the remaining ten patients

was a young patient from a drug rehabilitation program who ran

away from his program and did not return for further treatment after

his first injection. The remaining nine patients treated ranged in ages

of 35-69 years; 6 of the 9 were males. Baseline liver function tests

(ALT, AST and GGPT) were increased in the patients: ALT = 195

± 121 IU/L,AST= 111 ±64IUIL,GGPT= 115± IO9IUIL.Therisk

factors identified for Hepatitis C were blood or blood products

transfusion (3) and confessed unspecified drug usage (2); no history

of any other recognized risk factor was obtained from the remaining

4 patients. There was only one foreign born patient (Korea); the

remaining patients were from Hawaii, Guam or the mainland US.

ToxicityPatients initially experienced flu-like symptoms, including myal

gia, headache and fever which generally improved after the first

week or two of therapy; one patient (#905) had severe constitutional

symptoms which responded to dose reduction. The nine patients

tolerated their regimens and completed therapy. One patient (#934)

required dose reductions due to decrease in wbc’s and platelets.

Biochemical Liver Function TestsALT levels decreased in all patients during treatment, P<.05

(Fig 1), but only 4 patients normalized their ALT levels. One patient,

#905, who was infected after blood transfusion had normalized her

liver function tests after the first 6 months of treatment; she flared to

exceptionally high levels of ALT and was started on another course

of treatment. She responded to another 6 months of therapy with

continued normal liver function tests thereafter. The patients who

did not normalize had continued elevated levels or increased after

cessation of therapy.

Hepatitis C Virus (HCV) AssayAll patients were confirmed for the presence of HCV by PCR

analysis. Serial analysis during treatment of the patients only dem

onstrated the disappearance of both BP256 and BP157 markers in

one patient, again #905, demonstrating eradication ofthe virus. This

patient had flared her LFTs and required a second course of treat

ment.Baseline levels of branched HCV RNA analysis ranged from 8.4-

862.7 IOE+5 Eq/mi. The 4 patients who normalized their LFTs had

baseline levels of 8.4, 26.6, 66.9 and 108.2 1OE+5 Eq/ml. Only two

of the four patients developed unmeasurable levels of HCV RNA

after therapy whose baseline levels were 8.4 and 26.6 respectively.

The lower baseline levels of HCV RNA may possibly predict a

better response.HCV genotype analysis demonstrated a preponderance of geno

type 1, 7/9 patients. There was only single incidences of type 2 and


736

Fig 1.—Changes in ALT levels of chronic active Hepatitis C patients oninterferon therapy,X±SD. Elevated levels at baselinedecreased butnot to normal levels in all patients.

350

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DESCRIPTION: AZELEX )uoelaic acid cream) 20% contains azelaic acid, a naturally occurring saturated dicarbosylic acid Slructural Formula800C-)CH2)7-C000. Chemical Name: 1,7-heptanedicarbonylic acid, Empirical Formula C9H1604. Molecular WeighT t88,22, ActiveIngredient: Each gram of AZELEX contains azelaic acid 82gm 20% w/w). Inactive Ingredients: cetearyl octanoate, glycerin, glyceryl stearateand celearyl alcohol and cetyl palmitate and cocnglycxrides, PEG-5 glyceryl otearale, propylene glycol and purified water. Beozoic acid is present asa preseruatioe CLINICAL PHARMACOLOGY: The enact mechanism of action of azetaic acid is not known. The following in vitrodata are auaitable,but their clinical significance io unknown Azelaic acid has been shown to possess antimicrobial actiuity against Propionibacterium acoes andStaphy/ococcus epidermidis The antimicrobial action may be attributable to inhibition of microbial cellular protein syotheais A normalization utkeratinization leading to an anticomortonal effect ot azelaic acid may also contribute to its clinical actiuity Electron microscopic and immunohistochemical esaluation of 0km biopsieo rum human subtects treated with AZELEX’ demonstrated a reduction in thu thickness of the stratum corneom,a reduction in number and size of keratohyalin granules, and a reduction in the amount and distribution ot filaggrin )a protein comp0000t of keratuhyatin) in epidermal layers This is suggestruu ot the ability to decrease microcomedo formation. Pharmacnkinetics: Following a singleapplication of AZELEX to human skin in vitro, azelaic acid penetrates into the stratum corneum )apprueimately 3 to 5% of the applied dose) andother uiable skin layurs )up to 10% of the dose is found in the opidormis and dermis) Negligible cutaneous metabolism occurs after topical application Appronimately 4% of the topically applied anetaic acid is systemically absorbed. Anelaic acid is mainly eecreted unchanged in the urine butundergoes some 8-onidation to shorter chain dicarboxylic acids The obseroed half-lioeo in healthy oubtects are approximately 45 minutes after oralduoing and 12 hours after topical dosing, indicating percutaneous absorption rate-limited kinetics Azetaic acid is a dietary constituent )whote graincereals and animal producto). and can be formed endogenously from lunger-chain dicarboaylmc acids, metabolism of olsmc acid, and w-uoidat ion ofm000carboxylic acids Endogenous plasma concentration 20 to 80 ng/mL) and daily urinary eucrot ion 4 to 28 mg) of azutaic acid are highlydependent on dietary intake After topical treatment with AZELEX in humans, plasma concentration and urinary excretion of azolaic acid are notsignificantly di8erent from baseline leuels INDICATIONS AND USAGE: AZELEX is indicated fur the topical treatment of mild-to-moderate inflammatory acne uulgaris. CONTRAINDICATIONS: AZELEX is contraiodmcated in indiuiduats who haue ohown hypersensitiuity to any of its componentsWARNINGS: AZELEX’ in for dermatologmc use only and not for ophthalmic use There haue bess isolated reports of hypopigmuotation after use ofa,oelaic acid Since azelaic acid has not been welt studmod in patiunto with dark complexions, these patients should be monitored for early signo ofhypopigmentatios PRECAUTIONS: General: ft oensmtisity or seoere irritation deuelop with the usu of AZELEX’, treatment should be discontinuedand appropriate therapy instituted. Inlormation br patients: Patients should be told, t To use AZELEX’ for the toll prescribed treatment period.2 To auuid the use of occlusiae dressings or wrappings 3. To keep AZELEX’ away from the mouth, eyes and other mucous membranes If it doescome in contact with the eyes, they should wash their eyes with large amounts of water and consult a physician it eys irritation persiuts. 4. If theyhaoe dark complexions, to report abnormal changes in skin color to their physician 5 Due in part to the tow pH of azelaic acid, temporary skinirritation )prurifus, burning, or stinging) may occur when AZELEX is applied to broken or inflamed skin, uuually at the start of treatment Howeuer.this irritation commonly subsides if treatment is continued If if continueo. AZELEX should be applied oniy once-a-day, or the treatment should bestopped until these effects haoe subsided It troublesome irritation persists, use should be discontinued, and patients should consult their physicianSee ADVERSE REACTIONS ) Carcinogenesis, mutagenesis, impairment at terlilily: Azelaic acid is a human dietary component of a simple

molecular structure that does not suggest carcinogenic potential, and it does not belong to a class of drugu for which there is a concern aboutcarcinogenicity Therefore, animal studios to esaluate carcinogenic potential with AZELEX’ Cream weru not deemed necessary In a battery of testsAmes assay, HGPRT test in Chinese hamster osary cells, human lymphocyte test. dominant lethal assay in mice), azelaic acid was found to ho

000mutagenic Animal studies haue shown no adserse effects on fertility Pregnancy: Teratogenic Effects: Pregnancy Category B.Embrystoxic effects were obserued in Segment land Segment II oral studies with rats ruceiuing 2500 mg/kg/day of azelaic acid. Similar etfucts wereoboerued in Segment It studios in rabbits gioeo t 50 to 500 mg/kg/day and in monkeys giueo 500 mg/kg/day The doses at which these effects werenoted were all within tonic dose ranges for the dams No teratogenic effects were oboersed There are, howeour, no adequate and well-controlledstudies in pregnant women Because animal reproduction studies are not always predictise of human response, this drug should be used duringpregnancy only if clearly needed. Nnrsing Mnthers: Equilibrium dialysis was used to assess human milk partitioning in vitro At an azelaic acidconcentration of 25 yg/mL, the milk/plasma distribution coefficient was 07 and thu millctbufter distribution was 1.0, indicating that passage of druginto maternal milk may occur. Since less than 4% of a topically applied dose is systemically absorbed. the uptake of azelaic acid into maternal milkmu nut expucted to cause a significant change from baseline azetaic acid oust s in the milk, Howeuer, caution should be exercised when AZELEX’ isadministered to a nursing mother Pediatric Use: Safety and effectiseness in pediatric patients under 12 years of age haus not been establishedAOVERSE REACTIONS: During U.S. clinical trials with AZELEX, adserse reactions were generally mild and transient in nature. The most commonodserse reactions occurring in apprnximately t-5% of patients were pruritus, burning, stinging and tingling Other aduerse reactions such asurythema, dryness, rash, peeling, irritation, dermatitis, and contact dermatitis were reported in less than 1% of subjects There is the potential forexperiencing allergic reactions with usn of AZELEX In patients using azelaic acid formulations, the following additional adserse experiences hauxbeen reported rarefy: worsuning of asthma, sitiligo depigmentation. small depigmeoted spots, hypertrichssis, reddening signs of keratosis pilaris),and exacerbation of recurruot herpes tabialis. DOSAGE AND ADMINISTRATION: After the skin is thoroughly washed and pattud dry, a thin filmof AZELEX’ should be gently but thoroughly massaged into the affected areas twice daily, in the morning and euening The hands should be washedfollowing application The duration of use of AZELEX’ can sary from person Is person and depends oo the seserity of the acne lmprooemeot of thecondition occurs in the ma/orify of patients with inflammatory lesions within four weeks. HOW SUPPLIED: AZELEX is supplied in collapsiblesbus in a 30 gm size 38 g - NDC 0023-8694-30. Note: Protect from treezino, Store between t5-30’C )59-86’F). Caution: Federal )U S A)

law prohibits dispensing withouf a prescription. Distributed under license. U.S Patent No. 4.386,104

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type 3 genotype groups. Three of the fourpatients with a clinical response were type 1or 1 band the fourth was type 3a; the completeresponder was type lb. The relationship ofbranched chain HCV RNA levels and genotype classification and clinical response issummarized in Table 1.

DiscussionWe were able to achieve a clinical response

in four out ofnine patients completing therapyin this early utilization of Interferon alpha-2btherapy for Hepatitis C infection which isconsistent with the results of other trials.However, the antiviral effect of interferon didnot correspond to the clinical response; onlytwo patients achieved unmeasurable levels ofHCV RNA and only one of these two had notrace ofHCV with the sensitive PCR analysis.Grecht et a16 report that high viremia titerswere associated with advanced stages of thedisease. Low baseline HCV RNA levels arereported by other investigators7’8to be predictors of successful therapy, which may also beseen in some of our responders to interferontreatment.

In the United States, genotype I accountsfor about 75% of chronic HCV infectionswith half belonging to the 1 a subtype and halfto the lb subtype. Genotype 2 accounts for10-20% of isolates in the US and genotype 3for another 5% of isolates. The distribution ofHCV genotype in our study group followsthese reports. Genotypes 4, 5 and 6 are rarelyseen in the USA and when identified usuallyrepresents infection acquired abroad. Studieshave documented higher rates of long-termresponse to alpha interferon in patients infected with genotypes 2a, 2b, or 3a comparedwith genotype 1 .°“ Chemello and Alberti’2reports only 29% long term response for type1, versus 52% for type 2 and 74% for type 3patients. The predominanace of type 1 virusin Hawaii demonstrates a lowered chance ofsuccessful therapy in our patients. In contrasttype 2 predominates in the Japanese patients(69%) with 18 (%) Type 3; this gives them agreater probability of successful therapy thanour population)3 One type 3 patient had aclinical response and developed unmeasurablelevels of HCV RNA. The one complete responder to all three viral measurements wasgenotype ib; three of four clinical responderswere serotype lb or 1. In this study the genotype of HCV did not aid in identifying probable reponders except for one type 3 patientwho had a low level of HCV RNA (8.4) atbaseline.

Interferon still remains the only effective treatment for Hepatitis

C infection at present. The optimal duration and dose may still need

to be determined. Early trials suggested a better response at higher

doses; it has been recommended that patients unresponsive to the

standard dose be treated with higher doses.14 Bellary et al’5 utilized

a dose of 5 million units three times a week for 6 months andachieved a 59% reponse rate, but 50% of those with a total reponse

had a relapse. Lindsay et al’6 evaluated response rates of 3,5, or 10

million units given thrice weekly for 12 weeks; those not responding

after 12 weeks were then randomized to additional therapy at either

the same or higher dose for an additional 12 to 36 weeks. They

concluded that the initial response to interferon was not increased by

treatment with higher doses of the drug; although marginal, the

additional higher doses may still be worth the risk of intolerance to

the medication. Vogel et al’7 and Ferenci Pet al’8 in Austria reported

improved response to doses up to 10 million units but there was

varying intolerance to the medication. The treatment may also need

to be extended for longer periods as well as an increase in dosage.

The toxicity and expense of such regimens must be considered if this

is comtemplated. Poynard et al’9 extended the interferon treatment

randomly for another 12 months after their patients had been treated

for 6 months. Those receiving the same dose for an additional 12

months demonstrated a higher percentage with complete ALT and

liver histologic reponse.This early trial reveals only a 4/9 clinical response to Interferon

alpha-2b and only 2/9 developed unmeasurable levels of the Hepa

titis C virus. Further trials are required since interferon is the only

effective treatment at this time.

AcknowledgementsWe gratefully acknowledge the generosity and support ofSchering

Plough Corporation, Kenilworth, NJ for providing recombinant

interferon alpha-2b (Intron-A) for patients whose third party payers

refused payment and for providing funds for the research HCV

RNA and Genotype testing. We appreciate the HCV PCR analysis

provided by Dr Lawrence Lumeng and Dr C.H. Lee, Department of

Gastroenterology, Indiana University School of Medicine, India

napolis, IN. The Nursing Staff, Oncology Unit, St. Francis Medical

Center (Jean Nakagawa RN, coordinator) and the Hawaii-Biologi

cal Response Modifiers Research Staff are acknowledged for theirdedication, cooperation and assistance during this interferon treatment protocol with our patients.

References1 Hofnagle JH, Mullen KD, Jones DB et a!. Treatment ot chronic non-A, non-B hepatitis with recombinant

interferon: a preliminaly report. N Eng J Med 1 986;31 5:1575-1578.2. Davis GL, Bolart LA, Schif f ER et at. Treatment ot chronic hepatitis C with recombinant interferon alfa:

a multicenter randomized controlled trial. NEngJMed; 321:1501-1506.3. DiBisceglie AM. Martin PM, KasiandlesC et al. Recombinant interferon alfa therapyforchronichepatitis

Ca randomized, double-blind, placebo-controlled trial. N Eng J Med 1989; 321:1506-1510.4. Ching N, Lumeng J, Pang Ret al. Long term low dose Interferon atpha 2-b in the treatment of chronic

hepatitis B in multi-ethnic patients in Hawai. Hawaii MedJ. 1996, 55:201-203.5. Marwick C. Medical News and Perspectives. hepaittis C is tocus ot NIH panel. JAMA 1997; 277:1268-

1269.6. Gretch D, Corey L, Wilson Jet al. Assessment of hepattis C virus RNAby quantitative RNA polymerase

chain reacton: high-titer viremia correlates with advanced stage of disease. J Infect Dis 1994;169:1219-1225.

7. Lau JYN, Davis GL, KniffenJ etal. Significance of serum hepatitis C virus RNA levels in chronic hepatitisC. Lancetl993; 341: 1501-1504.

8. Martinot-Peignoux M, Marcellin P, Pouteau M et at. Pretreatment serum hepatitis C virus RNA levelsand hepatitis C virus genotype are the main and independent prognostic factors of sustained responseto interferon alfa therapy. Hepatology 1995; 22: 1050-1056.

9. Tsubata A, Kako M, Okamofo H. Factors predictive of response to interferon alpha therapy in hepatitisC virus infection. Hepatology 1994; 19:1088-1094.

10. Kohara M, Tanaka T, Tsukiyama-Kohana K et al. Hepatitis C vin.,s genotypes 1 and 2 respond tointerferon-A with different virologic kinetics. J Infect Dis 1995; 172:934-938.

11. Simmonds P. Variability of hepatitis C virus. HepatcAogy 1995; 21:570-583.12. Chemello Land Alberti A. Hepatitis C serotype and response to interferon therapy. NEngJMed 1994;

330:143.13. Yamada M, Kakumu SC, Yoshioka K et al. Hepatitis C virus genotypes are not responsible for

development of serious liver disease. Dig Dis Sci 1994; 39:234-239.14. Schiff ER. Treatment algorithms for hepatitis B and C. Gut 1993; 34:s148-149.15. Bellaiy S, Smith DG, Bankes Petal. High dose interferon a-2b therapy for chronic hepatitis C: an open

label study of the response and predictors of response. Am J Gasfroenterol 1995; 90:259-262.16. Lindsay KL, Davis GL, Schitf ER et al. Response to higher doses of interferon elfa-2b in pahents with

chronic hepatitis C: A randomized multicenter trial. Hepatitis ntervenfion therapy group. HepatcVogy1996; 24:1034-1040.

17. Vogel W, Graziadei I, Umlauft F et al. High dose interferon alpha-2b treatment prevents cflronidty inacute hepatitis C: A pilot study.

_________________________________________________

Dig Dis Sci 1996; 41(12Suppl):81 S-855.

18. Ferenci P, Stauby R, PropstA et [—f/\J/\I Ial. Dose increase augments response rate to interferon-alpha PATHOLOGISTSin chronic hepatitis C. Dig DisSd 1996; 41(l2Suppl): 103S-108S.

__________________________________________

19. Poynard T, Bedossa P,ChevallierMetal.Acomparison The Full Service Labotthe interferon alfa-2b regimensfor the long term treatment ofchronic non-a, non-b hepatitis.N Eng J Med 1995; 332:1457-1462.

Table 1.—Viral Genotype, HCV-RNA and Clinical Response

Patient Sex Genotype Clinical HCV HCV

No. Response RNA RNABaseline End

904 F 1 + 108.2 104.3

905* F lb + 26.6 <3.4

910 M la - 862.7 109.4

913 M 1 - 113.1 140.4934* M lb - 45.6 44.9

961 F 3a + 8.4 <3.4

962 M la - 186.9 19.4

963 M lb + 66.9 42.3

964 M 2b - 113.1 34

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The Effects of ArginMax, A NaturalDietary Supplement for Enhancement of

Male Sexual FunctionThomas Ito MIY; Kaye Kawahara MD, Anurag Das MD, FACS***, Warren Strudwick MD****

This study examines the role of ArginMax, a natural daily dietarysupplement, on male sexual function. 25 subjects diagnosed withmild to moderate erectile dysfunction were evaluated over a 4-weekperiod while on ArginMax. Of the 21 subjects that completed thestudy, 88.9% improved in ability to maintain erection during sexualintercourse and 75.0% improved in satisfaction with their overall sexlife. No significant side effects were noted.

IntroductionIt has been reported in the literature that dietary supplementation

with certain botanical extracts, vitamins, or amino acids have led tomodest improvements in male sexual function. No studies, however, have examined a systematically designed combination ofnatural products for the enhancement ofmale sexual function. Basedon the proposed and elicited mechanisms of various natural productsin the literature, we postulated that a combination regimen(ArginMax) could provide a major impact in support of male sexualfunction. First, a review of the supporting literature.

It is well established that nitric oxide (NO) is the key mediator forthe up-regulation ofcGMP which in turn mediates erectile function.’L-arginine is the precursor of nitric oxide. The conversion of Larginine to nitric oxide is mediated by nitric oxide synthase (NOS).Increasing tissue L-arginine levels results in the increase of NO and

Assistant Professor of Urology(University of Hawaii School of Medicine>**seciate Professor of Medicine(University of Hawaii School of Medicine)Director of Bone Marrow Transplantation(Saint Francis Medical Center>Director of Cancer Research(Queen’s Medical Center>•**Assistant Professor of SurgeryDepartment of Urology(Albany Medical College>****Sports Medicine SpecialistOrthopedic SurgeonU.S. Track & Field PhysicianNFL Team Physician

Reprints and correspondence to:Thomas Ito MD1010 S. King St. Sue 2188Honolulu, HI 96814

cGMP.23 Supplementation with L-arginine has been shown to besufficient to restore endothelial-derived nitric oxide production inmany disorders in which endothelial-derived nitric oxide is reducedor impaired including impairment resulting from diabetes andhypercholesterolemia.48Studies also point to the role of L-arginine

as not only a substrate for NOS in the up-regulation of cGMP, butalso acts to reduce cell-mediated breakdown of nitric oxide.9

The efficacy of Korean ginseng (Panax Ginseng) in treatingerectile dysfunction was recently demonstrated in a randomizedcontrolled clinical trial involving a total of 90 patients studied over3 months, 30 each receiving placebo, trazadone, or ginseng.’0Ginseng was the most efficacious treatment with improvements

measured in erectile parameters such as girth, libido, and patientsatisfaction. Frequency of intercourse, ejaculations, and erectionsdid not differ among groups. In a controlled study with 66 patients,Panax ginseng was demonstrated to increase spermatozoa count andmotility, testosterone, DHT, FSH, and LH levels in 66 patients withfertility problems.” Ginsenosides (the primary active component ofginseng) have been shown to increase NO production in endothelial

cells.’2.’4One observed mechanism for increase in NO production isup-regulation of NOS activity by ginsenosides.’4The effects ofginsenosides on NO production has implications for improvedsexual function, and may partly account for the aphrodisiac effect ofPanax ginseng used in traditional Chinese medicine.

Ginkgo biloba is well established to facilitate microvascularcirculation’5which may physiologically lead to improvement oferections. In addition to ginkgo biloba’s ability to facilitate microvascular circulation, potentially benefiting erectile functionthrough enhanced vascular blood flow, there is evidence that ginkgobiloba extract may also directly elucidate smooth muscle relaxationin the corpus cavernosum, likely via effects on the nitric oxidepathway.6?

B-complex vitamins are important to the activity of hundreds ofenzymes and in energy metabolism. Low levels of circulating folateand vitamin B6 confer an increased risk of peripheral vasculardisease,’8leading to potential reduction of erectile function.

Zinc is a fundamental mineral in the maintenance of humanreproductive function. Low levels of serum zinc has been shown tocause sexual dysfunction and is associated with infertility inZinc deficiency during growth periods results in lack of gonadaldevelopment in males.2’22 Zinc deficiency leads to depletion oftestosterone and inhibition ofspermatogenesis.23Zinc is also thoughtto help extend the functional life span of ejaculated spermatozoa.23

Selenium has a key influence on spermatozoa numbers andmotility. It is an essential element in normal spermatozoa develop-


741

ment. Selenium is incorporated in the sperm mitochondria capsuleand may thus affect the behavior and function of the spermazoon.24It has been shown that dietary supplementation with selenium-vitamin E statistically significantly increases sperm motility, percent live, and percent normal spermatozoa.25

It is well established that one of the key roles of seminal plasmais the protection of spermatozoa against reactive oxygen species.26In a study of 101 patients seeking consultation for infertility and 15fertile donors, a strong inverse relationship was found between totalreactive antioxidant potential in seminal plasma and infertility.26

ArginMax (The Daily Wellness Company, Mt. View, CA) is anatural dietary supplement which incorporates a highly standardized combination of ginkgo biloba (24% flavone glycosides, 6%terpene lactones), Korean ginseng (Panax Ginseng-30%ginsenosides), American ginseng (Panax Quinquefolius- 5%ginsenosides), L-arginine, along with B-vitamins 6 and 12, folate,antioxidant vitamins A, C, F, thiamin, riboflavin, niacin, biotin,pantothenic acid, zinc, and selenium. ArginMax was developed asa dietary supplement to support male sexual fitness. This paperreports our findings of a clinical pilot study of male sexual functionusing ArginMax as a daily dietary supplement in a group ofmen withmild to moderate erectile dysfunction.

MethodWe recruited male subjects with mild to moderate erectile dys

function through various medical clinics. Interested participantswere enrolled at a test center located in a urology clinic at aUniversity of Hawaii affiliated teaching hospital (Kuakini MedicalCenter). Subjects were enrolled in a consecutive manner until 25patients had been enrolled for this pilot phase of the study. Allinterested participants were allowed to enroll regardless of etiologyoferectile dysfunction. Initial work up consisted ofa detailed patientpast medical history including history and etiology of erectiledysfunction, treatment and medication history, and a physical examination including blood pressure, height, and weight. The subjects were then instructed on the use and a regimen of ArginMax asa dietary supplement and were requested to fill out a baseline SFQ(Sexual Function Questionnaire). Subjects started a twice-per-dayregimen of ArginMax, once in the morning upon waking and oncein the evening at bedtime. A 4-week supply of ArginMax wasprovided. After completing the 4-week regimen, patients wereinstructed to complete a 4-week SFQ and return to the test center forfollow-up evaluation and examination.

The SFQ (Sexual Function Questionnaire) was used as the primary test instrument. The SFQ is a self-administered questionnairebeginning with the validated IIEF (International Index of ErectileFunction used with permission) test instrument designed to measurechanges in erectile function and sexual function.27-29Following the11FF questions, the SFQ included questions regarding subject’sactivities, condition during the trial period, and quality of life.303’

Study ResultsSexual Function Improvements as Measured By SFQ

Patient responses to SFQ variables at 4 weeks were compared toSFQ responses at baseline. A comparison analysis was performedfor those subjects whose degree of erectile dysfunction were mild tomoderate as characterized by a minimal baseline score of 2 incomparison to their 4 week score on the same SFQ variable. Theresults were then pooled, summarized, and evaluated to reflect thepercentage of subjects with improvement in each of the SFQvariables. The following are our findings showing the two highestand two lowest SFQ variable results:

88.9% of subjects showed improvement in the ability to maintain erection during intercourse, as measured by the followingSFQ variable:

0 = Did not attempt intercourse

_________

1 = Almost never/never

2 = A few times (much less than

half the time)

3 = Sometimes(about half the time)

4 = Most times (much more that

half the time)

5 = Almost always/always

75.0% of subjects showed improvement in satisfaction withoverall sex life, as measured by the following SFQ variable:

_______

= Very dissatisfied

2 = Moderately dissatisfied

3 About equally satisfied and

dissatisfied4 Moderately satisfied

5= Very satisfied

20.0% of subjects showed improvement in number of orgasms,as measured by the following SFQ variable:

0 = No sexual stimulation/intercourse

1 = Almost never/never

2 = A few times(much less than half the time)

3 = Sometimes (about half the time)

4 = Most times (much more than half

the time)

5 = Almost always/always

12.5% of subjects showed improvement in the number of timesattempted intercourse, as measured by the following SFQ variable:

Subject Group Profile At Baseline

Total number of subjects- 25Age range- 40 - 77Number hypertensive- 19Number diabetes mellitus- 4

Over the past 4 weeks, how many times have you

attempted sexual intercourse?

o = No attempts

1 = One to two attempts

2 = Three to four attempts

3 = Five to six attempts

4 = Seven to ten attempts

5= Eleven + attempts

Over the past 4 weeks, during sexual intercourse,

how often were you able to maintain your erection

after you had penetrated (entered) your partner?

Over the past 4 weeks, how satisfied

have you been with your overall sex life?

Over the past 4 weeks, when you had

sexual stimulation t intercourse.

how often did you ejaculate?


742

Subjects DroppedOf the 25 subjects enrolled, 21 were included in the scoring of the

above shown results. Four (4) of the enrolled subjects were notincluded for the following reasons:

Loss of sex partner resulting in major change in sexual activity.(1 subject)Did not complete study due to personal problems- unspecified.(1 subject)Did not complete 4 week regimen in entirety. (2 subjects)

Side EffectsBlood Pressure Changes: no significant change in blood pressure.

Mean blood pressure at baseline:135/82 (s.devs: 14.9/11.71).Mean blood pressure at 4-weeks: 139/85 (s.devs: 12.26/13.17).

No other significant side effects as noted. The following are net %of patients reporting increase or decrease of:

headaches: 4.8%nausea: -4.8%stomach upset: -14.3%chest pain: 0%dizziness: 0%vision disturbance: 0%

DiscussionThe role of natural dietary supplements for

sexual health is an infrequently discussed yetextremely important subject. Our pilot studypreliminarily addressed the role ofa combinatorial natural product for the enhancement of malesexual health. The proposed mechanism bywhich ArginMax improves sexual health anderectile function is through increasing smoothmuscle relaxation, enhancing vascular dilatation, and improving peripheral circulation. Basedon review of the literature pertaining to theingredients in ArginMax, it is likely thatArginMax enhances the NO-cGMP pathway byproviding additional substrate forNOS, up regulating NOS activity, and decreasing the cell-mediated breakdown of cGMP. On a vascularlevel, ArginMax likely facilitates erectile function by increasing blood vessel dilatation andmicrovascular circulation.

It is important to recognize that this pilotstudy is a part of a larger scale ongoing clinicalevaluation of the health effects of ArginMax.Although designed as an open-label, pilot study,the results of the SFQ survey demonstrate significantly greater improvements in variablesrelating to erectile function than in non-erectilefunction related variables. It is reasonable toconclude that ifonly a placebo effect was noted,all variables would be impacted in a similarfashion. Thepresence ofmajor variations amongthe variables leads us to believe that there is aphysiological effect at play. Our pilot studyindicates that an expansion of our current studyto a larger population with a placebo-controlledprotocol is the logical next step in exploring thesexual function benefits of ArginMax.

It is important to recognize that as Americansdevelop an ever increasing interest in dietarysupplementation and the concept of wellness,that the role of a supplement for one of the mostimportant biological functions of life, sexual

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743

health, be clinically evaluated. After all, if we take a calciumsupplement for our bones, and an aspirin for our blood, why notconsider taking a supplement for our sexual health?

ConclusionIn a pilot clinical study of ArginMax (The Daily Weilness Com

pany, Mt. View, CA), a natural daily dietary supplement developedto support male sexual fitness, significant improvements were notedin male sexual function after 21 subjects, ages 40-77, with mild tomoderate erectile dysfunction, completed a 4 week regimen ofArginMax. 88.9% of the subjects experienced improvement inability to maintain an erection during intercourse. 75.0% of thesubjects experienced improvement in satisfaction with their overallsex life. There were no significant reports of side effects (headaches,nausea, stomach upset, chest pain, dizziness, vision disturbance,changes in BP). Based on the findings of this study, there appears tobe strong indication that natural dietary supplementation (ArginMax)may play an important role in sexual health and erectile function.

References1. Burnett AL Nitric oxide control of lower genitourinary tract functions: a review. Urology 1995 Jun;

45(6):1071-1083.2. Jung HC, Mun KH, Park TC, Lee YC, ParkJM, Huh K, Seong DH, Suh JK.Role of nitric oxide in penile

erection. Yonsei Med J 1997 Oct; 38(5):261 -269.3. Kimura K, Takahashi M, Naroda T, Iriguchi H, Miyarnoto T, Kawanishi Y, Nurnata A, Yuasa M, Tamura

M, Kagawa S. The relaxation of human corpus cavemosum caused by nitric oxide. Nippon HinyokikaGakkai Zasshi 1993 Sep; 84(9)1660-1664.

4. Creager MA, Gallagher SJ, Girerd XJ, Coleman SM, Dzau VJ, Cooke JP.L-arginine improvesendothelium-dependentvasoditahon in hypercholesteralerrichumans. JClinlnvestlgg2Oct;90(4):1248-1253.

5. Pieper GM, Dondlinger LA. Plasma and vascular tissue arginine are decreased in diabetes: acutearginine supplementation restores endothelium-dependent relaxation by augmenting cGMP production. J Pharmacol Exp Ther 1997 Nov; 283(2):684-691.

6. Wascher TC, Graier WF, Dittrich P, Hussain MA, Bahadori B, Wallner S, Toplak H. Effects at tow-doseL-arginine on insulin-mediated vasodilatation and insulin sensitivity. Eur J Clin Invest 1997 Aug;27(8):690-695.

7. Pieper GM, Siebeneich W, Dondlinger LA. Short-term oral administration of L-arginine reversesdefective endothelium-dependent relaxation and cGMP generation in diabetes. EurJPhamracoll996Dec19; 317(2-3):317-320.

8. Moody JA, Vemet D, Laidlaw 5, RajterJ, Gonzalez-Cadavid NF. Effects oflong-termoraladministrationof L-arginine on the rat erectile response. J Urol 1997 Sep; 158(3 Pt 1):942-947.

9. WascherTC, Posch K, Wallner S, HermetterA, KostnerGM, GraierWF. Vascutareffects of L-arginine:anything beyond a substrate for the NO-synthase? Biochem Biophys Res Commun 1997 May8;234(1):35-38.

10. Choi HK, Seong OH, Rha KH. Clinical efficacyof Korean redginseng forerectile dysiunction.IntJlmpotRex 1995 Sep;7(3):181-186.

11. Salvati G, Genovesi G, Marcetlini L, Paolini P, De Nuccio t, Pepe M, ReM. Effects of Panax GinsengCA. Meyer saponins on male fertility. Panminerva Med 1996 Dec; 38(4):249-254.

12. Chen X. Cardiovascular protection by ginsenosides and their nitric oxide releasing action. Clin ExpPharmacoiPhysiol 1996 Aug;23(8):728-732.

13. Han SW, Kim H. Ginsenosides stimulate endogenous production of nitric oxide in rat kidney. mt JBicchem Cell 81011996 May;28(5):573-580.

14. ChenX, LeeTJ. Ginsenosides-induced nitticoxide-mediatedrelaxationoftherabbitcorpuscavemosum.BrJPtrarmacol 1995 May;1 15(1):15-18

15. Auguet M, Delatlotte S, Hellegouarch A, Clostre F. Pharmacological bases of the vascular impact ofGinkgo biloba extract. Presse Med 1986 Sep 25;15(31):1524-1528.

16. Paick JS, Lee JH. An experimental study of the effect of ginkgo biloba extract on the human and rabbitcorpus cavemosum tissue. J Urol 1996 Nov; 156(5):1876.1880.

17. Chen X, Salwinski 5, Lee TJ. Extracts of Ginkgo biloba and ginsenosides exert cerebrat vasorelaxationvia a nitric oxide pathway. Cirr Exp Pharmacol Physiol 1997 Dec; 24(12):958.959.

18. Robinson K, Arheart K, Retsum H, Brattstrom L, BoersG, Ueland P, Rubba P, Palma-Reis R, MeleadyR, Daly L, Witteman J, Graham I. Low circulating folate and vitamin B6 concentrations: risk factors forstroke, peripheral vascular disease, and coronary artery disease. Circulation 1998 Feb 1 0;97(5):437-443

19. Khedun SM, Naicker T, Maharaj B. Zinc, hydrochlorothiazide and sexual dysfunction. CentAfrJMed1995 Oct; 41(10):312-315.

20. Mohan H, Verma J, Singh I, Mohan P, Marwah S, Singh P. Inter-relationship of zinclevels in serum andsemen in oligospermic infertilepatients and fertile males. Indian JPattrolMicrobioll 997 Oct; 40(4):451 -

455.21. Prasad AS. Zinc: an overview. Nutrition 1995 Jan; 11(1 Suppl):93-99.22. Nishi Y. Zinc and growth. JAm Coil Nutr 1996 Aug; 15(4):340-344.23. Bedwal RS, Bahuguna A. Zinc, copper and selenium in reproduction. Experientia 1994 Jut 15;

50(7(:626-640.24. Hansen JC, Deguchi Y. Selenium and fertility in animals and man—a review. Acta Vet Scand 1996;

37(1):19-30.25. Vezina D, Mauffette F, Roberts KD, Bleau G. Selenium-vitamin E supplernerrtation in infertile men.

Effects on semen parameters and micronutrient tevels and distribution. Bidi Trace EIein Res 1996;53(1-3):65-83.

26. Smith R, Vantman D, Ponce J, EscobarJ, Ussi E. Total antioxidant capacity of human seminal plasma.Hum Reprod 1996 Aug;11(8):1655-1660.

27. Rosen RC, Riley A, WagnerG, Osteitoh lH, KirkpatrickJ, Mishra A. The international index of erectilefunction (llEF): a multidimensional scale for assessment of erectite dysfunction. Urology 1997 Jun;49(6):822-830.

28. The Derogatis Interview for Sexual Functioning (DISFIDISF-SR): an introductory report. DerogatisLR.JSex Marital Ther 1997; 23(4(:291-304.

29. Conte HR.Development and use of self-report techniques for assessing sexual functioning: a reviewand critique. Arch Sex Betray 1983 Dee; 12(6):555-576.

30. Jenkinson C, Coulter A, Wright L Short form 36 (SF36) health survey questionnaire: normative datafor adults of working age. BrMedJ 1993 May 29; 306(6890):1437-1440.

31. Garralt AM, Ruta DA, Abdalla MI, Buckingham JK, Russell IT.The SF36 health survey questionnaire:an outcome measure suitable for routine use within the NHS? BrMedJl993 May29; 306(6890):1 440-1444.


1 YEAR• Excess risk of coronary heart

disease is half that of asmoker

5 YEARS• Lung cancer death rate for

average former smoker (onepack a day) decreases byalmost half

• Stroke risk is reduced to thatof a nonsmoker 5-15 yearsafter quitting

• Risk of cancer of the mouth,throat and esophagus is halfthat of a smoker’s

10 YEARS• Lung cancer death rate simi

lar to that of nonsmokers• Precancerous cells are

replaced• Risk of cancer of the mouth,

throat, esophagus, bladder,kidney and pancreas

decreases

15 YEARS•Risk of

coronaryheartdiseaseisthat

of a nonsmoker

20 MINUTES• Blood pressure drops to

normal• Pulse rate drops to normal• Body temperature of hands

and feet increases to normal

8 HOURS• Carbon monoxide level in

blood drops to normal• Oxygen level in blood

increases to normal

24 HOURS• Chance of heart attack

decreases

48 HOURS• Nerve endings start

regrowing• Ability to smell and taste

is enhanced

2 WEEKS te 3 MONTHS• Circulation improves• Walking becomes easier• Lung function increases

up to 30 percent

1 to 9 MONTHS• Coughing,

sinus congestion,fatigue,shortness ofbreath decrease

• Cilia regrow inlungs, increasing ability to handle mucus, cleanthe lungs, reduce infection

• Body’s overall energyincreases

Source: Ameucan Cancer Society;Cenrers for Daease Conrrol andPrevenrian

It’s Allin the

GenesWhat You Should

Know About the

AFuture of Health Care

drop of your blood contains the blueprint, or

genetic code, for your entirebody. Our genes will soonbecome like a reference book toour bodies, revealing good news(you don’t have the gene whichmakes you “susceptible” tobreast cancer) or bad news (youare predisposed to heart disease).

in the near future, when youvisit your doctor for a routinephysical, he may take a drop ofyour blood, have it analyzed bya DNA decoder and produce acomplete genetic profile foryou. The estimated 80,000genes on the 46 chromosomesof the human cell are beingsequenced by the HumanGenome Project, which has aprojected completion date of2001. Researchers have so faridentified approximately 770genes that cause specific humandiseases, with the number goingup on a weekly basis.

But what good is it to knowthe bad news about your genes—something you are born with?Physicians hope to replace defective genes with good ones or totreat people with drugs that turnbad genes off Bad genes candirectly cause diseases, such as incystic fibrosis. Other genes cause“susceptibility;” or a predisposition to disease if the person isexposed to specific environmental toxins or other factors caus

ing those genes to malfunction.The genetic code, or lan

guage, is beginning to makesense, giving rise to the field ofgene therapy. Promising research indicates that the futureof health care may be in thegenes. For example, experimental gene therapy is being conducted for many cancers. Theseinclude cancers of the lung,brain, central nervous system,colon, liver, ovaries and pancreas. Scientists are makinggains in gene therapy for otherdiseases such as heart disease,cystic fibrosis, high blood pressure, Alzheimer’s disease, muscoskeletal diseases and arthritis.Gene therapy also has thepotential to permanently cureselected genetic diseases.

A major obstacle in gene therapy is the effective delivery ofnormal genes to specific targets(like cancer cells) and have thegenes continuously operate atlevels that will help a patient.Many gene therapy experimentsuse modified viruses as “vectors”that shuttle gene coding into cellslike microscopic delivery trucks.Viruses have specialized mechanisms which allow them to bindto specific types ofcells and deliver their gene cargo inside the cell.The cells should then “express,”or manufacture, the needed proteins (which correctly carry outnecessary functions of the cell)specified by the introduced gene.In the case of viral vectors, bits ofvirus DNA are removed to cripple the virus, so it can infect cellsbut not reproduce.

Non-viral vectors are alsobeing used to deliver correctivegenes to cells. The use ofminute, hollow orbs calledlipoplexes are being studied.Composed of a lipid (fatty)membrane on the outside and awatery solution on the inside,lipoplexes can be created with

DNA cargo. Lipoplexes areabsorbed by cells and dispersetheir DNA after entering thecell membrane. The DNA thenenters the nucleus of the cell.

Currently, many gene therapy experiments are taking anapproach focused on using “suicide” genes to alter specific cells—such as cancer or HIV-infected cells—to produce proteinswhich make them vulnerable toattack by drugs or by the body’simmune system.

Gene therapy may also beable to prevent inherited diseasesat the very beginnings of life. Ifseparated at a very early stage,embryonic cells have the abilityto regenerate whole embryos(that’s how identical twins arise).By artificially separating theembryonic cells, gene therapycan alter the DNA of one—sayto correct sickle cell anemia—and return it to the mother forgestation. The embryo becomesa healthier clone of itself

The anatomical view of thehuman body has given way tothe genetic view. Once completed, the Human Genome Projectwill be for the practice ofmedicine what reaching themoon was to space exploration.With it, the diagnosis and treatment of human diseases may bebe far more successful than anyone could have imagined even adecade ago. The promises ofgenetic medicine now seemattainable. The future of healthcare is in the genes.

A special health message from

4THE QUEEN’S

MEDICAL CENTERHawaii Healthcare Leader

www.cns.queens.org/d2p. html.

PMD ADVERTISEMENT

Diagnosis and Management of FemaleUrinary Incontinence

Kevin C. Shandera MD*

Urinary incontinence is a prevalent condition affecting an estimated13 million Americans of which 85% are women. The types ofincontinence as well as their diagnosis and management are presented herein.

IntroductionUrinary incontinence (UI) is defined as the involuntary loss of

urine. Incontinence is a symptom not a disease and is quite common.The agency for Health Care Policy and Research reported thatapproximately 13 million Americans have UI of which 85% arewomen.’ The incidence of UI increases with age; however it is notlimited to the elderly. Ten to twenty five percent of women betweenage 15 and 64 have UI.’ The societal cost of incontinence in theUnited States in 1995 has been estimated to be over 26 billion dollarsfor only those patients 65 years and older.2 Incontinence producesemotional and physical discomfort, often causing individuals tolimit their activities for fear of ridicule or potential loss of self-esteem and resulting in depression. Despite this, it has been estimated that only 10% people with incontinence seek medical help fortheir incontinence. Recently, there has been a number of advancesin the diagnosis and management of UI. Health care providersshould be aware of these advances and take an active role in thediagnosis and management of UI with a goal of decreasing theimpact of this symptom upon our society.

Types of IncontinenceThere are several types of incontinence which fall into two basic

functional defects. Either the bladder fails to properly store urine orthe urethra fails to act as an effective sphincter. Bladder causes of UIinclude: urge incontinence and overflow incontinence. Urethralcauses include: stress urinary incontinence and instrinsic sphincterdeficiency.

Urge incontinence occurs when the bladder contracts withoutpermission either with or without warning. Commonly this ismanifested by a person who gets the urge to void but leaks prior to

Correspondence to:Keln C. Shandera MDHawes Urology Clinic, PA.1333 Romany RoadChadotte, NC 28204

reaching the toilet. When urge incontinence is secondary to aneurological lesion, such as cerebrovascular accident, Alzheimer’ sdisease, or multiple sclerosis, it is known as detrusor hyperreflexia.Urge incontinence from a non-neurological etiology is known asdetrusor instability.Overflow incontinence occurs when a full bladder overcomes the

resistance of the urinary sphincter and overflows. This form of UI isassociated with diabetes mellitus or pelvic trauma that disrupts thenormal sensation of the bladder. Consequently, the patient is unaware that his or her bladder is full.

Stress urinary incontinence (SUI) occurs when urethralhypermobility causes leakage in response to increases in intraabdominal pressure (stress). It is associated with exercise,sneezing,coughing, lifting or Valsalva. When the urethra is hypermobile, apressure differential between the bladder and urethra occurs withincreases in intra-abdominal pressure (stress). This pressure differential overcomes the urethral resistance, producing incontinence.

Instrinsic sphincter deficiency (ISD) is similar to SUI but leakageoccurs with a minimal increase in intra-abdominal pressure and theurethra is often well supported. ISD should be suspected in-patientswho have persistent incontinence following an incontinence procedure.

HistoryThe history should assess the risk factors associated with incon

tinence in an attempt to differentiate which type of incontinenceexists. Pertinent questions include:

• frequency, duration, and timing of UI?• when do you leak (cough, straining, on the way to the toilet)?• neurologic problem?• number and type of pads used per day?• menopause/hormonal replacement?• history of previous pelvic, vaginal, or incontinence surgeries?• constipation and/or encopresis?• frequent urinary tract infections (UTI)?• is this condition lifestyle limiting?• number of pregnancies, deliveries, vaginal vs. c-section?Urge incontinence is usually preceded by a strong desire to void.

Patients often will complain of having “accidents” on the way to thetoilet. Overflow incontinence typically causes frequent or constantdribbling as additional urine enters the full bladder. Whereas SIJIand ISD both present as UI with exertion (increased intra-abdominalpressure) but differ in that ISD is associated with minimal exertion.

HAWAII MEDICAL JOURNAL, VOL 57. DECEMBER 1998

746

Physical ExaminationA thorough physical examination (PE) of the vagina and the

rectum is performed to rule out atrophic vaginitis and/or neurologi

cal deficit. The anterior vagina is visualized as the patient Valsalvaswith a full bladder to determine the presence of and grade of acystocele. A digital rectal examination is performed to determine thestrength of the anal sphincter and the support of the posterior vagina.

A rectocele is herniation of the anterior rectum into the vagina onValsalva secondary to decreased posterior vaginal support. Theurethra should be evaluated for hypermobility (Figure 1). A simplemethod involves placing a lubricated cotton tipped applicator in theurethra and have the patient Valsalva. The applicator should initially

be horizontal (supine patient), with Valsalva the applicator should

rotate less than 15°. A rotation greater than 150 is consistent withurethral hypermobility.

It is important to reproduce the incontinence. First, the urologist

or urogynecologist will catheterize the bladder to determine thevolume of the post-void residual urine. A post-void of greater than50cc is abnormal. Once catheterized, the bladder is filled and patient

is asked to cough and/or Valsalva. Does the patient leak? Often apressure measuring catheter is used to measure the pressure necessary to produce UI. This is known as a cystometrogram orurodynamics. Finally urodynamics are used to determine the compliance of the bladder. The non-compliant bladder often presents

with symptoms of urge incontinence. A urinalysis should be performed to rule out a urinary tract infection and glucosuria.

The questions to answer on PE are:• Is the urethra mobile?• Does the patient have UI with Valsalva or cough?• Does the patient have other vaginal problems (cystocele, en

terocele, rectocele, atrophic vaginitis)?

Questions to be answered on Urodynamics include:• Is the bladder compliant?• At what pressure does the patient leak (Valsalva leak point

pressure)?Of note, a normal urethra will not leak at any pressure.

Treatment OptionsThe vast majority of patients with UI can be cured or improved.

The history and PE with urodynamics will allow the clinician todetermine if the UI is secondary to a bladder problem or a urethral

problem, or combination. Bladder problems are generally treatedmedically, whereas urethral problems are generally treated surgically.

Bladder problems produce urge incontinence. Diet modification,

decreasing the consumption of bladder irritants such as caffeinecarbonated beverages, spicy foods and artificial sweeteners, areoften helpful. Medications, namely anticholinergics such asoxybutynin chloride (Ditropan), hyoscyamin, and Tolteradine, arequite effective at delaying or preventing premature bladder contractions. Behavior modification, such as bladder retraining or timed

voiding, increases the time intervals between voids, and is often

helpful.Urethral problems are treated primarily with surgery if conserva

tive measures such as Kegel exercise and estrogen replacement have


Fig 1.—Urethral hypermobility. The arrow indicates direction of pressurefrom an activity such as coughing, causing the bladder neckandurethra to open briefly. Reference3.

IjUcIcle’

Fig 2.—Sling in place, secured to the pubic bone. Reference 3.

4

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Table 1 .—Typesof Urinary Incontinence

Type Pathopilysiology Signs and Symptoms

Urge Incontinence I Involuntary bladder contractions I Leaks on way to toilet.

Overflow Incontinence • 8ladder overdistention and • Poor utinary stream

leakage because of impaired • Constant ddbblirig

sensory feedback from the bladder. • No sensation of fullness

Stress Udnary

Incontinence(SUI) I Bladder neclurethral I Incontinence with cough,

hyperrnobility sneeze, or Valsalva

lntdnsic Sphincter I Urinaly sphincter failure I Marked incontinence with

Deficiency (lSD) standing, cough, sneezing,

Valsalva

failed. Kegel exercises are designed to strengthen the muscularsupport of the bladder, vagina, and rectum. There are three maincategories of surgeries used to treat SUT: retropubic suspensions(Marshall-Marchetti-Krantz, Burch culposuspension), transvaginalsuspensions (Raz, Stamey, Pereyra), and sling procedures. The goalof each is correct urethral hypermobility. The most durable of theseprocedures is the pubovaginal sling (PVS) procedure. The PVS usesa thin strip of autologous (rectus fascia or fascia lata) or cadevericfascia to create a hammock-like bolstering of the urethra (see Figure2). The long-term cure rate of PVS is about 83%.

Patients with ISD refractory to Kegels and estrogen replacementrequire either PVS or transurethral submucosal collagen injection tocoapt the open urethra. Estrogen replacement increases the vascularity of the vaginal mucosa and urethra thereby increasing thecoaptability of the urethra. Collagen injection is usually performedas an office based procedure under local anesthetic via a urethroscope. The collagen is injected under the urethral mucosa at theproximal urethra in an attempt to coapt the urethra.

SummaryUrinary incontinence affects an estimated 13 million Americans

of which 85% are women. It is an embarrassing and lifestyle limitingcondition for which effective treatment is available. Health careproviders should be alert to the signs and symptoms ofUI and pursueits etiology. Those patients who fail medical therapy, in whom theetiology for the incontinence is unclear, or those patients withconcomitant cystocele, enterocele, or rectocele, should be referredto an incontinence specialist.

References1. U.S. Department of Health and Human Services. Urinary incontinence in adults. Clinical Practice

Guideline. (AHCPR Publication No. 92-0038), 1992.2. Wagner T, The-Wei H. Economic costs of urinary Incontinence in 1995. Urology, 1998:335—361.3. Leach, G.E., Dmochowski, R.R., Appell, BA., Blaivas,J.G., Hadley, I-fR., Luber, KM., Mostwin, J.L.,

O’Donnell, P.D.: TheAmerican Urological Association Female Stress Urinary Incontinence GuidelinesPanel: The Surgical Management of Female Stress Urinary Incontinence. ADoctofsGuidefor Patients.Baltimore: American Urological Association, Inc., 1997.

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News and Notes Hen N Yokoyama MD

Life in These PartsMel Kaneshiro’s 61St birthday Bash(Kanreki Iwai) (Excerptsfrom MC TadIwanuma ‘shumorous script)

“Mel—Up here I feel like Elizabeth Taylor’snew husband on their wedding night. I know whatI’m supposed to do, but how am I going to makeit new and interesting. So, who else is better andmore insightful to start with but his wife, Pat. SoI asked her, ‘What’s good that I can say aboutMel?’ Her answer.—’Nothing.’ ‘But wait! thereis one good thing I can say about him, he haslearned well and says over and over’—Pat, Godheals, but I collect the fees.’

I respect Mel so much. He is a great doctor, agreat diagnostician. Just the other day, in fact, Iremember telling him about this puzzling case Ihad. The patient came to see me because the daybefore while sitting on the bench at Ala MoanaShopping Center, his neck kept getting stiff eachtime a woman walked by. I was puzzled about thediagnosis and mentioned it to him. ‘Eh!,’ he said,‘try ask him if he could have swallowed hisViagra too slowly that morning.’ ‘Doctors today,’ he said, ‘Ourjob is getting so hard; not onlydo we have to heal the sick, but we have to raisethe dead.’

We all know Mel to be diplomatic, and short;you know short statured and composed, but short.I always have to try not to talk down to him. Didhe tell you about the time he was in school atTulane and traveled by train to Pennsylvania?The tall lady selling tickets had, how shall I put itdiscreetly, an amazing hour glass figure. Melwalked up to the counter, eyes wide open, took adeep breath and said, ‘Aah,’ ‘Pickets to TitsburgPlease.’ He didn’t even notice her smile.

Mel came to be a ‘big deal’—Chief of Staff, VPof Medical Affairs, HAPI Board, and MedicalSchool faculty. He’s like a chicken doctor, ‘He’severywhere, he’s everywhere.’

You all don’t know this, but when Mel wasyounger, he was, what shall I say—youthful, anda drinker. He wanted to donate his organs so hefigured he would try to pickle them. There wasthe time we were at a benefit with EugeneMatsuyama, and Mel was having a few. To ourconsternation, he kept eyeing this ravishing creature all dressed upincrimson red. He kept drinkingmore and more and finally said, ‘I’m going todance.’ He got up from his chair. Mats and Ilooked at each other; I grabbed him and Matswhispered, ‘Eh Mel, wait, wait—that’s the Archbishop Cardinal of Honolulu.’

Did you see the size of Mel’s office, 802.5 SCKuakini Medical Plaza? SC stands for ‘StorageCloset.’ The 802.5—half an SC. I went to see himas a patient. ..for real. It’s the only exam room I’vebeen in where in order to lie down you have tostand up.

There was the time when Mel was Chief ofStaff and JCANO came to survey Kuakini.JCANO is the national accrediting body that ratesus every 3 years and very stressful times for all ofus. One year we received several unfoundedcriticisms and Mel was responsible for compos

ing a reply. This is what he wrote: ‘Dear JCANO,I am sitting on a oval seat in the smallest room ofmy home which also has a tile floor and a bathtuband deodorant. I have your review before me.Soon it will be behind me.’

Mel’s allegory: We have been doing all thiswork for managed care. Endless meetings, manywith HMSA. Mel says HMSA is the hungry lion.The doctors are the gullible missionary. The lionhas somehow trapped the missionary and is readyto pounce. Auwe, the missionary sinks to hisknees and starts to pray. To his amazement thelion also sinks to his knees and starts to pray. ‘It’sa miracle, the savage beast joins me in holyprayer.’ ‘Quiet,’ thelionsays, ‘Iamsayinggrace.’

I advised Mel not to get too involved withManaged Care for when he gets to the PearlyGates he’s going to hear ‘This physician is authorized only a 3 day stay with us.’ ‘No worry!,’ hetells me, ‘I’m set. I’ve got the guarantee to getin—My United Way Card.’”

Our party boy his name is MelAnd we all know he’s really swell.We came here to celebrate,Before he reaches the PEARLY Gate.

He has two kids and a wife named Pat,No dog, no pony, no pussy cat.He rules his house with an iron hand,As long as Pat says he can.

He’s a VP ofour Medical StaffTo lead us fore, we hope not aft.So Mel, listen to this good adviseWe don’t want to say it twice.

On this evening ofyour KANREKIThis is how your estate should be.Forget—KODOMO NO TAME NILeave all your money to Kuakini.

Estate Planning Rap (Modified) with apologies

Thyroid Cancer RateHawaii has the highest thyroid cancer rate in the

nation which may be related to our high volcanicactivity. Our thyroid cancer rate is on par withNew Zealand antI Iceland which also have volcanic activity. Queen’s Marc Coel suggests thatpatients have their thyroid glands checked because thyroid cancer is highly curable.

Giving the Gift of a LifetimeEighty seven year old Walter Chotzen, retired

business man, poet, writer of short stories andgentle soul released his dying body to the “WilledBody Program” of the UH Medical School. Advertiser medical writer Beverly Creamer describesWalter’s poignant meeting with the young medical students. His son Daniel read aloud one of hisfather’s poems.

“Mourn me not, my children...The flesh has returned to my


750

beloved earth whence it came...All existence is flow and I am

of the river.As you are touched by the

winds of Life, rejoice...I am caressing you.”

This Mysterious UniverseA 67-year-old Asian male developed a severe

Rt subacromial bursitis overnight. He found achiropractor in the yellow pages who had himstand in front and threw imaginary bolts ofenergywith hand gestures at the affected joint. When thepatient questioned the beguiling therapy, the “doctor” explained that there was energy imbalanceand that he was restoring the energy balance withbolts of energy. The bewildered patient decidedagainst the 12 treatment program at $30 per vi sitand opted for a single physician administeredXylocaine-cortisone shot.

Making Miracles, Changing LivesBy Don Chapman, MidWeek, July 19, 1998 (Excerpts therefrom)

Transplant surgeon Linda Wong remembersthe moment she knew she wanted to do transplants. “It hit home at the end of my fellowship inSan Francisco. There was this young girl, andwhen they brought her in she was in a coma. Shewas on a respirator, and had all these tubes andcatheters in her. She was totally unresponsive.She was bleeding; all sorts of bad things werehappening. Meanwhile, the transplant team founda matching donor in New Mexico, so they sent meon ajet to Albuquerque. It was a couple of hoursdown, then do the operation to remove the donorliver, a couple of hours back. And then I helpedthe team put this liver in for four or five hours,took her to the recovery room, and to the intensivecare unit. I was totally exhausted; it had been 18hours of running around and surgery. Then I wenthome and slept for four hours. When I came back,she was up and watching the Flintstones on TVand all the tubes were out. I mean, this is a girlwho was going to die in a day and she was up andsmiling. It was exciting. Liver patients are on thebrink of death, and you bring them back. I remember thinking it was just the wildest thing.”(Linda’s dad is transplant surgeon, LivingstonWong and mom is internist Rose Wong).

Physician MovesJuly: Richard Sakimoto retired after practicingOB-GYN for 60 years.August: Charles Ushijima announced the opening of his new practice in OB-GYN at Queens,POB I.September: KMC Director of Laboratories, pathologistFrankFukunaga who started at Kuakiniin 1964 retired. Kent K. Kumashiro, specializingin pediatrics joined Hilo Medical Associates at 73Pu’uhonu Place, Hilo

Letters to the Editor“HMSA’s plan to grade doctors and then finan

cially reward them is both misguided and arrogant.

HMSA is attempting to skew doctors’ behaviormore to HMSA’s liking without utilizing physicianinputorguidance. If HMSA thinks itknowsmore about what constitues excellent medicalcare than do doctors, why doesn’t it hang out it’sown shingle and let people come to them whenthey are sick?

If HMSA has all this extra cash lying around,why not reward its consumers with lower premiums rather than using it to bribe doctors forloyalty (Business relationship with HMSA) andobedience (quality ofcare) as defined by HMSA.”

Gene Altman MD, Advertiser July 24, 1998.

Doctor Digs“WoodwardlWhite might publish a list that

contains the Best Doctors in America, but the listthat it produced has nothing to do with the realquality of physicians in Hawaii. A correct andcomplete poll of the physicians of this statewould yield a markedly different list. It is mypersonal opinion that without a direct polling ofevery practicing physician in the state of Hawaii,this list should never be published. It is a disservice to every patient and every doctor in this state.Are we to understand that there is not one doctoron a Neighbor Island, other than Dr Evslin, onKauai, that is worthy of mention?I would stronglyadvise that the next time WoodwardfWhite comespeddling it’s wares, tell them we are not interested.”

Stuart L. Rusnak MD,Honolulu Magazine, June 1998.

MiscellanyDoctors are running their practices like an as

sembly line these days. One fella walked into anHMO office and the receptionist asked him whathe had.

He said, “Shingles.”She took down his name, address, medical

insurance number and told him to have a seat.Fifteen minutes later a nurse’s aid came out and

asked him what he had.He said, “Shingles.”So she took his height, weight, a complete

medical history and told him to wait in the examining room. A half-hour later, a nurse came inasked him what he had.

He said, “Shingles.”The nurse took his blood pressure, gave him a

blood test and took an EKG. She told him toundress and wait for the doctor. An hour later, thedoctor came in and asked him what he had.

He said, “Shingles.”The doctor said, “Where?”He said, “Outside in the truck. Where do you

want them?”(BiliBurlingame, America Online: Skinyouluv

Aug 7)

BewareA mother once asked me if her daughter could

take B complex vitamins. I told her I thought itwould be safe to do so, but asked why she posedthe question. Her reply was that she was worriedbecause the child’s father was highly allergic tobees.

Robert Smith MD, Stitches Jun ‘98

Trust MeMy wife was to have elective surgery on her

knee. During the pre-op tests, she was asked if shehad any preference for the anesthesiologist. Shereplied, “It really doesn’t matter,”

On the morning of surgery, as the OR nursewheeled her into surgery, my wife thought theywere alone and said, “You know, I think I madea mistake. During pre-op I mentioned that itdidn’t matter who put me to sleep. I should havesaid that I wanted the best,”

Immediately, she heard a reassuring voice directly behind her say, “I am the best.”

Connon Barclay, Zeeland, Mich

The kindergarten teacher was showing her classan encyclopedia page picturing several nationalflags. She pointed to the American flag andasked, “What flag is this?”

A little girl called out, “That’s the flag of ourcountry.”

“Verygood,”theteachersaid. “Andwhatisthename of our country?”

“‘Tis of thee,” the girl said confidently.

You Said ItWorking as a rural surgeon, I saw a 25-year-old

woman who presented with a graphic descriptionof her problem with hemorrhoids. She told me herwhole life story and that her hemorrhoids were aconstant “pain in the ass.” After examining her, Iagreed with the magnitude of her problem and

advised surgery.She was slated for hemorrhoidectomy under

spinal, but all through the procedure she continued her discourse on how hemorrhoids had ruledher life. She often refused her husband intercourse because it “upset my hemorrhoids.” Theanesthetist tried to quiet her with a sedative, butshe refused. Finally the procedure was completedand I announced “There you are Pat, we’re alldone.”

Pat suddenly went silent and then asked, “AmI a perfect ass hole now, Doc?”

Without hesitation, I replied, “Yes, ma’am.”Dr SM. Amin Fun Flon, Man.

Potpourri(More condensed medical anecdotes fromStitches, the Journal ofMedical humor)Foreign Body

Dublin medical students in the 60’s led sheltered lives. Contraception wasn’t only unavailable,but illegal. There was no information on othermatters sexual. Any book that had the word “sex”in its title was automatically prescribed and thatincluded medical books that dealt with normalsex. As for aberrant sex, the “filthy perversions”of many a clerical diatribe, well, our uninformedimaginations boggled. And this applied to ourefforts to interpret case histories as described intextbooks.

Take for example, that grand old fountain ofsurgical wisdom, Bailey and Love’s Textbook ofSurgery. In the last weeks before finals, myroommate and I, two innocent young Irish women,soon to be fully qualified physicians, were buffing up our knowledge of surgical problems of therectum as described by Bailey and Love.

There was suddenly a horrified squeak as myfriend got to the section about rectal foreignbodies. Eyes bulging, she read aloud the paragraphs describing how, using obstetrical forceps,a turnip was extracted from the rectum of agentleman who’d presented with constipation.

“Wan’t that a terrible thing!” She was clearlyappalled.

“Dreadful!” I agreed, brooding on the logisticsof this situation. “How do you think a turnipwould get into anyone’s rectum?”

She thought for a moment.“Well, now,” she pronounced, “He can’t have

swallowed it, so he must have sat on it!”Dr Patricia Mark, Nanoose Bay, B.C.

EDWARD W. Ko, MBA, CPATax Oriented Strategies & Innovative Alternatives

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(Condensed versions of medical humor fromStitches, September ‘98)Overkill

A pleasant, well dressed woman came in for herannual physical examination. She’d recently experienced some vaginal irritaton which sheattributed to a mild infection. When asked ifshe’d used anything to treat the problem, sheadmitted she had: “Pinesol.” I couldn’t quite hidemy surprise and she became a bit defensive,telling me that after all, “It is a disinfectant!”

“Yes,” I replied, “but for floors!”We obtained vaginal cultures and when the

culture report came back, it read, ‘Organismsresembling vaginal flora.”

The poor things—they were mere shadows oftheir former selves.

Dr Linda Lambert, Calgary


Cranial Emissions

The elderly woman stared at the psychia

trist and me (a psychologist) disdainfully.

Her family doctor had sent her to us for

evaluating Alzheimer’ s. She had a history of

hypertention so we felt it might be a vascular

problem and the studies supported multi-

infarct dementia.

We were meeting with the patient to give

her our impression. Unfortunately her fam

ily members were invited, but she had come

alone. The psychiatrist presented the infor

mation logically and clearly, but we had a

sneaky suspicion that the vocabulary was

over the head of the patient.I accompanied her back to the waiting

room, and I asked for her impression of the

meeting.“I don’t think that doctor knows what he’s

talking about!”“It’s ridiculous,” she continued. “The very

idea of saying I have a fart on my brain!”

Dorothy Cotton, Kingston, Ont.

Conference Notes“New Strategies for Achieving Metabolic Control in Type 2 Diabetes” (Extractedfrom a July28, 1998 lecture by Michael Bornemann MD,FACP and Scott Hashimoto Pharm D)

Classification DM• Typel• Type II• Secondary Diabetes• “Type 1.5”

- MODY (Maturity Onset DM in youth)- LADA (Latent autoimmune DM in adults)- STERNE: obese teenagers, acanthosis- MIN (mixed IDDM, NIDDM)- SPIDDM (Slowly progressive IDDM)

Type IIHyperglycemic 4-7 years prior to Dx; may

already have complicatoins when dxedType I

Seldom have complications at presentation;start screening 5 years after presentationHelpful tests

Islet cell antibodies, glutamic decarboxylaseantibodies, C-Peptide.

Algorithm for Treatment Type II

Sy’s+ Sy’s± N0SysFPGs300mg/dI FPG2Go3OO FPG<200rapHbAIC>12% HbAtc>8% HbAtc<8%

Inuele Sirgie DietInsulie Rn Oral Agent Errercae

f1YeTherapy Care

Therapeutic Agents• Oral Agents: (Consider obesity, lipids, re

nal/hepatic diseases, symptoms)**Low blood sugar

- Metaformin- Troglitazone- Prandin- Acarbose

**High blood sugar- Sulfonylureas plus above

(&/or insulin)• Insulin

* * *Therapeutic Options- BIDS regimen

(Bedtimelnsulin, Daytime sulfonurea)- BIDS Variations

Other oral agents (Troglitazone,metforrnin, prandin, acarbose) 70/30 insulin atdinner for obese pts

- Insulin onlyNPH qd or bid70/30 bidNPH (Humalog bid)Ultralente/Humalog

• Insulin and Atherogenicity

[ne*FaiOr [. I Ij I

Classified Notices

To place a classified notice:HMA members.—Please send a signed and type

written ad to the HMA office. As a benefit of membership, HMA members may place a complimentary onetime classified ad in HMJ as space is available.

Nonmembers.—Please call 536-7702 for a non-member form. Rates are $1.50 a word with a minimumof 20 words or $30. Not commissionable. Paymentmust accompany written order.

For Sale

For Sale—Whirlpool 25 cu ft, side-by-side Refrigerator/Freezer, white, $600. Call Nelson (808) 536-7702ext. 2220.For Sale.—Office fumiture including desk, chair, cabinets, & files. Call 533-3368.

Locum Tenens

Board Certified family practitioner.—Available forshort term practice coverage. Liability insurance provided. Please contact: V. Braslavsky, MD (913) 383-3285. httpi/www.concentric.net/-4ocumdr/1 .htm.Locum Tenens available—Board-certified FamilyPractice, 14 yrs clinical experience in Hawaii. Officecoverage, Deborah C. Love MD: home Oahu: (808)637-8611; cel ph: (808) 295-2770.

Misc.

Mask & Glove Relief.—Sensitivity barrier gel reducesirritation from latex, nitrile, polyethylene face masks &gloves. Free evaluation sample to USA physicians(1 per office). Sahara Cosmetics Oahu 808-735-8081,USA toll free 1-877-280-2020, record complete delivery address.

Office Space

Pearl City Business Plaza.—Tenant ImprovementAllowances for Long Leases; 680+ sq ft; 24-hr security;free tenant/customer pkg; Gifford Chang 581-8853DP, 593-9776, 531-3526.St. Francis Outpatient Bldg.—Office space in beautiful new building at St. Francis Medical Center in Liliha.Up to 2200 sq ft available, including large procedureroom. contatct Tina Pai at 944-8884.Ala Moana BIdg.—Small group practice seeks additional physician(s) to share space and support services. Must have strong interest in physical rehabilitation. Time-share arrangements, available from half-day to full week. Contact administrator, RehabilitationAssociates, 955-7244.For Sale.—Established, thriving, general practice inKailua-Kona. Completely equipped. TURNKEYOPERATION. 3 exam rooms, B/fl. Modem building,good parking, access. Flexible arrangements possible. Call 329-6682.

• Alternative to increasing insulin:* Add metformin, sulfonylureas, discon

tinue insulin (Success: insulin usage <0.8 U/kg,BMI < 34, short duration of insulin usage)

* Troglitazone

childrenActFastSo Do POISONS!

4

HawaiiPoison Center941-4411Neighbor Islands Toll Free

Donate to help

1-800-362-3585 us save wes.

HAWAII MEDICAL JOURNAl.. VOL 57. DECEMBER 1998

732

Index to the Hawaii Medical JournalVolume 57, 1998

Compiled by Marlene M. Ah Heong and Carolyn S.H. Ching of the Hawaii Medical Library

Keyword Index

ACQUIRED IMMUNODEFICIENCY SYNDROME.Gradual loss of IgG antibodies against GB virus C/hepatitis G virus in a patient with AIDS [Harry L. Arnold Jr.MD case of the month], 57(12): 733ALTERNATIVE MEDICINE. Interest in alternative medicine by first year medical students at the John A. BurnsSchool of Medicine [Medical school hotline], 57(7):553AMERICAN MEDICAL ASSOCIATION. President’smessage, 57(1)370ANGIOSTRONGYLUS CANTONENIS. Eosinophilicmeningitislangiostrongyliasis from eating aquacultureraised snails: a case report [Harry L. Arnold Jr. MD caseof the month], 57(l0):652ASBESTOS. A quantitative study of environmental asbestos exposure in Honolulu, 57(6):536ASBESTOSIS. A quantitative study of environmentalasbestos exposure in Honolulu, 57(6):536ATHLETIC INJURIES. Common sports injuries seen bythe primary care physician part II: lower extremity,57(5):502ATTITUDE TO DEATH. Do Hawaii residents supportphysician-assisted death? a comparison of five ethnicgroups, 57(6):529ATFITUDE TO HEALTH. Interest in alternative medicine by first year medical students at the John A. BurnsSchool of Medicine [Medical school hotline], 57(7):553BRAIN INJURIES. Guest editor, 57(9):605— [Governor’s proclamation], 57(9):609— Deep pockets or blueprint for change: traumatic braininjury (TBI) proactive strategy, 57(9):6I 1— Vocational rehabilitation of people with traumaticbrain injury, 57(9):618— Hawaii neuropsychology program gets results: the nutsand bolts of neurotraining, 57(9):625— Phantom loss of function in traumatic brain injury,57(9):629— [Legislature proclamation], 57(9):634BRAIN INJURY AWARENESS MONTH. [Governor’sproclamation], 57(9):609— [Legislature proclamation], 57(9):634CHILD. Accidental poisoning in children with specialreference to kerosene poisoning. 1951 [classical article],57(3):433— Clinical pearls in pediatric toxicology: a systematicapproach to the poisoned child, 57(3):445CHILD ABUSE. Achieving better outcomes for Hawaii’schildren, 57(9):617CHILD WELFARE. Achieving better Outcomes forHawaii’s children, 57(9):6l7CHOLANGIOPANCREATOGRAPHY, ENDOSCOPICRETROGRADE. CT demonstration of a pancreatic ductstricture and obstructive pancreatitis with ERCP and intraoperative correlation [Harry L. Arnold Jr. MD case of themonth], 57(3):43lCOMMUNICATIONS MEDIA. What’s new in medical

communication? 1998 [classical article], 57(l2):729COMMUNITY HEALTH PLANNING. Deep pockets orblueprint for change: traumatic brain injury (TBI) proactive strategy, 57(9):61 1CONFIDENTIALITY. 10 common medicolegal questions on HIV infection, 57(5):507CONGRESSES. 14 1st HMA annual meeting, 57(1):387— Primary care update: highlights of the HMA scientificsession, 57(I):388— 1997 HMA annual meeting and presidential inauguration, 57(1):390CONTRACEPTIVES, ORAL. Noncontraceptive healthbenefits of the oral contraceptive pill, 57(8):59 1COST SAVINGS. A possible solution to the cost explosion of the emergency department, 57(2):404COSTS AND COST ANALYSIS. The Hawaii PoisonCenter: what’s it worth to you?, 57(3):45 1COUNSELING. Clinical techniques in crisis intervention: emergency counseling in cases of acute poisoning,57(4):474COVER ILLUSTRATIONS. Chanter, 57(1):367— Makoa, 57(2):397— Maile, 57(3):423— He’e, 57(4):467— E hula e, 57(5):491— E wa’a e, 57(6):523— ‘0 he’e, 57(7):547— Maui snaring the sun, 57(8):575— Kipahulu, 57(9):603— E Pele e, 57(l0):643— Leho he’e, 57(1 l):683— Wa’a kaulua, 57(12):723CRISIS INTERVENTION. Clinical techniques in crisisintervention: emergency counseling in cases of acutepoisoning, 57(4):474CROSS-CULTURALCOMPARISON. Prenatal care utilization in Hawaii: did it improve during the last 16 years?,57(2):412— Do Hawaii residents support physician-assisted death?a comparison of five ethnic groups, 57(6):529CURRICULUM. Evidence-based medicine: educatingphysicians in the science behind the art [Medical schoolhotline], 57(2):402DELIVERY OF HEALTH CARE. What do we want tobe? a health care industry or the profession of medicine?[President’s message], 57(5):493—The socialization of health care, slice by slice. 1998[classical article], 57(5):496DIAGNOSIS. Phantom loss of function in traumatic braininjury, 57(9):629—Laparoscopic staging of malignant disease, 57(1 l):705—. Diagnosis and management of female urinary incontinence, 57(12):746DIAGNOSIS, DIFFERENTIAL. Chronic meningococcemia mimicking acute rheumatic fever [Harry L. ArnoldJr. MD case of the month], 57(8):583DIAGNOSTIC ERRORS. Phantom loss of function in

traumatic brain injury. 57(9):629DIETARY SUPPLEMENTS. The effects of ArginMax,a natural dietary supplement for enhancement of malesexual function, 57(12):74lDIRECT SERVICE COSTS. A possible solution to thecost explosion of the emergency department, 57(2):404DOMESTIC VIOLENCE. Pity and compassion are notenough, 57(9):616EDITORIALS. Editorials, 57(l):369— Mahalo to Elizabeth M. Adams MD [Editorial],57(2):401— March special issue [Editorial], 57(3):425— Clinical toxicology and the Hawaii Poison Center[Guest editors], 57(3):425— Editorials, 57(4):469— Socialization of healthcare/slice by slice [Editorial],57(5):493—Governor’s blue-ribbon panel on living and dying withdignity [Editorial], 57(6):525— Pain management: recommendationsof the Governor’sBlue Ribbon Panel on living and dying with dignity.[Editorial], 57(7):549— City honors our editor [Editorial], 57(8):577— “silent epidemic”: traumatic brain injury [Editorial],57(9):605— Guest editor, 57(9):605— Pity and compassion are not enough, 57(9):6l6—Editorial, 57(l0):645— Change in medical care has come too fast. 1998[classical article], 57(l0):650— Editorial, 57(1 l):685— Editorial, 57(12):725— What’s new in medical communication? 1998 [classical article], 57(l2):729EDUCATION, MEDICAL The impact of changes inmedical care on medical education [Medical schoolhotline], 57(l):375— Evidence-based medicine: educating physicians in thescience behind the art [Medical school hothne], 57(2):402—role of geriatric psychiatry in medical education [Medical school hotline], 57(3):429— Fund-raising for medical education [Medical schoolhotline], 57(4):470— Emergency medicine in the problem-based learningcurriculum [Medical school hoffine], 57(5):495EDUCATION, MEDICAL, GRADUATE. Militaryunique curriculum [Military medicine], 57(l):372— Hawaii benefits from graduate medical education[Medical school hotline], 57(1 l):686EDUCATIONAL MEASUREMENT. An update on theUSMLE performance of medical students at the John A.Bums School of Medicine and computer-based testing[Medical school hotline], 57(10):646EMERGENCIES. Clinical techniques in crisis intervention: emergency counseling in cases of acute poisoning,57(4):474EMERGENCY MEDICAL SERVICES. Tripler’s emer


gency medical response team [Military medicine],

57(3):427— Christmas Island rescue: a true story [Military medicine], 57(5):497EMERGENCY MEDICINE. Emergency medicine in theproblem-based learning curriculum [Medical school

hotline], 57(5):495EMERGENCY SERVICE, HOSPITAL. A possible solu

tion to the cost explosion of the emergency department,

57(2):404ENDOSCOPES. A laparosopic update, 57(11 ):683ENVIRONMENTAL EXPOSURE. A quantitative studyofenvironmental asbestos exposure in Honolulu, 57(6):536ENVIRONMENTAL HEALTH. William Crawford

Gorges he set the standard of military preventive medi

cine, 57(l):377EOSINOPHILIA. Eosinophilic meningitis!

angiostrongyliasis from eating aquaculture-raised snails:

a case report [Harry L. Arnold Jr. MD case of the month],57(I0):652EPIDEMIOLOGY. Epidemiology ofcongenital diaphrag

matic hernia, Hawaii, 1987-1996, 57(8):586EVIDENCE-BASED MEDICINE. Evidence-based medi

cine: educating physicians in the science behind the art

[Medical school hotline], 57(2):402FACULTY, MEDICAL. The John A. Burns School of

Medicine (JABSOM) status report on finances and contributions [Medical school hotline], 57(6):527FINANCIAL SUPPORT. The John A. Burns School of

Medicine (JABSOM) status report on finances and contributions [Medical school hotline], 57(6):527FRAUD. Federal fraud enforcement: why you should

have an effective compliance plan [President’s message],57(2):40lFUND RAISING. Fund-raising for medical education

[Medical school hotline], 57(4):470GERIATRIC PSYCHIATRY. The role of geriatric psy

chiatry in medical education [Medical school hotline],

57(3):429GOLDSTEIN, NORMAN. City honors our editor [Edito

rial], 57(8):577GORGAS, WILLIAM C. William Crawford Gorges: he

setthestandardofmilitarypreventivemedicine, 57(1):377HAWAII. Herbal medicines in Hawaii from tradition to

convention, 57(1)382— Prenatal care utilization in Hawaii: did it improve

during the last 16 years?, 57(2):412Do Hawaii residents support physician-assisted death?

a comparison of five ethnic groups, 57(6):529— Epidemiology of congenital diaphragmatic hemia,

Hawaii, 1987-1996, 57(8):586— Achieving better outcomes for Hawaii’s children,

57(9):617— Cancer pain guidelines: are they being used? results of

a multi-site study conducted by the Hawaii Cancer Pain

Initiative, 57(lO):655—Hawaii benefits from graduate medical education [Medi

cal school hotline], 57(1 l):686HAWAII MEDICAL ASSOCIATION. President’s mes

sage, 57(l):370— 141st HMA annual meeting, 57(1):387— Primary care update: highlights of the HMA scientific

session, 57(1 ):388— 1997 HMA annual meeting and presidential inaugura

tion, 57(l):390—Happy Halloween, 57(l):391— Federal fraud enforcement: why you should have an

effectivecomplianceplan [President’s message], 57(2):40l

— President’s message, 57(3):426— Council highlights, 57(3):457— President’s message, 57(4):469— Council highlights, 57(4):482— What do we want to be? a health care industry or the

profession of medicine? [President’s message], 57(5):493Council highlights. 57(5):5l3

— President’s message, 57(7):550— Managed care concerns [President’s message],57(8):58 1— Council highlights, 57(8):593— Where do we go from here? [President’s message],

57( 10):645— President’s message, 57(l2):725HAWAII MEDICAL LIBRARY. Editorial, 57(lO):645

HAWAII MEDICAL SERVICE ASSOCIATION.President’s message, 57(12):725HAWAII POISON CENTER. Clinical toxicology and theHawaii Poison Center [Guest editors], 57(3):425— Who calls the Hawaii Poison Center?, 57(3):437— Hawaii Poison Center forty years of saving lives andhealth costs, 57(3):440— Hawaii Poison Center: what’s it worthtoyou?, 57(3):45 1

— Hawaii Poison Center data reveals a need for increasing

hazard awareness about household products, 57(4):476

— “Inside ‘da poison center”, 57(4):479HAWAII STATE HOSPITAL. Admissions, length of

stay, and discharge barriers at the Hawaii State Hospital,

57(7):561— neuropsychology department at Hawaii State Hospital,

57(9):624HEALTH CARE COSTS. Hawaii Poison Center fortyyears of saving lives and health costs, 57(3):440— socialization of health care, slice by slice. 1998 [classi

cal article], 57(5):496— Deep pockets or blueprint for change: traumatic brain

injury (TBI) proactive strategy, 57(9):6l IHEALTH EDUCATION. Hawaii Poison Center data re

veals a need for increasing hazard awareness about house

hold products, 57(4):476HEALTH SERVICES ACCESSIBILITY. Prenatal care

utilization in Hawaii: did it improve during the lest 16

yetirs?, 57(2):412HEALTH SYSTEMS PLANS. UH med school’s plan.

1998 [classical article], 57(8):578HEPATITIS AGENTS, GB. Gradual loss of IgG antibod

ies against GB virus C!hepatitis G virus in a patient with

AIDS [Harry L. Arnold Jr. MD case of the month], 57(12):

733HEPATITIS C, CHRONIC. Interferon alpha-2b in the

treatment of chronic hepatitis C: early experience,

57(1 2):735HERNIA, DIAPHRAGMATIC. Epidemiology of con

genital diaphragmatic hernia, Hawaii, 1987-1996,

5T(8):586HERNIA, INGUINAL. Laparoscopic inguinal hernior

rhaphy: thenew gold standard of hernia repair, 57(11 ):700HISTORY OF MEDICINE. William Crawford Gorgas he

set thestandard of military preventive medicine, 57(1 ):377— Hawaii Poison Center forty years of saving lives and

health costs, 57(3):440— [re: physician asisted suicide], 57(8):577— laparosopic update, 57(1 l):683HIV INFECTIONS. 10 common medicolegal questions

on HIV infection, 57(5):507HONOLULU. A quantitative study of environmental as

bestos exposure in Honolulu, 57(6):536HOSPITAL COMMUNICATION SYSTEMS. What’s

new in medical communication? 1998 [classical article],

57(1 2):729HOSPITALS, PSYCHIATRIC. Admissions, length of

stay, and discharge barriers at the Hawaii State Hospital,

57(7):561HOUSEHOLD PRODUCTS. Hawaii Poison Center datareveals a need for increasing hazard awareness abouthousehold products, 57(4):476IGG. Gradual loss of lgG antibodies against GB virus C!

hepatitis G virus inS patient with AIDS [Harry C. Arnold

Jr. MD case of the month], 57(12): 733IMI HO’OLA. Commitment to “diversity” [Medical school

hotline], 57(8):580IMPOTENCE. The effects of ArginMax, a natural dietary

supplement for enhancement of male sexual function,

57(12):74lINDEX. Index to the Hawaii Medical Journal, volume 57.

1998, 57(I2):753INFORMATION SYSTEMS. The selected information

sources on poisoning and toxicology, 57(3):455— What’s new in medical communication? 1998 [classi

cal article]. 57(12):729INTERFERON ALPHA-2B. Interferon alpha-2b in the

treatment of chronic hepatitis C: early experience,

57(12)735INTERNSHIP AND RESIDENCY. Military unique cur

riculum [Military medicine], 57( l):372—role of geriatric psychiatry in medical education [Medi

cal school hotlinel, 57(3):429JAPANESE. Seizures in eastbound visitors to Hawaii,

57(2):408JOHN A. BURNS SCHOOL OF MEDICINE. The impact

of changes in medical care on medical education [Medical

school hotline], 57(1)375— Evidence-based medicine: educating physicians in the

science behind the art [Medical school hotiine], 57(2):402

—role of geriatric psychiatry in medical education [Medi

cal school hotline], 57(3):429— Fund-raising for medical education [Medical school

hotline], 57(4):470— Emergency medicine in the problem-based learning

curriculum [Medical school hotline], 57(5):495— John A. Bums School of Medicine (JABSOM) status

report on finances and contributions [Medical school

hotline], 57(6):527— Interest in alternative medicine by first year medical

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

school hotline], 57(7):553—UH medschool’splan. 1998 [classicalarticle],57(8):578— Commitment to “diversity” [Medical school hotline],

57(8):580— Student profile: class of 2002 at the John A. Burns

School of Medicine [Medical school hotline], 57(9):606

—update on the USMLE performance of medical students

at the John A. Burns School of Medicine and computer-

based testing [Medical school hotline], 57(l0):646JURISPRUDENCE. 10 common medicolegal questions

on HIV infection, 57(5):507KEROSENE. Accidental poisoning in children with spe

cial reference to kerosene poisoning. 1951 [classical ar

ticle], 57(3):433LAPAROSCOPY. Laparoscopic ultrasound: a valuable

adjunct to laparoscopic surgery. 57(1 l):696

— Laparoscopic staging of malignant disease, 57(1 l):705— Advanced laparoscopy: “the next generation,” the

adrenal, kidney, spleen, pancreas, and liver, 57(1 l):710

— laparosopic update, 57(1 l):683LECTURES AND LECTURING. RobertT, Wong, M.D.

lecture series announces speakers for 1999 [Announce

ment], 57(l2):726LEG INJURIES. Common sports injuries seen by the

primary care physician part II: lower extremity, 57(5):502

LENGTH OF STAY. Admissions, length of stay, and

discharge barriers at the Hawaii State Hospital, 57(7):56l

LET’I’ERS TO THE EDITOR. Letter to the editor,

57(l):372— [re: doctor assisted death with dignity], 57(6):526

— [re: physician assisted suicide], 57(8):577LEUKEMIA-LYMPHOMA, T-CELL, ACUTE, HTLV

I-ASSOCIATED. HTLV-l associated adult T-cell leuke

mia in a Micronesian patient: the first reported case [Harry

L. Arnold Jr. MD case of the month], 57(1 ):372MALARIA. William Crawford Gorges he set the standard


of military preventive medicine, 57(l):377MANAGED CARE PROGRAMS. Managed care concerns [President’s message], 57(8):58 I— Change in medical care has come too fast. 1998[classical article], 57(lO):650MEDICAID. The socialization of health care, slice byslice. 1998 [classical article], 57(5):496— assessment of Hawaii QUEST medical plans performance using Medicaid HEDIS measures, 1996-1997,57( lO):662MEDICAL AUDIT. Chart audit of inpatient treatment ofschizophrenic patients: implications for development ofcoordinated care paths, 57(7):557MEDICARE. The socialization of health care, slice byslice. 1998 [classical article], 57(5):496MEDICINE, HERBAL. Herbal medicines in Hawaii fromtradition to convention, 57(1 ):382MENINGITIS. Eosinophilicmeningitis/angiostrongyliasisfrom eating aquaculture-raised snails: a case report [HarryL. Arnold Jr. MD case of the month], 57(lO):652MENINGOCOCCAL INFECTIONS. Chronic meningococcemia mimicking acute rheumatic fever [Harry L.Arnold Jr. MD case of the month], 57(8):583MICRONESIA. HTLV-l associated adult T-cell leukemia in a Micronesian patient: the first reported case [HarryL. Arnold Jr. MD case of the month], 57(1):372MILITARY MEDICINE. Military unique curriculum[Military medicine], 57(1):372— William Crawford Gorgas: he set the standard ofmilitary preventive medicine, 57( l):377— Tripler’s emergency medical response team [Militarymedicine], 57(3):427— Christmas Island rescue: a true story [Military medicine], 57(5):497NEOPLASM STAGING. Laparoscopic staging of malignant disease, 57(1 l):705NEOPLASMS. Cancer pain guidelines: are they beingused? results of a multi-site study conducted by the HawaiiCancer Pain Initiative, 57(l0):655— Laparoscopic staging of malignant disease, 57(11 ):705NEUROPSYCHOLOGY. The neuropsychology department at Hawaii State Hospital, 57(9):624— Hawaii neuropsychology program gets results: the nutsand bolts of neurotraining, 57(9):625OKAMOTO, GARY. The “silent epidemic”: traumaticbrain injury [Editorial], 57(9):605PAIN. Editorial, 57(l0):645PAIN, INTRACTABLE. Pain management: recommendations of the Govemor’s Blue Ribbon Panel on living anddying with dignity. [Editorial], 57(7):549— Cancer pain guidelines: are they being used? results ofa multi-site study conducted by the Hawaii Cancer PainInitiative, 57(lO):655PALLIATIVE CARE. Pain management: recommendations of the Govemor’s Blue Ribbon Panel on living anddying with dignity. [Editorial], 57(7):549— Cancer pain guidelines: are they being used? results ofa multi-site study conducted by the Hawaii Cancer PainInitiative, 57(lO):655PANCREATIC DUCTS. CT demonstration of a pancreatic duct stricture and obstructive pancreatitis with ERCPand intraoperative correlation [Harry L. Arnold Jr. MDcase of the month], 57(3):43 1PANCREATITIS. CT demonstration of a pancreatic ductstricture and obstructive pancreatitis with ERCP and intraoperative correlation [Harry L. Amold Jr. MD case of themonth], 57(3):431PATIENT ADMISSION. Admissions, length of stay, anddischarge bamers at the Hawaii State Hospital, 57(7):56 IPATIENT COMPLIANCE. Prenatal care utilization inHawaii: did it improve during the last 16 years?, 57(2):4 12PATIENT DISCHARGE. Admissions, length of stay, anddischarge barriers at the Hawaii State Hospital, 57(7):56l

PHYSICIAN-PATIENTRELATIONS. lOcommonmedicolegal questions on HIV infection, 57(5):507PHYSICIANS. William Crawford Gorgas: he set thestandard of military preventive medicine, 57( l):377PLANTS, MEDICINAL. Herbal medicines in Hawaiifrom tradition to convention, 57(l):382POETRY. Transformation, 57( l):393— Mahm. 57(5):494— Proud father, 57(6):526POISON CONTROL CENTERS. Who calls the HawaiiPoison Center?, 57(3):437— Hawaii Poison Center forty years of saving lives andhealth costs, 57(3):440— Hawaii Poison Center: what’s it worth to you?, 57(3):45 1— Hawaii Poison Center data reveals a need for increasing hazard awareness about household products, 57(4):476— “Inside ‘da poison center”, 57(4):479POISONING. Clinical toxicology and the Hawaii PoisonCenter [Guest editors], 57(3):425—Accidental poisoning in children with special referenceto kerosene poisoning. 1951 [classical article], 57(3):433— Who calls the Hawaii Poison Center?, 57(3):437— Clinical pearls in pediatric toxicology: a systematicapproach to the poisoned child, 57(3):445— selected information sources on poisoning and toxicology, 57(3):455—Toxicologic teasers: testing your knowledge ofclinicaltoxicology, 57(4):47 1— Clinical techniques in crisis intervention: emergencycounseling in cases of acute poisoning, 57(4):474POLICY MAKING. A possible solution to the cost explosion of the emergency department, 57(2):404PORTRAITS. 1997 HMA annual meeting and presidential inauguration, 57(l):390— Happy Halloween, 57(l):39IPRACTICE GUIDELINES. Cancer pain guidelines: arethey being used? results of a multi-site study conducted bythe Hawaii Cancer Pain Initiative, 57(l0):655PRENATAL CARE. Prenatal care utilization in Hawaii:did it improve during the last 16 years?, 57(2):4l2PREVENTIVE MEDICINE. William Crawford Gorgashe set the standard of military preventive medicine,57(I):377PRIMARY HEALTH CARE. The impact of changes inmedical care on medical education [Medical schoolhotline], 57(l):375— Primary care update: highlights of the HMA scientificsession, 57(l):388PROBLEM-BASED LEARNING. Emergency medicinein the problem-based learning curriculum [Medical schoolhotline], 57(5):495PROGRAM EVALUATION. An assessment of HawaiiQUEST medical plans performance using MedicaidHEDIS measures, 1996-1997, 57( lO):662PUBLIC OPINION. Do Hawaii residents support physician-assisted death? a comparison of five ethnic groups,57(6):529PUBLICATIONS. The selected information sources onpoisoning and toxicology, 57(3):455QUALITY ASSURANCE, HEALTH CARE. An assessment of Hawaii QUEST medical plans performance usingMedicaid HEDIS measures, 1996-1997, 57( l0):662QUALITY OF HEALTH CARE. Chart audit of inpatienttreatment of schizophrenic patients: implications for development of coordinated care paths, 57(7):557QUEST PROGRAM (HAWAII). Editorial, 57(lO):645— assessment of Hawaii QUEST medical plans performance using Medicaid HEDIS measures, 1996-1997,57( I0):662REHABILITATION. Hawaii neuropsychology programgets results: the nuts and bolts of neurotraining. 57(9):625REHABILITATION, VOCATIONAL. Vocational rehabilitation of people with traumatic brain injury, 57(9):6l8

RHEUMATIC FEVER. Chronic meningococcemia mimicking acute rheumatic fever [Harry L. Arnold Jr. MD caseof the month], 57(8):583RIGHT TO DIE. Editorials, 57(4):469— Govemor’s blue-ribbon panel on living and dying withdignity [Editorial], 57(6):525— Pain management: recommendations of the Governor’sBlue Ribbon Panel on living and dying with dignity.[Editorial], 57(7):549SCHIZOPHRENIA. Chart audit of inpatient treatment ofschizophrenic patients: implications for development ofcoordinated care paths, 57(7):557SEIZURES. Seizures in eastbound visitors to Hawaii,57(2):408SLEEP DEPRIVATION. Seizures in eastbound visitors toHawaii, 57(2):408SPORTS MEDICINE. Common sports injuries seen bythe primary care physician part II: lower extremity,57(5):502STRONGYLDIA INFECTIONS. Eosinophilic meningitis/angiostrongyliasis from eating aquaculture-raised snails:a case report [Harry L. Amold Jr. MD case of the month],57(l0):652STUDENTS, MEDICAL. The John A. Bums School ofMedicine (JABSOM) status report on finances and Contributions [Medical school hotline], 57(6):527— Interest in alternative medicine by first year medicalstudents at the John A. Bums School ofMedicine [Medicalschool hotline], 57(7):553— Commitment to “diversity” [Medical school hotline],57(8):580— Student profile: class of 2002 at the John A. BumsSchool of Medicine [Medical school hotline], 57(9):606— update on the USMLE performanceof medical studentsat the John A. Bums School of Medicine and computer-based testing [Medical school hotline], 57(10):646SUICIDE, ASSISTED. Doctor-assisted death with dignity. 1997 [classical article], 57(l):37I— Governor’s blue-ribbon panel on living and dying withdignity [Editorial], 57(6):525— Do Hawaii residents support physician-assisted death?a comparison of five ethnic groups, 57(6):529— President’s message, 57(7):550— [re: physician assisted suicide], 57(8):577SURGICAL PROCEDURES, LAPAROSCOPIC.Laparoscopic ultrasound: a valuable adjunct to laparoscopicsurgery, 57(1 l):696— Laparoscopic inguinal hemiorrhaphy: the new goldstandard of hernia repair, 57(1 1):700— Advanced Iaparoscopy: “the next generation,” theadrenal, kidney, spleen, pancreas, and liver, 57(1 1):710— laparosopic update, 57(1 1):683TETANUS. Tetanus: still “inexcusable”, 57(1 1):689THERAPEUTICS. Chart audit of inpatient treatment ofschizophrenic patients: implications for development ofcoordinated care paths, 57(7):557THERAPY. Cancer pain guidelines: are they being used?results of a multi-site study conducted by the HawaiiCancer Pain Initiative, 57( I0):655— Diagnosis and management of female urinary incontinence, 57(12):746TOMOGRAPHY SCANNERS, X-RAY COMPUTED.CT demonstration of a pancreatic duct stricture and obstructive pancreatitis with ERCP and intraoperative correlation (Harry L. Arnold Jr. MD case of the month],57(3):43 ITOXICOLOGY. Clinical pearls in pediatric toxicology: asystematic approach to the poisoned child, 57(3):445— selected information sources on poisoning and toxicology, 57(3):455— Toxicologic teasers: testing your knowledge of clinicaltoxicology. 57(4):47 ITRAVEL. Seizures in eastbound visitors to Hawaii,

HAWAS MEDCAL JOURNAL, VOL 57. DECEMBER 1998755

57(2):408TRIPLER ARMY MEDICAL CENTER. Tripler’s emer

gency medical response team [Military medicine],57(3):427ULTRASONOGRAPHY. Laparoscopic ultrasound: avalu

able adjunct to laparoscopic surgery, 57(1 l):696URINARY INCONTINENCE. Diagnosis and management of female urinary incontinence, 57(12):746VACCINATION. Tetanus: still “inexcusable”, 57(11 ):689WOMEN’ S HEALTH. Noncontraceptive health benefitsof the oral contraceptive pill, 57(8):591— Diagnosis and management of female urinary incontinence, 57(12):746YELLOW FEVER. William Crawford Gorgas: he set the

standard of military preventive medicine, 57(l):377

Author Index

ADAMS EM. Primary care update: highlights of the HMAscientific session, 57(l):388AH HEONG MM. Index to the Hawaii Medical Journal,volume 57, 1998, 57(12):753AHINA D. Who calls the Hawaii Poison Center?, 57(3):437— “Inside ‘da poison center”, 57(4):479AHMED I. role of geriatric psychiatry in medical education [Medical school hotline], 57(3):429ALEXANDER GR. Prenatal care utilization in Hawaii:did it improve during the last 16 years?, 57(2):412ANDERS RL. Chart audit of inpatient treatment of schizophrenic patients: implications for development of coordinated care paths, 57(7):557BAIRD DE. CT demonstration of a pancreatic duct stric

ture and obstructive pancreatitis with ERCP and intraoperative correlation (Harry L. Arnold Jr. MD case of the

month], 57(3):43lBARUFFI G. Prenatal care utilization in Hawaii: did itimprove during the last 16 years?. 57(2):4l2BEHNKE BS. Hawaii Poison Center: what’s it worth to

you?, 57(3):45 IBERG BW. Military unique curriculum [Military medi

cine], 57(l):372— HTLV-l associated adult T-cell leukemia in aMieronesian patient: the first reported case [Harry L.Arnold Jr. MD case of the month], 57(l):372BLAKE 0. Letter to the editor, 57(l):372BLANCHETTE PL. Fundraising for medical education[Medical school hotline], 57(4):470BOGDEN P. Evidence-based medicine: educating physicians in the science behind the art [Medical school hotline],

57(2):402BOTI’ICELLI MG. UH med school’s plan. 1998 [classi

cal article], 57(8):578BRAUN KL. Do Hawaii residents support physician-assisted death? a comparison of five ethnic groups,

57(6):529CASHMAN TM. William Crawford Gorgas: he Set the

standard of military preventive medicine, 57(1 ):377CAYETANO BJ. [Governor’s proclamation], 57(9):609CHING C. Interferon alpha-2b in the treatment of chronichepatitis C: early experience, 57(l2):735CHING CSH. Index to the Hawaii Medical Journal, volume 57, 1998, 57(l2):753CHING NPH. Interferon alpha-2b in the treatment of

chronic hepatitis C: early experience, 57(l2):735CHING NWH. Interferon alpha-2b in the treatment of

chronic hepatitis C: early experience. 57(12):735CHINN PL. President’s message, 57(l2):725CHUA PK. Gradual loss of lgG antibodies against GBvirus C/hepatitis G virus in a patient with AIDS [Harry L.

Arnold Jr. MD case of the month], 57(12): 733CHUN LT. Accidental poisoning in children with special

reference to kerosene poisoning. 1951 [classical article].57(3):433

CRAINE J. Hawaii neuropsychology program gets re

sults: the nuts and bolts of neurotraining, 57(9):625CRISP BJ. Christmas Island rescue: a true story [Militarymedicine], 57(5):497CUMINGS MD. HTLV- I associated adult T-cell leukemia in a Micronesian patient: the first reported case [Harry

L. Arnold Jr. MD case of the month], 57(1 ):372DAS A. effects of ArginMax, a natural dietary supplementfor enhancement of male sexual function, 57( 12):741DASHWOODWM. Gradual loss of lgG antibodies againstGB virus C/hepatitis G virus in a patient with AIDS [Harry

L. Arnold Jr. MD case of the month], 57(12):733DUH QY. Advanced laparoscopy: “the next generation,”the adrenal, kidney, spleen, pancreas, and liver. 57(11 ):7 10

ELIAS MF. Seizures in eastbound visitors to Hawaii,

57(2):408FERNANDES D. Admissions, length of stay, and discharge barriers at the Hawaii State Hospital. 57(7):561FLOWERS RS. Mahm, 57(5):494— Proud father, 57(6):526FO WSO. Phantom loss of function in traumatic brain

injury, 57(9):629FORRESTER MB. Epidemiology of congenital diaphragmatic hernia, Hawaii, 1987-1996, 57(8):586FRIEDMAN RB. impact of changes in medical care onmedical education [Medical school hotline], 57(1 ):375FUDDY U. Prenatal care utilization in Hawaii: did it

improve during the last 16 years’?, 57(2):412FUJII DEM. neuropsychology department at Hawaii State

Hospital, 57(9):624FURUMOTO N. Laparoscopic inguinal herniorrhaphy:the new gold standard of hernia repair, 57(1 l):700

GARDINER BN. Laparoscopic inguinal herniorrhaphy:the new gold standard of hernia repair, 57(1 I):700GOEBERT D. Admissions, length of stay, and discharge

barriers at the Hawaii State Hospital, 57(7):561GOLDSTEIN N. Editorials, 57(l):369— Mahalo to Elizabeth M. Adams MD [Editorial],57(2):401— March special issue [Editorial], 57(3):425— Editorials, 57(4):469— Socialization of healthcare/slice by slice [Editorial],57(5):493— Governor’s blue-ribbon panel on living and dying with

dignity [Editorial], 57(6):525— Pain management: recommendations of the Governor’sBlue Ribbon Panel on living and dying with dignity.

[Editorial], 57(7):549— “silent epidemic”: traumatic brain injury [Editorial],

57(9):605Editorial, 57(l0):645

— Editorial, 57(1 l):685— Editorial, 57(12)725— What’s new in medical communication? 1998 [classi

cal article], 57(l2):729GRESS FM. HTLV- I associated adult T-cell leukemia in

a Micronesian patient: the first reported case [Harry L.Arnold Jr. MD case of the month], 57(1 ):372HAMMAR SL. John A. Burns School of Medicine(JABSOM) status report on finances and contributions

[Medical school hotline], 57(6):527HARIHARAN A. Advanced laparoscopy: “the next gen

eration,” the adrenal, kidney, spleen, pancreas. and liver.57(1 l):710HAWAII. LEGISLATURE. [Legislature proclamation].57(9):634HISHINUMA ES. Admissions, length of stay, and dis

charge bathers at the Hawaii State Hospital, 57(7):56l

HOLSCHUH FC. Pity and compassion are not enough,

57(9):616— Change in medical care has come too fast. 1998

[classical article], 57(lO):650HONBO L. assessment of Hawaii QUEST medical plans

performance using Medicaid HEDIS measures, 1996-1997, 57(I0):662HOWARD L. President’s message, 57(l):370— Federal fraud enforcement: why you should have aneffective complianceplan [President’s message], 57(2):40 I— President’s message, 57(3):426— President’s message, 57(4):469— What do we want to be? a health care industry or theprofession of medicine? [President’s message], 57(5):493— President’s message, 57(7):550— Managed care concerns [President’s message].57(8):58 1— Where do we go from here? [President’s message],57(lO):645HUNSTIGER T. Vocational rehabilitation of people withtraumatic brain injury, 57(9):618INABA AS. Clinical toxicology and the Hawaii PoisonCenter [Guest editors], 57(3):425— Clinical pearls in pediatric toxicology: a systematicapproach to the poisoned child, 57(3):445— Toxicologic teasers: testing your knowledge of clinicaltoxicology. 57(4):47 1ITO T. effects of ArginMax, a natural dietary supplement

for enhancement of male sexual function, 57(1 2):74 1

IZUTSU S. Commitment to “diversity” [Medical school

hotline], 57(8):580— Student profile: class of 2002 at the John A. BurnsSchool of Medicine, 57(9):606JAHRAUS TC. [re: physician assisted suicide], 57(8):577JEROME LW. Clinical techniques in crisis intervention:

emergency counseling in cases of acute poisoning,57(4):474JOHNSON RE. Tripler’s emergency medical responseteam [Military medicine], 57(3):427JUDD NLK. Commitment to “diversity” [Medical school

hotline], 57(8):580KALUA PM. Cancer pain guidelines: are they being used?

results of a multi-site study conducted by the Hawaii

Cancer Pain Initiative, 57(10):655KASUYA R. Evidence-based medicine: educating physi

cians in the science behind the art [Medical school hotline],

57(2):402KAVANAGH B. Admissions, length of stay, and dis

charge barriers at the Hawaii State Hospital, 57(7):561

KAVOLIUS JP. CT demonstration of a pancreatic duct

stricture and obstructive pancreatitis with ERCP and intraoperative correlation [Harry L. Arnold Jr. MD case of the

month], 57(3):43IKAWAGUCI-lI EM. Emergency medicine in the prob

lem-based learning curriculum [Medical school hotline],

57(5):495— Interest in alternative medicine by first year medicalstudents at the John A. Burns School of Medicine [Medical

school hotline], 57(7):553KAWAHARA K. effects of ArginMax, a natural dietary

supplement for enhancement of male sexual function.

57(12):74lKELLEY RR. socialization of health care, slice by slice.1998 [classical article], 57(5):496KIMURA R. Council highlights, 57(3):457— Council highlights, 57(4):482—Council highlights, 57(5):513— Council highlights, 57(8):593KOBAYASHI G. Gradual loss of lgG antibodies against

GB virus C/hepatitis G virus in apatient with AIDS [Harry

L. Arnold Jr. MD case of the month], 57(l2):733KODAMA AM. Hawaii Poison Center data reveals a need

for increasing hazard awareness about household prod

ucts, 57(4):476KOSASA TS. Noncontraceptive health benefits of the oralcontraceptive pill, 57(8):591KUBO Ti’. 10 common medicolegal questions on HIV

infection, 57(5):507

HAWAIt MEDICAL JOURNAL, VOL 57, DECEMBER 1998

756

LAPSCHIES B. Advanced laparoscopy: “the next generation,” the adrenal, kidney, spleen, pancreas, and liver,57(1 1):710LAWLER S. Deep pockets or blueprint for change: traumatic brain injury (TBI) proactive strategy, 57(9):61 1LOKE M. assessment of Hawaii QUEST medical plansperformance using Medicaid HEDIS measures, 1996-1997, 57(lO):662LUMENG 1. quantitative study of environmental asbestosexposure in Honolulu. 57(6):536— Interferon alpha-2b in the treatment of chronic hepatitisC: early experience, 57(12):735MACHI I. Laparoscopic ultrasound: a valuable adjunct tolaparoscopic surgery, 57(1 l):696— Laparoscopic inguinal herniorrhaphy: the new goldstandard of hernia repair, 57(ll):700MAKINI GK JR. Admissions, length of stay, and discharge barriers at the Hawaii State Hospital, 57(7):56lMARQUARDT SP. Achieving better outcomes forHawaii’s children, 57(9):6l7MARSH CM. Eosinophilic meningitis/angiostrongyliasisfrom eating aquaculture-raised snails: a case report [HarryL. Arnold Jr. MD case of the month], 57(10):652MENON P. Hawaii Poison Center data reveals a need forincreasing hazard awareness about household products,57(4):476MERZ RD. Epidemiology of congenital diaphragmatichernia, Hawaii, 1987-1996, 57(8):586MILLER CF. HTLV- 1 associated adult T-cell leukemia ina Micronesian patient: the first reported case [Harry L.Arnold Jr. MD case of the month], 57( 1):372MILNE CIP. Gradual loss of IgG antibodies against GBvirus C/hepatitis G virus in a patient with AIDS [Harry L.Arnold Jr. MD case of the month], 57(12):733MONTELL EM. [re: physician assisted suicide]. 57(8):577MOORE MD. Chronic meningococcemia mimicking acuterheumatic fever [Harry L. Arnold Jr. MD case of themonth], 57(8):583MOR JM. Prenatal care utilization in Hawaii: did it improve during the last 16 years?, 57(2):412MORTON WS. Hawaii Poison Center forty years ofsaving lives and health costs, 57(3):440MULLINS ME. Seizures in eastbound visitors to Hawaii,57(2):408MYSLIWIECAG.Tetanus: still “inexcusable”, 57(1 l):689NAGUWA GS. update on the USMLE performance ofmedical students at the John A. Burns School of Medicineand computer-based testing [Medical school hotline],57(l0):646NAKAYAMA RT. Noncontraceptive health benefits ofthe oral contraceptive pill, 57(8):591NELSON JM. CT demonstration of a pancreatic ductstricture and obstructive pancreatitis with ERCP and intraoperative correlation [Harry L. Arnold Jr. MD case of themonth], 57(3):431NERURKAR yR. Gradual loss of IgG antibodies againstGB virus C/hepatitis G virus in a patient with AIDS [HarryL. Arnold Jr. MD case of the month], 57(12): 733NORTON SA. Herbal medicines in Hawaii from traditionto convention, 57(l):382OISHI AJ. Laparoscopic inguinal hemiorrhaphy: the newgold standard of hernia repair, 57(11 ):700OISHI RH. Laparoseopic inguinal herniorrhaphy: the newgold standard of hernia repair. 57(11 ):700OKAMOTO G. Guest editor, 57(9):605

Deep pockets or blueprint for change: traumatic braininjury (TBI) proactive strategy, 57(9):6l IOLSON T. Chart audit of inpatient treatment of schizophrenic patients: implications for development of coordinated care paths, 57(7):557ONAKA AT. Prenatal care utilization in Hawaii: did itimprove during the last 16 years?, 57(2):4 12OR FW. Interferon alpha-2b in the treatment of chronic

hepatitis C: early experience, 57(1 2):735PAIK YK. quantitative study of environmental asbestosexposure in Honolulu, 57(6):536PANG G. Interferon alpha-2b in the treatment of chronichepatitis C: early experience, 57(l2):735PANG R. Interferon alpha-2b in the treatment of chronichepatitis C: early experience, 57(12):735PATFIAK A. Transformation, 57(1 ):393PATRICK V. Admissions, length of stay, and dischargebarriers at the Hawaii State Hospital, 57(7):561PAYNE JH JR. Laparoscopic staging of malignant disease, 57(ll):705— Advanced laparoscopy: “the next generation,” theadrenal, kidney, spleen, pancreas, and liver, 57(1 1):7l0PERSKE KF. Prenatal care utilization in Hawaii: did itimprove during the last 16 years?, 57(2):4l2PERSON DA. Chronic meningococcemia mimicking acuterheumatic fever [Harry L. Arnold Jr. MD case of themonth], 57(8):583PETERSON JE. Gradual loss of JgG antibodies againstGB virus C/hepatitis G virus in a patient with AIDS [HarryL. Arnold Jr. MD case of the month], 57(l2):733POHL S. Deep pockets or blueprint for change: traumaticbrain injury (TEl) proactive strategy, 57(9):6 IIPROCHAZKA EJ. possible solution to the cost explosionof the emergency department, 57(2):404RACINE JF. Clinical toxicology and the Hawaii PoisonCenter [Guest editors], 57(3):425—Hawaii PoisonCenter: what’s itworth toyou?, 57(3):45 ISAKAJ D. Evidence-based medicine: educating physicians in the science behind the art [Medical school hotline],57(2):402SATO C. selected information sources on poisoning andtoxicology, 57(3):455SCHIEL S. Hawaii benefits from graduate medical education [Medical school hotline], 57(1 l):686SCOGGIN IF. Common sports injuries seen by the primary care physician part II: lower extremity, 57(5):502SHANDERA KC. Diagnosis and management of femaleurinary incontinence, 57(12):746SHIKUMA CM. Gradual loss of lgG antibodies againstGB virus C/hepatitis G virus in a patient with AIDS [HarryL. Arnold Jr. MD case of the month], 57(12): 733SHIMAMOTO A. “Inside ‘da poison center”, 57(4):479SMOLENSKI J. Clinical techniques in crisis intervention:emergency counseling in cases of acute poisoning,57(4):474SMYSER AA. Doctor-assisted death with dignity. 1997[classical article], 57(1)371SOUSA P. Evidence-based medicine: educating physicians in the science behind the art [Medical school hotline],57(2):402STODD RT. weathervane, 57(l):394

weathervane, 57(3):462— weathervane, 57(4):486— weathervane, 57(5):5l8— weathervane, 57(6):542— weathervane, 57(7):570— weathervane, 57(8):598— weathervane, 57(9):638— weathervane, 57(lO):678— weathervane, 57(1 l):7l8— weathervane, 57(1 2):758STRUDWICK W. effects of ArginMax, a natural dietarysupplement for enhancement of male sexual function,57(12): 741TAKESHITA J. role of geriatric psychiatry in medicaleducation [Medical school hotline], 57(3):429TAM LO. Emergency medicine in the problem-basedlearning curriculum [Medical school hotline], 57(5):495TAM LQ. Interest in alternative medicine by first yearmedical students at the John A. Burns School of Medicine[Medical school hotline], 57(7):553

TAN SY. 10 common medicolegal questions on HIVinfection, 57(5):507TASHIMA W. Advanced laparoscopy: “the next generation,” the adrenal, kidney, spleen, pancreas, and liver,57(ll):710TATSUGUCHI RK. Phantom loss of function in traumatic braln injury, 57(9):629THOMPSON G. Vocational rehabilitation of people withtraumatic brain injury. 57(9):618UYEDA C. City honors our editor [Editorial], 57(8):577VAREZ D. Chanter, 57(l):367— Makoa, 57(2):397— Maile, 57(3):423— He’e, 57(4):467— E hula e, 57(5):491— E wa’a e, 57(6):523— ‘0 he’e, 57(7):547— Maui snaring the sun, 57(8):575

Kipahulu, 57(9):603— E PeIe e, 57(l0):643— Leho he’e, 57(1 l):683— Wa’a kaulua, 57(l2):723WARD KL. Prenatal care utilization in Hawaii: did itimprove during the last 16 years?, 57(2):412WASHECKA R. Advanced laparoscopy: “the next generation.” the adrenal, kidney, spleen, pancreas, and liver,57(1 l):7l0WISHART J. quantitative study of environmental asbestos exposure in Honolulu, 57(6):536WONG ED. laparosopie update, 57(1 l):683WOOD DW. Deep pockets or blueprint for change: traumatic brain injury (TBI) proactive strategy, 57(9):6l 1WOODWARD CL. Gradual loss of IgG antibodies againstGB virus C/hepatitis G virus in a patient with AIDS [HarryL. Arnold Jr. MD case of the month], 57(12):733YANAGIHARA R. Gradual loss of IgG antibodies againstGB virus C/hepatitis G virus in a patient with AIDS [HarryL. Arnold Jr. MD case of the month], 57(1 2):733YANG HY. quantitative study of environmental asbestosexposure in Honolulu, 57(6):536YANG YYL. quantitative study of environmental asbestos exposure in Honolulu, 57(6):536YOKOYAMA HN. News and notes, 57(l):392— News and notes, 57(2):4I7— News and notes, 57(3):459— News and notes, 57(4):484—News and notes, 57(5):514— News and notes, 57(6):540— News and notes, 57(7):568— News and notes, 57(8):595— News and notes, 57(9):635— News and notes, 57(l0):674— News and notes, 57(1 l):716— News and notes, 57(12):450ZACHER LL. Tetanus: still “inexcusable”, 57(1 l):689


The Weathervane Russell T. Stodd MD

I got in at two with a ten, and woke up at ten with atwo.

The study on drug use done at UCLA School of Medicine reported in

JAMA reveals that molecular abnormalities in the respiratory tracts of heavy

smokers of marijuana and crack cocaine suggest these druggies are at

increased risk ofdeveloping lung cancer. While there are still some crackheads

and pot puffers who seem to think that cocaine and marijuana are not as

dangerous to human tissue as tobacco, this study shows that similar molecu

lar events are set in motion leading to lung cancer. Moreover, the study

reveals that smoking more than one substance causes more potentially

cancerous molecular changes than smoking tobacco alone. California voters

passed a law two years ago to legalize medical marijuana, and evidence now

shows that marijuana smoking is increasing among teenagers and even

children as young as nine years old. The thought has been offered that the

heavy campaign to curb teenagers tobacco smoking, may be having the

effect of increasing use of marijuana.

Those who dont study the past will repeat its errors.Those who do study it, will find other ways to go wrong.

The American Society of Cataract and Refractive Surgery (ASCRS)

conducted a retrospective anonymous survey of 4400 members regarding

the incidence of infection with cataract surgery. 1284 surveys were returned

revealing that one surgeon in seven (14%) had an infected patient in 1997.

No statistical difference was found among comeal, limbal or scieral-corneal

incisions. Incision length had no bearing, nor did intraoperative aseptic

prophylaxis, draping of lids and lash margins, nor the use ofpovidone-iodine

directly in the prep. Almost all, 96.5%, use topical antibiotics at some time

during the perioperative period. The only factor which was statistically

beneficial in decreasing incidence of infection was the placement of antibi

otics in the infusion bottle or beneath the conjunctiva..

Medicare and Medicaid are the greatest measures yetdevised to make the world safe for clerks.

Those ever-creative schemers in the HCFA bureaucracy want to establish

a Medicare + Choice or Part C. The expectation is that Medicare beneficia

ries are supposed to be able to choose from a variety of alternatives to

traditional fee-for-service. So far, only one Medicare provider-sponsored

organization (PSO) is likely to be in operation by January 1st, but others may

come on later in the year. Two applications for new preferred provider

organizations have been received but none for medical savings accounts, the

plan which could have great appeal if properly marketed. Of course, MSAs

don’t offer insurance carriers the income generated by other plans. Managed

care is a growing part of Medicare, but despite l-ICFA hoopla, enrollees in

managed care plans still make up only 17% of the Medicare population.

Intelligence tests are biased toward the literate.A woman who was eight months pregnant visited a medical center ER

complaining of a sore throat. The physician performed a blood test and throat

culture which revealed Hemophilus influenzae as a source of her infection.

He prescribed a fluoroquinolone antibiotic after consulting the Physicians

Desk Reference (PDR), which noted a warning against using the drug for

children or pregnant women. That evening the patient noted some shortness

of breath and dizziness, and the following day a routine OB checkup revealed

that the fetus was dead. The patient sued claiming that the drug led to an

allergic reaction that caused the death of the fetus. The trial judge refused the

patient’s request that the jury be instructed that the warning in the PDR be

accepted as the standard ofcare. PDR entries are written to comply with FDA

requirements, to provide useful information and to limit the manufacturer’s

liability. The court ruled that failure to adhere to PDR warnings, by itself,

does not constitute negligence.

Everything is still the same. It’s just a little differentnow.

Louis Harris and Associates recently surveyed the public in regard to

occupations and how they are held in public regard. Doctors are at the top of

the list at 61% (up from 52% in 1997) of 17 occupations. This is the highest

score doctors have achieved since 1977. Pollsters believe that the numbers

reflect a growing recognition that doctors are the primary advocates for

patients in disputes with health plans. For two years in a row doctors have

beat out scientists for number one. Teachers, the clergy and police officersmake up the rest of the top five, while at the bottom in public esteem are

journalists, union leaders, accountants, bankers and businessmen. No men

tion was made of lawyers, but then the list only went down to number 17.

If you think the problem is bad now, just wait until theysolve it.

Today’s doctor of medicine must get the undergraduate degree, struggle

through four years of medical school, devote three or four more years to

specialty training, and then get challenged by a patient who has made his own

diagnosis off a web page. In some parts of the country, fully one-third of

Americans get their health information on-line. Moreover, the patient may

arrive with a copy ofa piece downloaded from an organic food magazine, and

ask you to discuss it. Whether the article is useful or not, the confrontation

demands an extended conversation. And now, it’s the retirement population

that is computer surfing. When their semi-monthly dose of Viagra has worn

off, they sit down at the computer, and these are the people with diabetes,

cancer, high blood pressure, glaucoma, urinary retention, arthritis, emphy

sema, alopecia, gout, ad nauseum. Remember those pre-computer times

when B. Gates was merely a German greeting?

If a light sleeper sleeps with the light on, does a hardsleeper sleep with...the window open?

Just a few months ago Pfizer executives were celebrating in conference

rooms as their impotence drug Viagra was rolling at 300,000 prescriptions

a week, a figure unheard of for a new drug, thanks in part to the media

coverage. Sales in the second quarter were $411 million, but in the third

quarter dropped off to $115 million, far below projections. “We all miscal

culated the demand.” So, what happened? Analysts stated that worries over

adverse reactions, including death, slowed things down. “My wife worries

more than it worries me.” The FDA has received over 100 reports of severe

adverse reactions, such as heart attacks, strokes or death while taking Viagra.

Still, it is impossible to know how many events are actually related to the

drug. Also there is the limited action, or as one man said, “It’s a Disney ride

with an hour of waiting for a 2 minute ride.” Also, the related impotence

problems of relationships, depression, and other health factors, do not

disappear, as some expected. Of course, there is no reason for Pfizer to be

disappointed since the current use is at 170,000 prescriptions each week, and

the drug will be around indefinitely.

If you’re already in a hole, there’s no reason to continuedigging.

The Health Care Financing Administration’s bundled fee for the facility

and the corneal tissue for penetrating keratoplasty performed in ambulatory

surgery facilities goes far beyond a cut. The proposed reimbursement bundle

of $1648 for the two components would bring PKP surgeries to a halt in

ASCs. The cost of donor tissue alone ranges from $1400 to $1800 from the

eye bank, and that figure is often subsidized by charitable donations. This

would leave the facility fee unmet. The American Academy of Ophthalmol

ogy, the American Society of Cataract and Refractive Surgery and Eye Bank

Association of America met in mid-September with officials of HHS and

HCFA in an attempt to alter the proposal. Medicare reimbursement sched

ules for ASCs are paid for from Medicare part B, while hospitals are paid by

part A where they simply add on charges for goods and services.

Addenda+ Queen Victoria smoked marijuana to cure her cramps.+ I admire our Congress. Everything is in the 70s; the temperature, the

ages, the lQs.+ Is it illegal to charge admission to a free-for-all?Aloha and keep the faith — rtsR

HAWAII MEDICAL JOURNAL. VOL 57. DECEMBER 1998

750

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PH I LI PSSt. Francis Medical Center Maybe you’ll never need an MRI.ASubsdiary of St. Francis Healthcare System of Hawaii But if you do, try us on for size.

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