HAWAIIMEDICAL

JOURNALApril 2002 Volume 61, No. 4 ISSN: 0017-8594

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EditorsI dHor: Norman Goldstein Ml)

Nerr Ednor: I-lenrv N. Yokoyama \ U)Contributing Editor: Riessell 1. Stodd Nil)

Editorial BoardJr’hn Breinich MLS, Satoru Izutsu Phi).

Dourrl.ts G. Massey M[), Myron P. Shhasu MD.Dank I... Tahrah MD, Alfred D. Morris Ml)

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Contents

The Phrase: “No Ifs, ,rids, or Buts” and Cognitive Testing,Lessons from an Asian-American community.Ojcior G. I/a/sour Ml), Ia/total H. Macok) Mi),

EditorialVomurtt (4 i/u.s re/ti ill) 64

Lrologic Complications of Placenta Percrcta Invading the Urinary Bladder:A case report and res jew of the literatureRoir’r- 111 lieu kit ill.) uuuul 1 iutandui Ru-It/lit ii (iii

Chylothorax and cirrhosis of the liver: A case reportBlake }osh,d i/St/It rid Intw hi Jo/w ihi Nil)

and Patricia L. B/am 1 Ire /111), iN/PH 72

Medical School HotlineSaudi Tin/ut/a’ ilk) aitul ( ‘u,dtr Be/I .1-il) 75

Cancer Research Center Hotlineitt/itt .S. B1’t’tt’ittt P/ti) 77

Classified Notices SI

WeathervanePusan/I T Stodd iIii) 82

1 ( or er art by Dtctt’ich Vitrei. N ttle:trto. Hrtwati. All rttrhls

resers rid h the arttal.

‘(1 I’i

Reters 10 spearinu Fish.

63

Editorial

Norman Goldstein MDEditor, Hawaii Medical Journal

Office and Emergency Room Violence

According to John Nicoletli PhD, a police psychologist and authorof Violence Goes to School: Lessons Learned from Columhme

I unL I 9’s9 md \ lolL n CioL 5W COllL Ilk \uthoi it mtn CJuidLto Prex ention and Interx ention (()ctober 2001 t. ‘‘Sur\ ivors oIx ork—

place violence have one characteristic in common: the were prepared for it. xx ith responses and communication systems in placebefore the violence occurred.

‘‘Surgeons and other physicians often lix e in a xx orld of den alThey don’t consider the possibility that their patients would become

iolent or that anything would happen in their office. So a lot of

times, they’re caught off guard. They have no real safety proceduressetup and no way of notifying otherpeople in the office that a violent

act is occurring.”1Violence in our local hospitals and offices does occur, We usually

see briefreports of these incidents in daily newspapers. Majorevenissuch as the Xerox Co. shooting make headlines internationally. Amanager of one of our major hospitals sax s. “Violence in our

emergenc\ room is not common, but we are seeing more of it.” Datafrom our police departments about the incidence of violence inmedical offices, hospitals. and emergency rooms is not available and

is not being collected.A study in the Annals of emergency Medicine found that violent

events are frequent in emergency departments and that educationalprograms might reduce the number of cx ents at least temporarily.hut do not clearly reduce violence in the long—term.2

Despite the fact that we cannot prevent all violence in emergencyrooms and offices, we must prepare for the possibility that it canhappen:

• The prex alence of handguns and other xx eapons - as high as 25

pei’cent — among patients. their families. or friends. The increase—ing use of hospitals b\ police and the criminal justice systems br

criminal holds and the care ofacutel disturbed, violent mdix idu

• The increasing number of acute and chronical l mentall\ illpatients now being released from hospitals without folIos’, up

care, who now has e the right to refuse medic inc and who can nolonger he hospitalized involuntarily unless they pose an immediate threat to themselves or others

• The availability of drugs or money at hospitals, clinics and

pharmacies. making them likely rohher\ targets

• Situations and circuinstantmal factors such as unrestricted mox e

incnt of the public in clinics and hospitals: the increasing le’f gang member’, drug or alcohol abuser’., trauma patients. or

distraught familr members: long waits in emergency or clinic

areas, leading to client t’rustration over an inability to obtain

needed services pmmptlv

• Low staffing lex els during times of specific iticreased actix itv

such as meal times, visiting times, and when staff are transportingpatients

• Isolated work with clients during examinations or treatment

• Solo work. olten in remote locations, particularly in high—crimesettings. xx ith no backup or means of obtaining assistance such ascommunication des ices or alarm s stems

• Lacking of training for staff in recognizing and managing escalating hostile or assaultive behavior

• Poorl lighted parking areas

The Occupational Safety and Health Administration (OHSA) hasdeveloped violence prevention guidelines for reducing workplaceviolence for healthcare workers. The Guidelines for PreventingWorkplace Violence for Healthcare and Social Science Workers canbe found in GOVDOC L 35.8:H 34/2. 1996. This related referencescan be found in the Hawaii Medical Library.

At the ver\ least, you should form a plan for your own office or

clinic. According to Dr. Nicoletti. attack notification measures arevital. Sonic offices and emergency rooms use a PA system. Hestrongly suggests to use common codes for trouble. Under

duress, people don’t remember the codes. Clarity and brevity arenecessary. He advises “shots are fn’ed in the reception room. etc.Prompt notification of law enforcement agencies is obvious, butsome telephone systems do not get right to 911 . You may have to dial9 first. Putting a sticker on each telephone will help: “Emergency911” or “ e’9-l’. Train all staff members to be aware of

possible incidents; be knowledgeable about unusual behavior and beprepared for it.

Since the other 911, the September 11th terrorism attack, metaldetectors are more commonly seen in public and private buildings.A study at the Vanderbilt Unix ersit Medical Center in Nashvilleins estigated patron I i.e. parents and relatives of pediatric enlergencvroom patients) attitudes about metal detectors in emergency rooms.It concluded “fear that patrons will he disturbed or that the presenceoi’a metal detector reflected negatix clv upon the institutions appearto he untounded.

Just as xx e are noxx preparine for biological and chemical terrorism, physicians should also prepare for office, emergenc\ room andhospital violence,

ReferencesJoshua, C PrePlan for inOffice Violence from Emi.ioyee, Pahent, Doom Aura Times :25, 2002 March

2. Fernandes, CM. eta VIolence ED. Studs aroup. Ann Errrero Med3gl’ll:47’55. 2002 icc3, Matfox. at ai. Pod Emero Care 16i3ii635.. 2000 Jen.

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Brian Souza

Urologic Complications of PlacentaPercreta Invading the Urinary Bladder: Acase report and review of the literature

Robert Washecka MDk and Arnanda BehHng*

Abstractlrn7oclij53on

Placenta percreta 53 ading the ur/nary Oladoer may cause hemor

rhagic shocs, hemattria and urn/ogic complcatons at parturition,

Ths ret rospc:cti, a sun eyotS4 parents rcy cc n’aterna character

5(5 _‘

MethodsThe first reported case 01 placenta nercreta with urinary h/adder

iris asiori in Hsaaii 15 presented. tvied!rie searcn and rterature

reviess dentttieo an additional 53 patients. A meta-anaiusis oiai/5-l

cases was performedResultsHematuria was present inittaily in 31% f 17 5% parents Of These. 9

of 17 required transtiision support. A preoperative diagnosis was

established by ultrasound or MRI ir 33% of patients. Cystoscopy

was performed in 12 patiots ano did not make a preoperative

diagnosis in any pa/rent. 39 urologic comp/Thatrons included b/ad

der laceration 26%, urinary fistula 13%, gross hematuria 9%, ure

feral transection 6%. and small capacity bladder 4%,

Partial cystectomy was performed in 44% (24.54k Three mater

nal deaths and 14 fetal deaths occurred. Only 1 patient subse

quently had a delivery,ConclusronReadrly io:entrfrabio risk lactors by history are important to suggest

placenta percreta in pregnant patIents with gross hematuria. Ultra

soundanOorMRi can establish a prcoperative dragnosrs. Custom

copy did not ‘dentrfyanypatientpreoperativeiy. Partial csstectomv

ik commonly reourrea tor extensive or deep Oladder invasion.

IntroductionThe placenta is a pels ic organ of wicommon urologic concern. Yet.

abnormal placentation with urinary bladder involvement may cause

essanguinatine hemorrhage. hcmaturia and urologic complications.

Placenta percreta or accreta is an adherent placenta that des elops

beyond the myornetrium due to a del icient Nitabuchs membrane or

absence of local ileeidua ha’alis, It may invade the urinary bladder

or cont guous organ’ The rep ned incidence of placenta percret a

varies from I :3.333 to I :400.00(1 births. Cesarean section, placenta

previa. multiple pregnancies and uterine trauma are risk factors for

placenta percreta: We present a new patient and review 53 addi—

Conesporrbence.Robert Washeoka MDK5ser Perrn:anenteDeoarrrre’-: ci

Hew/u, HI 96819

tional reported cases with bladder invasion.’4 Due to the rarity of

placenta percreta no single institution will accumulate a serie’. we

therefore present a meta-analysis to discuss maternal characteris

tics, surgical management, urologic complications, and outcomes of

this challenging clinical problem.

Case ReportA 3$ near old woman 65, P3 with a historr of 3 previous cesarean

sections presented ‘.s ith vagmal bleeding at 28 weeks. Evaluation b

ultrasound revealed placenta previa. The patient was treated with

bed-rest At 34 weeks vacinal bleeding increased. Cesarean section

and hysterectomy were performed. The bladder was densely adher

ent to the lower uterine segment. Severe hemorrhage ensued with

placental dissection .A bladder laceration occurred and ses crc

hematuria and clot retention developed. \ cvstotomy tube was

inserted. An intraoperative diagnosis of placenta percreta with

bladder invasion was made. The patient was unstable despite 36

Linits of PRBCs. 24 units of platelets. 6FFP. and 10 err oprecipitate

tor an estimated blood loss of 25 liters. The patient’s wound was

packed and then closed 2 days later. 46 units ofPRBCs. 20 units FFP.

20 units crvoprecipitate. and 43 units of platelets were given in total.

Subsequently, both the mother and child were discharged from the

hospital.

Literature ReviewMean age at presentation was 31 years (range I 9 - 42 years). The

mean gestational age Cs as3t> weeks range l4-39. Ninetr -four

percent had had a previous cesarean section Sixts—si\ percent were

at least gravida 4 (range 4-14r Only’ 3 of 54 patients were

pruiy’ras idae.Bleeding was the most common presenting complaint. Vaginal

bleeding occurred in 26 of 54 (48’-ks. Hematuria was found in 17 of

54 01% : three cuts had onlr microscopic hematuria. Due to

bladder hemorrhage 9 of 1 7 53%) required transfusion support

(range 2-I 1 UPRBC). One preoperatise diagnosis was made based

onlr on clinical presentation. 01’ the I 7 patients with hematuria. 9

had a prei perati e diagnosis established by sonogram or \ I RI.

Ultimately 8 of 17 patients with hematuria had a partial cystectomy

and eesarean hr cterectomv. Table I enumerates “ill presentations.

Eortv—sis patients had preoperative soflograhlis while S had IRl.

Placenta previa was identified in 38 patients. Ewo had placenta

previa plus hemorrhage and 1 had placenta previa plus a maccrated

fetus. Eighteen percretae \s crc dent i tied pre perati veIn Blood

clots in the bladder were seen in 6 patients by sonographv.

66

Cystoscopv was performed in 1 2 patients. Two patients hadcvstoscopy plus irrigation. One patient had 3 csstoscopies plusbladder hiopss which resulted in e\sanguinatinc hemorrhage andemergency by sterec tomv. One patient underss ent 2 cvstoseopic clotevacuations and fulguration and developed uncontrollable hemorrhage at the second lulguration . Another patient had 2 cvstoscopicclot ev,ieuatlon’ The initial exanunation was normal, however, thesecond clot es acuation released bladder tamponade and attemptedfulguration was unsuccessful. Endoscopy res ealed active bleeding(4 patients), niarked vascularitv (2 patient). exophtic growth (Ipatient). erosive lesion (2 patients). granular lesion ( I patienti. anda normal examination (3 pitients Surgical management is listedin Table 2. Significantly, 2 1 (39( patients had partial cystectomyand cesarean hysterectomy. Fourteen had bladder repair plus cesarcan hysterectomy. Cr stotonrs was performed in I 2 22% andureteral reimplantatiun in 3 patients. Hvpogastric ligation in 19t35%) and packing in 7 (13%) were adjuncts to control hemorrhage.Ancillary urologic interventions included exploratory laparotornyplus partial cvstectoinv (2. ileal cvstoplastr ( I . nephrostomr andJJ stent I delased hvsterectomr . partial cvstectomr and bilateralureteral reimplantation (1).

Hemorrhage is a conspicuous feature of placenta percreta due toheniaturia and attempts to resect an invasive placenta. The meanblood loss was 5.570 ml (range I .500 — I 7.00)) ml) in 7 patients andmean replacement was 24 units (2-115 LPRBCj in 30 patients.

Urologic complications are enumerated in Table 3. Bladderlaceration was the most common problem occurring in 14 (26%followed by cross hematuria in 5 (9% . vesicovaginal fistula in 5(9%), and vesicouterine listula in 2 (4%), Ureteral transectionoccurred in 3 patients, 1 unilaterally and 2 bilaterally.

Three maternal deaths and 14 fetal deaths occurred. Maternaldeaths occurred at 2t). 35. and 35 weeks secondary to hemorrhagicshock, Two died during surgery and one expired four hours postoperatively. All 3 had had subtotal hysterectomy. Fetal deaths occurredat Il, 14. 16. 16. 20. 20. 20. 22. 22. 24. 26.26. 27 and 27 weeks ofge stat ioi i.

In 3 patients with retained placenta. significant ur()Iogic complications developed. Two developed gross hematuria and shockrequiring partial cystectomv at postoperative day I and 2 monthspostpartum. One des eloped multiple pelvic abscesses. ()ne patienthad urinary ascites due to a 5 esicouterine fistula. Only six patientshad their uterus conserved, Two developed vesicouterine fistulas.Two underwent delayed hysterectomy at 2 and S weeks postpartum.One patient had methotrexate and suction currettage postpartum.Se\ crc hemorrhage ensued. ilecessitatine hysterectomr

. partial crtectonw and ureteral reimplantation seven ss eeks after delivery.Only one patient subsequently had a delivery.

DiscussionPlacenta percreta with urinary bladder ins asiou is a critical urologicobstetric cmergenc with a maternal and fetal mortality of 6% andI 9’ respect ts dr. lr mpt rccoen it ion and treat inent are paranu muto minim i/c maternal mortalitr and murhiditr This rerrospectis eseries confirmed multiparitv. multiple cesarean sections, placentaprevia, and utei)ne trauma as risk factors for the development ofl)l acenta pe rereta sv it h bladder ins asH m

A preoperatis e diacno’.is wa established in 35’ I o/54 of

Table 1 .— Clinical Presentation

Clinical Presentation # of Patients % of Patients

Vagina: Beedg 26 48%Hematuria 17 31%Abdominal Pa,n 7 13%Elecated APP 2 3%P’eeciarnpsa 2Pmmaeure R.oni’e o Mm’brares 2 4%Hyperemesis graedarum 1 2%Retroplacental Bleeding 1 2%Premarure Labor 2%

Table 2.— Surgical Management

Procedure # of Patients % of Patients

Cesarean Section 39 72%Parhal Cystectomy

C-Hysterectomy’ 21 39%Hypogastric Ligaton 19 35%Bladder Repair+ C- Hysterectomy’ 14 26%Cesarean Hyserectomy 12 22%Cystotomy 12 22%SPTube 9 17%Hypogastric Catnetenzation 3 6%Re!mptant Ureter 2 4%Packing 7 13%Bladder Repair 1 2%Bladder Uterus Repair 1 2%JJ Stent 1 2%Ureterolithomy 2%Cesarean Hysterectomy + Abortion 1 2%Hysterectomy 1 2%Splenectomy 1 2%Median Sternotomy 1 2%Tracheostomy 1 2’sHysterotorny 1 2%‘C-hysterectomy = cesarean

hysterectomy

Table 3.— Urologic Complications

Urologic Complications # of Patients % of Patients

Bladder Laceration 14 26%G’css Her=at5;a 5 9’,ljTl 5\!es7o.:ac—a: a 5Ureierai Transection .3 9%Small Capacity Bladder 2 4%Vedcouterine Fistula 2 4%HOrDneD’OSS ‘ 2-:.

Bladder Caaus r 2%

67

patients almost invariabl by sonography or N.IRI. L Itrasound is the

preferred modality for evaluation of third trimester bleeding. On

ultrasound, criteria for an invasi\ e placenta include: I) absence of

the norrnall\ visible retroplacenial sonolucent space. 2) presence of

unusually large dilated essels extending from the placenta through

the mvometrium, 3 thinning or disruption of the linear hyperechoic

boundary echo representine the uterine serosa and is interface with

the posterior wall of the bladder and. 4 local nodular protections

be ond the expected plane or the bladder. Neither ultrasound nor

MRJ predicts the degree of bladder invasion found at surgery.

Although 3 I % of patients had hematuria. cvstoscopv was per—

lormed in only 12. Hos ever. endoscop did not establish a preop—

erati\ e diagnosis in an patient. Bladder biopsy can lead to severe

hemorrhage and should he avoided. Clot evacuation may release

bladder tamponade and cause exsanguinating hemorrhage from the

dilated sinusoids of the invasive placenta.

Urologic management had been predicated by the extent. depth.

and location of the invasive placenta. Twenty-one of 54 patients had

immediate partial cvstectomy and cesarean hvsterectomx. An addi

tional 3 patients had a delayed partial cvstectonlv at postoperative

day I and 2 months postpartum for severe hematuria. The third

patient required partial cystectomy after failed conservative man

agement with methotrexate and attempted suction currettage 7

weeks postpartum. Of the patients treated ith partial cvstectom

subsequent complications include 3 vcsicovarinal fistulas and I

small capacity bladder requiring ileal cvstoplast . Bladder repair

was needed in 16 patients to treat 14 lacerations and minimal or

small volume placenta percreta. Of these patients. one patient

developed a bladder calculus from esical sutures. Gross hematuria

occurred in 5 patients. 2 of whom reqtnred partial cystectomy. Two

vesicovaginal fistulas developed in the bladder repair group.

Thirty—nine urologic complications developed in 54 patients with

bladder involvement h placenta percreta. I .ate complications iii—

eluded small capacity bladder (2), gross exsanguinating hematuria

(I). vesical calculus (I), and bilateral ureteral transections (I). lleal

augmentation cvstoplastv. partial c stectonlv. partial cvstectomv

plus bilateral ureteral reimplantation. and stone removal were per

formed in I patient each. No maternal deaths, hut 6 fetal deaths

occurred in patients with an established preoperative diagnosis. Of

this group urologic complications included ureteral transection.

VTl. and hematuria (I patient eachr

The surgical management of placenta percreta requires an explor

atory laparotomy through a vertical midline incision under a general

anesthetic. Disappearance of the cul de sac between the uterus and

bladder and presence ofo erdes eloped blood sessels running on the

serosa of the bladder and uterus provides isual con) irmatmon.

Cesarean section should he performed as far from placental insertion

as possible. Initial dissect ion of the placenta should he avoided,

Severe heno rrhage often requires hy terectom\ With anterior

placenta percreta subtotal h sterectomy should he avoided since

most arteries (that is cervical, vaginal, and vesical) remain uncon

trolled and reoperation rates approach 9fl( in these patients.

yloreo er. in three maternal mortalities all had a subtotal hysterec

tomy and died of hemorrhagic shock, A posterior approach mobiliz

ing the uterus by dividing the uterosacral ligaments and entering the

vagina posteriorly is recommended.-’ B\ retracting the meters

laterally and the uterus muediall . uterine essels and pa1mn1etria

medial to the ureler are ligated from cephalad to caudad direction.

Early cystotomy is a useful adjunct to identify tissue planes. With

minor bladder invasion, simple bladder repair was performed in

nearl 25 of patenn. With extensive invasion extirpation of’ all

tissues invol\ ed is important to avoid delayed complications. Partial

cstectom with hysterectomy was ultimately necessary in 44f (24

/54) of the patients. Isolation of the posterior bladder suture line from

the aci nal cuff by omental interposition will minimize fi stula

form at ion.

In obstetrics the optimal management of placenta percreta is

controversial. In a survey of 335 members of The Society of

Perinatal Obstetricians 69cr opted for consers ative management

vith the placenta left in situ after delivers of the fetus when the

bladder was involved:’ Yet in a review of 109 recent cases of

placenta percreta surgical removal of the uterus and involved tissue

was performed in )3c ( 11)1 cases) and conservative treatment with

the placenta let in situ after dclix er was performed in onE 7’

cases Moreover the single greatest factor affecting outcome yvas

fhe antepartum identification of abnormal placentation. That is

possible b\ ultrasound in StY of patients.

ConclusionReadily identifiable risk factors by history can suggest placenta

percreta in preenant patients ‘.x ith gross heniaturma. A preoperative

diagnosis can he achieved by ultrasound in 5(Y/ of patients and can

decrease morbidity, Partial c stectomy for extensive or deep blad

der invasion is commonly reqtured and decreases urologic compli

cations. The clinical presentation. location, extent and depth of the

bladder invasion will dictate the degree of urologic reconstructive

surgery. In the retrospective series cystoscopy had minimal diag

nostic and therapeutic value.

AuthorsRobert Washecka MD. Departtnent of Surery Unixersity of

Ha au John A Burns School ot Mcdicmne

\manda I3ehling.l_ ni LI sit ot Hass aim John .\. Burns School ol

\ledici ne

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to oac nta ire-’ -p It S D J M d 48 ‘.-1-12 1995E a cimR Knan R B n R ..ra M r’ Pa ni percre’.. t I ntraQtu e he vie’ ‘ a

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69

Chylothorax and cirrhosis of the liver:A case report

Blake Yosh.da MSlll’ and Jinchi Tokeshi MD

AbstractChy/othorax ccurrino in the setting of a lymphoma or a surgicalomcecue [r.Q.’rQ me .aa arcra ‘‘ doct s a 1

KflOfl oOe emenon. Less coni!YioP rS 100 OccLJrre000

cor?junct’err Odo “çç .f ,‘ Doe to toe DaucS

‘5 c c ‘ lot’ 0 x s a essoc aw C ‘ran uvoer ueSign of cirrhosts. The case reports in toe literature favor the former,

as demonstrated in this case of a patient with cirrhosis of the ltver

who deveiooed a chyorhorax

Case PresentationThis is an i I —ear—oId male with no prior history of significant

medical illness or surgery who several months prior to admission

presented to his primary care physician’s office with mild abdomi

nal distension and abnormal liver function tests An upper abdorni—

nat ultrasound was performed and demonstrated cn’rhotic changes

of the liver. splenomegal and a 3.4 cm heterogeneous echogenic

solid mass in the nght lobe of the liver, Abdominal CT scan

confirmed these findings and raised the possibility of a hepatoma. A

liver gallium scan revealed no significant uptake of gallium by the

liver. Spironolactone decreased the distention and the patient lost

weight. A repeat CT scan 3 months later revealed an increase in the

size of the us er tumor 103.7cm and laparoscopic exploration of the

patient’s abdomen was recommended. At this time, the patient was

still asymptomatic.On physical examination, the patient had several small spider

anutomas on his chest wall but no other stigmata of hepatic dvsfunc—

lion. On the abdominal exam there was mild distention, a slightl

finn. non-tender liver palpable below the costal margin in the

midclavicular line and a fluid wave. Trace/I + edema vs as noted in

the lower extremities. The rest of this patient’s physical examina

ti(n was vs ithin normal limits Alpha—fetoprotein was 4.( ng. total

hiliruhin was 0.5 mg/dL. albumin vs as 2.X sin/dL, prothrombin time

was 13.3 seconds, activated partial thromboplastin time was 29.2

seconds, International \ormaliied rat io was 1 .0. complete blood

count and electrolytes were within normal limits,

A laparoscopic exploration was performed and ultrasound guided

biopsy taken. Biopsy revealed well-differentiated heparocellular

carcinoma vs ith changes suggestive of cirrhosis. \k ith this finding

radiofrequcncv thermal ablation treaintent was perldrnied. Ap—

proxirnatelx 500 in L of penn meal fluid was noted during the

surgery.

Ccr’esoomence.12

1451 South Kha Street, 209Honoi,u)u, Hi 96814(808) 5496221

Post—operatively the patient began to complain of shortness of

breath, a productive cough. and pain on his right thorax upon

inspiration. Crackles vs crc heard in his lungs along with decreased

breath sounds and his abdomen was still distended hut non—tender.

The assessment was post-operative ascites and the patient’s spirono—

lactone dosage was mcreased arid respiratory therapy was ordered.

The patient’s condition did not improve over the next few days and

a chest x-ray revealed increased pleural effusion. An ultrasound

cuided thoracentesis was performed on the patient’s rtght hemitho—

rax and 1.5 L ofdark ellow clear fluid was aspirated. A repeat chest

x—ray revealed a significant decrease in pleural effusion and con

firmed placement of the internal jugular catheter tip in the proximal

superior vena cava. An abdominal CT revealed no ascites, The

patient’s condition improved.

Approximately 2 days following the rhoracentcsis, the patient

again began to become increasmglv short f breath and coughing

recurred. Pleural effusion began to reaccuniulate in the patient’s

right pleural space per physical examination and chest x-ray. 1-us

abdominal distention increased and he developed a 12-15 cm

h drocele of his scrotum. A second ultrasound—guided thoracentc

sis was pcrfarmed on the right side, 2 liters of cloudy fluid were

drained, and a chest tube was placed. The placement of the chest

tube was assessed radiographically revealing no pneumothorax.

Pleural fluid was sent ft)r analysis. The chest tube was kept in place

until the fluid stopped draining.The patient’s condition impros ed dramaticall\ after the second

thoracentesis. His activity level increased, he was weaned oft’ of

oxygen, his abdonii nal distention decreased and his hvdroce Ic

resolsed. The chest tube continued to drain a cloudy, milky fluid.

Analysis of this fluid revealed 399 ing/dL triglycerides’’and no

bacterial growth consistent with a chvlothora. Diet was switched

initially to fat restriction then to TP. The color of the drainage

chanced front milky vs hite to sti’av—c l wed and over the next two

weeks the olume of’ f’luid drained dai l\ decreased. The chest tube

was clamped then removed and on the 31 ‘ post-operatis e day the

patient was discharged from the hospital.

DiscussionA c h\ lothora\ is diagnosed vs hen the pletn’ttl fluid has a triglyceride

les el ei’eater then 110 nigidl a pleural fluid to serum ti’iglveeride

ratio higher than I. and a pleural fluid to serum cholesterol ratio

lower than I . It is often common practice for physicians to rely upon

the cross appearance of the pleural fluid to make the diagnosis of

hvdrothorax or chvlothorax. hut this may not alwaxs hold true, In

a series f 2—f patients with confirmed ehylothorax reported h\

Romcro et at. 14 were milky .5 were bloody. 3 vs crc turbid yellow.

md 2 wrc. ek. ii vullovs Only SSC of the patient s di mined th

70

classic mi lk\ 55 hite llrnd. Thus the common assumption that astraw —colored pleural fluid is n nchvlous ma\ contribute to chv—lothorax bei ic underreported.

The ii oracle duet norniall cons e\ s between 150(1 and 50t( mLof chvle dails so a leak in the ft niphatic system can has e majorphvs ioloe1c repercussions. I oss ol excess anlounts of ch\ Ic can leadto malnutrition. \s ater and electrol\ te loss. h polipidenna. andimmunosuppresslon. The causes of chylotfora\ include tumor5$( ti nm 2ij idiopuhft t 1 mdmiscll liLOi () 01tumors, ft mphoma is the cause of chylothorax 75( of the time.Traumatic causes include cardiovascular and thoracic surgical procedures. esophageal resections and transhiatal resection, Non-surgical traumatic causes documented in the literature includenonpenetrating trauma in which the spine is hvperextended or avertebra is I ractured afterthe ingestion ota fatty meal. ss eight lifting.Ntrainine scs crc bouts of coughing or s onliting. childbirth, and

icorous stretchmg while \ ass nnsc.Chvlothoiax is the most conunon type of neonatal pleural effu

sion. These chvlothoraces mar be due to rupture of the thoracic ductfrom trau ma during del iver\ u— des e lopmental abut irma Ii ties ofthe thoracic duct.

Just :is a hr do thorax can an sc I rum ascites a chr liii 1i )rax mayalso originate from chylous ascites. Also. chr Ions ascites mayoriginate from cirrhosis of the liver and this is thought to occur in 6f4of patients with cirrhosis. This combination of cirrhosis. chvlousascites and ch lothorax is an unusual finding. Its rarity precludesany accurate estimates as to its actual incidence hut one author hasestimated that up to I f of chslothoras cases are caused hr cirrhosisof the lis er. Attother author stated that 2O (5 out of It of theirpatients ss oh chr loihorax had cirrhosis as the main cause.

The proposed meehanis ni is that increased portal hr pertensionsecondarr to cirrhosis of the liver mci-eases the flow and thuspressure into the hepatic lymphatic system and this pressure istransmuted to the thorac ic duct causing transudation of chr Ic intothe peritoneal cas tv producinc ch\ Ions ascmtcs. This ss as proven inpart by Dunu mt and Mulholland w ho showed that ft mph floss in thethoracic duct is markedly increased in patients with cirrhosis.Alternatiselv, exceptionally high pressure together with degenerative changes in the splanchnic lymph vessels may lead to rupture ofsmall lvmphaties and leakage of whole intestinal lymph into theascitic fluid. This ch bus fluid then enters the pleural cavity viamicroscopic anatomical defects in the diaphragm. Cirrhotic chylothoras ss as aks ass a transudate according to Light s criteria andthe- pleural ci fusions is almost alss ar s on the right side

In the case presented abuse tIme patient had cmnhosi of the liver.pleural ctlusion and ascites Tlit’r,icentesis was pci’ionued twice butunIv fluid to tm the second t was analr icd. The ascitesdecreased folloss in aspiration ot leural fluid demonstratinc anopen comuntunication hetsscen the pcritoucum and the pleural cayitv , A5 stated above, the gross appearance is not alw a\ s a reliableindicator of a pleural fluid being chr bus or nonchr ions. Thus twopossibilities exist for this patient. The fIrst is that ss e assume thepatient’s pleural effusion was initially ehybous even though the firstthoracentesis did not reveal fluid of a milky white color. Then thepath.og.e.riesis of the c.hyiothorax ss. onid be. as described alnove wh.e.re.the increase n prcssu in the portal system secondarr itt cirrhosisof the lis en i ransterred to the is nphatic system and mrausudate

from the Is mphatie system enters the peritoneal cavity Since thispatient had pust reeeis ed RITA to the lis er. the liv er capsule andadjacent diaphraciu might have undergone inflainmatorr- changesincluding, increased vessel permeahilitr. further facilitating tImetransfer of Iltud from peritoneurn to pleural cay tv.

The second possihilmtr is that the patient’s original pleural cffu—smon vs as not chvious and that the ehylothorax did not develop untilses eral days into the patient’s hospital course . Again, the first taprevealed strasv—colored fluid and not milkn fluid hut in this scenariowe are assuming that initial l the fluid is nonehr Ions, Nonehylousascites is a relatively more common complication of cirrhosis of theliver svhen compared syith chylous aseites. As has been previouslydemonstrated and is now ss elI known, unidirectional flow ofascitesfluid ihiough diaphragmatic defects into the pleural space in patientsss ith cirrhosis can occur causing a hydrothora in association vs ithcirrhosis. This pleural flLimd mar h0ye turned chrIoLis after theseveral dar of couching the patient had after the first thoracenmesis.Hem-c a I though the ascites did not originally contain clix be. chv Ic marhas e started to accumulate ss i thin the pen toneal cay i tr when theincreased mntraahdominal pressure secondary to cotighing damagedthe Ir mphatic vessels that s crc already under incm’eased pm’essunel’i’om the cirrhotic liv er.

it is also possible that the ehylothorax was secondar to traumafrom thoraeentesis, NnimeroLms thoracie duct anomalies have beenreported and the existence of such an anomaly would certainlyincrease the chance of a traumatic etiobog. Nevertheless, boththoracenteses were pert orined under ultrasound guidance and assuch the combined probahihmtr of having an anomaly of the thoracieduct and also damaging it during an ultrasound—guided thoraeentesisis highlr unlikelr -

One last assumption has to be made in order for all of this to hetrue. The iscites fluid ss as never analyzed or visualized directly.Yet. ss e may assunie that the aseites fluid was ideimtical to the pleuralfluid and tImat the two were in direct connection with each other sincethe decrease in aseites ss as sr nehronous with the decrease in pleuralfluid.

ConclusionA eh bothorax secondary to cirrhosis of the liver is a rare finding. Inmost instances the diagnosis of chylothorax will be grossly- evident,hut at other times a high degree of suspicion yvill he needed Sincethe treatment of achvlothorax does differ slightlr from the treatment

of a hr drothorax an accurate diagnosis is critical. Therefore, it isunpom’tani ton phs sicians to know that their patients vs ith cirrhosis ofthe is em and a pleumal cffnmsion could possibly has e a chybothorax.

Authors

Blake ‘ oshida NISIII. L ins ersity of Hawaii. John A. Burns School0 N Icdmcmmme

--.Iinichi Iokeshm Ml). Associate Clinical Professor. Liiiversitn ofHawaii. John A. Burns School of Medicine

ReferencesH9erda Cl Chfothoraa and seudochyClthoran 0xr Ffeayfrj 1997; 10; 11571162Murray 1-CldeI Textbook of Reafratory Mx.dClire 35 Ed 0 B Saundera Cc. 2000

IO r5x 9_s a SJ a 95 as re 2O a Ku P a r S I 0 —nc Ca e i r g —

71

The Phrase: “No Ifs, Ands, or Buts”and Cognitive Testing.

Lessons from an Asian-Americancommunity.

Victor G. Valcour MD, Karnal H. Masaki MD, and Patricia L. Blanchette MD, MPH

Abstract77cc’ study assesseo the :i:nica.( ut:iitv of repeat%g the phrase 124

it, ands, or huts” tSr cognitive testing in Hawaii, 242 subects were

screened: 25 (10% 1 had cognitive impairrr7ent. 68% of a!! subjectscc 32

—-

IntroductionDementia is a chronic debilitating disease primarily ol’ the old.

\ hue pre\ alence rates art. most experts concur that the ‘ate

doubles approxinateir everr five rears from age sixty ‘[‘his ields

a dementia prevalence rate of greater than 30% for people over 55

years of ace.Appropriate care of patients with dementia requires early detec

tion which, in turn, requires sensitive screening tools. Maxiniuni

sensitivit\ I’or anr cognitu cc test must consider baseline abilitr to

communicate in the language ot the test and must recogni/e nuances

01’ various dialects that might affect testing. This latter issue is noted

in l-lawaii where the primary lancuage is English. vet other influ

ences. including cultural lactors andeducation. affect the expression

of tIns language and mar affect i’esults on cognitive tests. Not

i’ccognizing these aspects can lead to inappropriately labeling a

person with an acquired deficiency in memory and thinking when

none exists,The i’.land of I-Ian an have des eloped with influences from a

an niher of Asian and Pacific Island countruesc As such, a large

degree of cultural diversitr is present. Increased cultural diversitr

throughout the United States. particularly in the older population is

expected in the futtire.’ lessons learned from Hawaii concerning

cultu ra_l influences on cognitive testin ts ill become hroadlr impor

tant.e e aluated the clinical utilitr of the phrase “No if. rinds, or

huts” in the Foistein Mini—Mental State exam (MMSE). Folstein

Covesponderoe to:Vfotor 0, 24oour MD,Asshtant Professor of Mediotog

347 Kk. t. Street

originallr described his \ Iini—\leiital State Exam in I M’75.— ‘[‘he

population described consisted of psychiatric ard iripatients and

ambulatory elders from a senior center in New York State, The

ethnic makeup of the population is not described, While normal

ranges for ace and level 0 education have been described pre i—

ouslv, little data are available concerning applicabilitr in culturally

di\ erse communities where English is the primarr latiguage,”

The phrase “No ifs, ands, or huts” is generally’ regarded as’a test

for two domains of cognition: attention and language. Since these

domains are important in normal human cognition, it isessential that

ther bees aluated pi’operly. In this study, e determine how well this

portion of t[ie Mini—Mental State Exam correlates with the diagnosis

of cognitive impairment in an Asian—American community. We

also evaluate the clinical utility of two other phrases from the

Cognitive Abilities Screenmg Instrument i CASt

MethodsThe study took place in a multi—physician group practice within a

predominantly Asian—American community of Honolulu. Hawaii,

A list ol’ all patients 65 rears of age or creater \as generated as

patients crc seen in a husr multi—physician gr mp practice. Si.ih—

seqnetttlr . patients on the list were called, in the oi’dcr that they v em’e

seen, and asked to participate in a one—hour inter\ iew by a geriatri—

cian, Further details of methods have been previously’ pnhlishedh

Participants sell—reported their ethnicitr . All parIicipant’ i’epoi’ted

sufficient languav’c skills to coniplete the cognitive testing mi En

glish.( ognition ss is tsscsscd h th. C o3tuti\c Abilutucs Sctccning

Instrument i( \Sl past memom s testin, md m clock di cx inc

task.” Participants also completed the Mini-Mental State Exam.

The (‘AS! includes several questb us that are part f the \I \ISE and

also tests other coe’nitls C’ domains not tested hr the MNISE. C-\S I

scores ranire froni 0 to 100, O erlapping questions on both the

MYISE and the CASI were not duplicated. However, in die writing

portion of the (‘ASI thee xaniinerdictatcs the sentence to be writteui:

“He ssould like to so home”. Participants are snnplr asked to scrite

it. In contrast, in the standard yIMSE, participants \vrite a sentence

oftheirchoosing. Forthis question, the C.-\Sl sentence Wus accepted

for the N! MSE despite this small difference. Notahl . the phrase “He

ssonld like to go home” i’ repeated prior to being written. ‘1’hu, the

ue of this pllr:tse for the written potion would not at’fcct th

repetition pn’tion.

12

In our study, all participants were asked to say the phrase: “No its,ands, or huts”. They were prompted with this phrase: “Listencarefully and repeat exactly what I say”. The phrase was stated onlyonce. Participants’ best response was graded. The phrase had to herepeated correctl\ to act full credit. including the appropriate use ofplurals.

The C.-\ SI e aluation requires repent ion of t\\ o phrases \ ohdifferent leels of difficulty: “i-Ic \\ould hke to go home” and “This

elloo circle iS heavier than hlue square ‘. Subjects were promptedvvith: ‘Repeat e\actlv ‘s hat I say.” Sentences s are stated only once.smoothl and vs ithout pause. The I irst sentence was stated in 2second’, and the second in 3 seeond’.

Screening tor the presence of depression svas included as well,using the ( eriatric Depression Scale—modilied I 5—question versionGDS— 15 and a ph\ sictain inters ess based on major depression

criteria from the Diagnostic and Statistical Manual, fourth edition

(DS\I-lParticipants identified a second person. usually a family member,

to pros ide subjective data on cognition. These proxy interviews

included a jorms and Korten 26 item Questionnaire, the BlessedActivities of Daily Living (ADL) assessment tool, the BehavioralPathology in Alzheimer’s Disease Rating Scale (BEHAVE-AD),and a questionnaire concerning occupational and social function)

A geriatrician provided an opinion reaarding the presence ofdementia uing Benson and Cummings criteria. Stage of diseasev as rated using the Clinical Dementia Rating scale (CDR),1T

For the puignose of this analysis. cognitis e impairment was de—

I med as a Cr\SI score of less than 74 and a CDR greater than (I. Thus,to be considered impaired. subjects vs crc required to have both thepresence t l pt e r pert irmance on testing and functional dccli ne dueto cognition .A CASI score ot 74 corresponds closely to an MMSEof22, \inct\ —six percent of men ulnmatel diagnosed with dementia in the Honolulu—Asia Aging Stud\ had a score of 7$ or less on

CASI screening. Cognitive impairmeilt was considered mild if theCDR 55 as equal to 11.5 or I. moderate if the (DR ‘5 as equal to 2. ande\ crc if the Ci)R was 3 or greater.

We used the SAS software, version ‘It S.AS Institute, Inc., Cars.North Carolina; for all statistical anal sis. A series of chi squared

and Fisher Exact analyses were used to determine the sensitivities ofvarious phrases when compared to cognition Informed consent

was obtained in all cases and an Institutional Review I3oard approved the protocol.

ResultsOne thousand and thirta’-eight patients over 64 years old were seenin the physicians’ offices during the study period. Forty-six ($.$%

were excluded due to lack of home phone tr our inability to contact

them h ph tile Si\t\ patients 5.5’ vs crc excluded due to knoss n

enrollment iii the Honolulu-Asia Aging Studr, a lt’nc’itudinal study

of .lapanese- \nlerican men which includes regular cognitive test-These subjects would has e been pm’ev iously exposed to

cognitis e tctmc with the CASI vs hich could have affected their

per tormance ui our study.Ot the remmiainu’ig 032 possible participarts. 5’r 51 reported

he \s’ci’c too hus or not interested in participitig’ and 65 6.0’”

cIt too ill. \sere cai’egivers, or had died before mher vveie called tu

pai’tcipate. Other reasons, including transportatitn problems. ac

counted for the final 2,6’$ of subjects who refused.The final participation rate was 20.302 yielding 316 subjects.

0 hundred and forty—four participants completed the MMSEportion of the testing, which was added to the main study after theoriginal study began. Two of these subjects were excluded fromanaL sis because of a positive depression screen thought to at feetcognition. Tss enR-—tis a ot the 242 patients ; Ill’) were found tohave ctignitis e impairment.

I)eimiographic intormation comparing suhiects with and vs ithouict gnit iv e impairment is pros tded ni table I - The average age olpiirticipaitts was 74.6 years. Greater than 95.fi’ of subjects i’epoi’tedan .-\sian or Pacific Island heritage, the vast majority being Japanese

.-\nierican. Cognitive test scores vs crc significantly diffcri’nt between the is\ o groups.

I’he mean number of vcai’s of tormal education svas 1 2. Therevs crc significant diffei’ences between the two gi’oups. with loss er

educational achievement noted for the cognitis. civ- impaired group.

C’ognitivclx impaired subjects vscrc inoi’e often women and vs areolder.

Si sty—eight percent ofpai’ticipants. i’egardlcss of cognitive status,

vs crc unable to say the phrase ‘‘No ifs ands or huts’’ (table 2 i Boththe eognitivelv intact and cognitis clv impaired grorips correctlypronounced the phrase “He would like to go home” more often thanthe MMSE phrase All subjects without cognitive impairment wet’eable to say this phrase. In contrast, the second CASI phrase wasseldom pronounced correctly despite cognitive status, similar torcpctitton of th1. phi ;sc No its ands ot huts

Table 1 -— Demographic Data and Characteristics of Subjects

cogn.wve impairment Statusred Not imotA. red 34

Age iyrs.’iEducation (yrv)

Asian-Amer.‘5 remaieNumoer of MedsCASI Score (Ave.)tIMSE Score (Ave.:

80.2 73.8 74.6 <0.001’8,9 12.4 12.0 <0.001*

96 96 96 1.00080 02 62 ot050236 2.87 2.81 0.20457.3 87.0 84.0 <0.001’17.0 25,5 24.6 <0.001’

2-fafea f-test or continuous data, ch-souare test or Fsher s Exact test for dmhctorr’Ojs data.

Table 2.— Subjects inability to say three phrases (02 unable to say:

C-ogn.itiv1.moairnwt Status(nioared Mci. nc.aned .Aii o

73

The sensitivity, specificity. and predic live values of the MMSEphrase and the two CASI phrases are displayed in table 3. When

considermg the MMSE phrase and the second CASI phrase. aninability to repeat each phrase was a sensitive predictor of cognitiveimpairment. However, the specificity for each was poor. Alternatively. the phrase “He would like to go home’’ had less sensitivity.hut much more specificity tor the diagnosis ol cognitive impairmentin this population.

DiscussionLanguage is an important domain in the evaluation of cognitiveimpairment. Three questions directly address this domain correlating to three points out of 3() potential points in the MMSE. Aninability to repeat this phrase, regardless of cognitive status, has asignificant impact on the evaluation of this domain. These datasuggest that the functional maximum attainable points on the MMSEin this population would be 29 almost seventy percent of the time.

Most people would consider the MMSE a screening test fordementia. In such a capacity, a high sensitivity is favorable, even atthe cost of specificity. The rvIMSE phrase does meet this criterionin our study. For a confirmatory test, on the other hand, highspecificity is sought. The phrase “He would like to go home” mayhe a more suitable choice bar a confirmatory test in this population.We recommend judicious use of each phrase in the Japanese-American population of Hawaii. Readers should he aware thatsimilar substitutions for other English speaking ethnically diversepopulations might he appropriate, however, further research isneeded.

There may he limitations to generalizing these data to otherpopulations. This is particularly true for mainland United Statespopulations that may have had a different degree of exposure topeople of sian descent compared to European descent. It ispossible that local customs and traditions have affected languagelocally in Hawaii, thus affecting ability to say the phrases. Clinicalutility of these phrases in Caucasian populations may have similarlimttations: further research is needed.

It is also possible that past familiarity with a phrase affectsrepetitive ability in a test. Nevertheless, it remains important toconsider local language nuances in any population when testing forpresence of acquired cognitive abnormalities .A larger analysis,considering people of more varied ethnic origin could clarify thisissue.

Some clinicians suggest that there may he more merit to repetitionof these phrases than testing language and attention. Some examiners appreciate the linguistic manipulation needed to say the M SEphrase and use it to observe facial muscle symmetry and dysphonias.The CASI phrases might not provide the same degree of usefulnesswithin this arena.

Our investigation took place in a multi—physician group privatepractice setting Since subjects were called and asked to participate.a selection bias may possibly he present. Since little data is knownabout subjects who declined, it is not possible to rate the degree ofbias, if present.

This study exemplifies the limitations in clinical utility of thesentence repetition portion of the MMSE. It may imply the importance 01’ language and dialect in the appropriate interpretation ofcognitive testing within an Asian—American community of Hawaii,however further data on other populations including Caucasianpopulations is needed. It is timely, as ethnic diversity in thepopulation of elders will increase in the future.

AuthorsAll authors: Geriatric Medicine Program, John A. Burns School orMedicine, University of Hawaii, Honolulu, Hawaii and KuakiniMedical Center. Honolulu. Hawaii.

AcknowledgementsThe authors wish to thank the John A. Hartford Foundation Centerof Excellence in Geriatric Medicine at the University of Hawaii andthe HMSA Foundation. We would also like to thank the physiciansand staff at the Central Medical Clinic for making the study possible.

ReferencesLubitz 0 E a PW rnmk ME Nit n NP tamo phy of A H b 0 Dv Ni H

Murphy J8 d P m w yNibu A Cro C rn vi r. to m ov U

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Table 3.— Sensitivity and Specificity for cognitive impairment(inability to say phrases)

Posihve NegativePredictive Predictive

Sensitivity Specificity gfge fgkg

‘No its, ands. or bats’ 82.6 33,2 11.6 94.7

“He would like togo home’ 20.0 100 100 91.6

‘This yellow cirlce isheavier than blue square” 83.3 34.1 12.3 94.9

I’iAWAii 000 11001 001001001. VCIL. ‘ii. APRiL2007

74

Medical School Hotline

Imi Ho’ola Post-baccalaureate Program:One solution to the crisis of inadequaterepresentation of minorities in medicine

Sandy Tsuhako MD and Cathy Bell MDFellows Medical Education Fellowship

John A. Burns School of Medicine

There is still an alarming disproportionate number ofunderrepresented minorities matriculating through medical schoolsin the United States Among the students entering medical school in2000, the number of underrepresented minorities (URM) made upI 0.5% of the overall student body whereas URM made up 21 U ofthe population.’

In 1970, the Association of American Medical Collages (AAMC)established a task force that was the first to address the issue ofaccess to medicine for URM, Soon after, various programs weredeveloped which involved establishing links between medical schoolsand undergraduate. and secondary and elementary schools to increase awareness and enrich the students in the sciences,2 Thatdecade unfolded a significant increase in the total enrollment ofURM to medical school. Unfortunately, after this period, a plateauof total enrollment of URM was observed.

Project 3000 by 2000 (goal of increasing enrollment of URM to3000 by the year 2000) was launched in 1991 by the AAMC toaddress the worsening problem of minority underrepresentation inmedical schools.4The percentages of URM began to rise again from1 .470 in 1990 (9.2% of total student body) to a record of 2,014 in1994 (124% of the total student body). However, since 1994, totalenrollment of URM into medical school has started to decline,5

Three significant blows to affirmative action were the 1992Hopwood decision. Proposition 209 in California, and Proposition200 in Washington. which all disallowed the consideration of racein higher education admissions practices. Consequently, these anti-affirmative actions have impacted negatively the number of U RMapplying to medical schools.6Therefore, although there has been asignificant increase in the total enrollment of URM since the l97()s.the percentage of URM in medical schools is still below what isexpected for adequate representation of this population in the UnitedStates,

The importance of increasing the URM enrollment in medicalschool is emphasized in the need for high-quality health care to theunserved and underserved,6Research has found that minority physicians disproportionately serve minority patients as well as the poorand Medicaid populations. Furthermore, although there is a significant association between physician and patient socioeconomicbackgrounds. a stronger association exists between physician andpatient ethnic background.5Physicians who understand the language and culture of their patients may offer a more complete type0f health care for these people.5

The interest in pursuing a medical career is prevalent among URMcollege freshmen, Unfortunately, a high percentage of URM arediscouraged by financial harriers, academic/educational harriers

(including lack of educational support trom parents, low expectations of URM, and overt discouragement from pursuing healthprofessions65),and/or inadequate preparation to cope with scholastic rigors in undergraduate as well as in medical school.2 Furthermore, URM retention rates are significantly lower than non—URM.In part, the lowered retention rates ma have to do with academicdifficulty that URM status is associated with,’6 All of these harriersaccount for the low number of URM physicians practicing today,

A method to increase the pool of qualified URM applicants andthe retention rate of URM in medical school is through post—baccalaureate and pre—matriculation programs. Various post-baccalaureate and pre-matriculation programs across the nation have beenshown to affect positively total enrollment and retention rate ofURM in medical school,’ In fact, participation of URM in post—baccalaureate programs appear to he significant in the academicsuccess in medical school, despite their lower GPAs and MCATscores.2 It is most interesting to note that medical schools that do nothave these pre-admission URM programs are the ones who have themost declines in total enrollment of URM.’2

The Imi Ho’ola Post—baccalaureate Program at the University ofHawaii John A. Burns School of Medicine (JABSOM) is one suchprogram that is dedicated and crucial in ensuring adequate representation of the unique population of the Pacific—West Basin .Since theprograms establishment in 1973, Imi Ho’ola (Those 9,7io Seek To

Heal) has significantly contributed to the enrollment of URM intomedical school by providing educational opportunities for NativeHawaiians, Filipinos. Samoans. Micronesians, Chamorros. NativeAmericans, \‘ietnamese, Laotians and Cambodians.’5According toJudd and Tim Sing,4 nearly half of all JABSOM students withHawaiian, Filipino, and Chamorro ancestry and all of JABSOMstudents with Samoan and Micronesian ancestry are tormer ImiHo’ola students. Therefore, the Imi Ho’ola program is essential inultimately increasing the number of qualified physicians that arefrom these underrepresented populations.

The Imi Ho’ola program has undergone various changes in itscurriculum since its inception almost 30 years ago. The programstarted initially as a premedical enrichment program. which had noguarantee of acceptance into medical school. In 1995, the programdeveloped into a post-baccalaureate program, which had a provisional acceptance into the John A. Burns School of Medicine. In2000, in addition to the post—baccalaureate program, Imi Ho’oladeveloped partnerships with local high schools and communityorganizations to increase the awareness and interest of the healthcare profession. Ultimately. Imi Ho’ola will increase the number ofURM in medicine by not only targeting the retention of thesestudents in medical school, hut also by increasing the pool ofqualified applicants.

The I 2-month, formally structured post-baccalaureate programdescribed by Judd and Tim 5ing consists of three components:Phase I, Summer Orientation and Assessment: Phase II, Post-baccalaureate Enrichment: and Phase III, Pre-matriculation, The If)enrollees undergo extensive testing during Phase I to assess theirbaseline knowledge and skills in biology, biochemistry. chemistry.reading. and critical thinking. The results of these assessments areused to develop individual educational plans that include improvingacademic skills such as organization. note taking and test taking.The students and faculty then implement and incorporate what was

JOURNAL USD5. ,DL APRL 201075

determined in Phase I into Phase II. Phase II emphasizes strengthening basic science knowledge in biology and biochemistry/chemistry as well as addressing speech and ethics, Finally, Phase [11further promotes successful adjustment to medical school by following the curriculum format of the school of medicine, whichin olves Probleni-BasedLearning as well as introductiontoClinicalSkills.

Imi Hoola embraces and is dedicated to the three components thatTa\ br and Rust described as being essential lbrthe success ol’LRNIprograms. The first component is creating a supportive environment for [R \1 students who may’ have had to face various socialobstacles, ,\warencss of certain heha mrs leg. expressing little

interest to students’ questions or concerns. physical distance orstereot\ ping that may affect these students performances is of

utmost importance in order to pros ide [RNI students with high sell’-esteem and feelings ot equality and inclLision. The second component is addressing the different learning styles of [JRM students.Teachers must realize that European American students are morelikel\ than URM students to succeed in an environment that emphasizes analytic thinking, individual competition, and independentlearning. Teachers need to incorporate interactive learning, establish clear and organized objectives, frequently assess learning, andpresent material in various ways. Irni Ho’ola incorporates traditional learning with hands-on lab experiences (e.g. cadaver dissection) and highly interactive case-ctnccpt map and tutorial sessions.The third component involves teachers who make an effort to learnand value a diverse set of backgrounds. In the Imi Ho’ola program.not only does the staff and faculty themselx es often come fromunderrepresented minority populations. hut they are also highlyactive in the areas of diversity and culture competency.

There is a desperate need to increase the number of physicianswho are from underrepresented minority populations. Research hasshown that these ph sicians are most likely to serve minority

populations. and may be able to provide a more complete type ofhealth care because they and their patients can identify with one

another. An effective method of increasing the number of theseURM physicians is post-baccalaureate programs like Imi Ho’ola atthe John A. Burns School of Medicine. Imi l—lo’ola has contributedgreatly to the representation of URM in medicine, especially in thePacific—Basin population, through its emphasis on strengthenmsiacademic skills. knoss ledge base. and personal growth as well as its

commitment to recoeniting. accepting and x aluing differences

among its students.

ReferencesCone-,i AWoro c’T’.eP’es.oe’C ReaW-’ -nW’ Oon.I”etto D:,’nn’u MUG Reoo&’. 2C

2.G.croa B.e’ai EffvcnreasctaFo’ma’Povtbaocad.’eate°’e’medYAeP’oo’amU”umder”tt’no-’y S:oe—tv. Academ:c Mccc’s 27W 8 844818

3. Assoc’ato or Ame”ca- i-./ene AAF’C S:ate—’e—: o” Mecca’ Eouca:’c.r o Mm’ C G’o..o SC0CMSAMID weosite June 1987

4 Assocat.onofAmericanColleges M nonty snuevrrd :nvo’mat.on, P’olect3000bv2000 AAI.IC xeov teDecember 1999.

5 Thomson WA, Desk JP. Pronrotmc D’verv:t Ce Mewcal School Pipe/ne: A Nahona: Overmeu.Academic Medicine. 1999:74i4f312-314.

A Thomson WA, Desk JR Achieving High-qua/tv Health Care and Access for AC. Academic Med:c Se,1999 :74i4):305-307.

8. Cohen JJ. Finding New Roads to Diversity. MMD Reporter. 1999:8i5).Cantor JC. et al, Physician service to the underserved: implications for aftirmarive action in med:cai

education, lnquny. t996:33(2):167-180.9, McGlinn S. et al, Pnstbaccalaureate Medical/Dental Education Preparatory Program lMEDPREP’ at

Southern illinom Universay School of Medicine. Academic Medicine, 1999:74l4i:380-382,10. Huff KG Fang D. When Are Students Mostat Rak of Encountering Academic Difficulty’? A Study of ‘ne

1992 Matriculants to U.S. Medical Schoos Acscernc Medicine. 1999:74l4):454-460.1’ St’ayhom C. Demsy K. Do Pre-admsEon Programs Make a Difference in the Enrolment 4

Unde’represented-minority Students at U.S Medical Schools Academic Medicine t999’74/A:431’

434.12 Strayhorn C Participation in a Premedical Summer Program for Urderrepresenteo-mv’ority Stucen:s

as a Predicto’ of Aoaderrnc °erformance in Ifre Frs! Three Years of Medical School. Two Studier.Acaoemic Medicne. 1.9:9:9.744,435.447

13, Judd NLK, duau S. Commitmen.t to D:sersi:y. Hawai: Medics Journal. 1998:5.78.9‘4. judd NLK Tim Sing PM.. mi Hoola Post-Baccaaureate P’ogram: Recnuitment. Retention ano

Craduat’on of Asian American and Pacifc Islander Students i” Medicne. “i.n Press’ Fal: 2001‘5. Taylor V. Rust G.S. The Needscf SruoentW’om DrerseCuitures. AcademicMedicine. 1999 74i4: 302-

304.

Until there’s a cure, there’s the American Diabetes Association.

Until there’s a cure, there’s the American Diabetes Association.

/4,u/J:AII MEDICAL ,i( :i i//r.:..4i CL.:, ii.

76

Cancer ResearchH Center Hotline

Carotenoids and Human Health

John S Bertram PhDProfessor of Cell and Molecular Biology

Cancer Research Center of Hawaii

“Eat up your egetables” has been a s idely employed if not popularphrase for centuries. and has now been reinforced by messages fromthe ational Institutes of Health, the American Cancer Society, theAmerican heart Association and other organizations concernedwith disease pi’e\ ention At a recent meeting held in [lonolulu,Januar 6- I I . 2002. sponsored b\ the Cancer Research Center ofHawaii, about 225 delegates Ironi 26 countries discussed theirrecent research which focussed on the role of carotenoid in humanhealth, This meeting, the 13th International Carotenuid SocietySymposium was organized b Dr. Bertram from the Cancer Research Center ho also served as Program Chair.

Carotenoids are pigments frund in leaves and in yellow and redvegetables. They play an important role in the health of both plantsand animals: in plants they act to improve the efficiency of photosynthesis and to protect against photochemical damage: in animalssome carotenoids are a vital source of vitamin A-for others theirrole in human health is just being discos ered. For esample. thecarotenoid lutein plays a major role in plants. and research presentedat this symposium suggests that it ma ha ea similar function in thehuman retina. Dr. Khachik. University of Maryland. presented datashowing that lutein concentrates in the macula (the -eIlo spot ofthe human retina and is responsible for this coloration. That luteinprotects the retina from photodamae as it does in plants is becomingapparent from epidemiological studies linking an increased incidence of macular degeneration with low dietary intake of lutein. Dr.Bernstein. from the Moran Eye Center, University of LTtah presentedclinical studies demonstrating 32i- lower lutein concentrations inretinas of subjects with macular degeneration vs. age-matchednormal eves. Studies were conducted in collaboration ith Dr.Gellermann front the Department of Ph sics, Universit\ of Utah.utilizing a non—invasive spcctrocraphic method to measure lutemnlevels in the human maculaH ‘I’ hese clinical associations werereinforced b\ pre—clinical studies I rom another eroup conducted innon—human primates which denionstrated that lutein snpplementa—ion can protect against photodamage to the retina. In v eu of thetact that senile macular deeencration m’ a major cause ot blindnessin the elderl . affecting over I ( ni i Ilion Americans. the prospects bridentifying high—risk individuals and for prevention of this diseaseseem exciting.

In Third World countries, vitamin A deficiency is a major causeof blindness in inftnts and of death from infectious iseases,Supplementation studies have shown that up to 5(Y of infantmorta1it can be prevented if these infants are supplied sufficients ltanimn \ L_ ntom tun ttclx in tI i ounri mes ni nit md ‘, oune

children are generally not fed diets rich in the carotenoid beta—carotene. u hieh is hi’oken dou n in the gut to yield two molecules of

vitamin .\ As an alternative to vitamin A supplementation—--difficult in remote areas. efforts are now underss a\ to create staplefoods containing beta—carotene. This has been achieved with rice.“the golden rice project” and. as was presented at this meeting ha eromip from Germanx . has nou been achie\ e d u mth potatoes. Ingenetieall engineered plants. an approximate sm\—told increase intotal carotenoid content in tubers was achie ed Also presented atthis conference was the information that an unusual strain of bananacontains beta-carotene, suggesting that the introduction of this strainin tropical communities could decrease vitamin A deficiency, Whilegenetically modified foods are receiving a hostile reception in manyregions of the world, it is dill icult to understand why persuading arice platit or a potato plant to synthesize carotenomds in its seed ortimber respectively, in addition to its leaf. could cm’eate en ironmentalor ethical problems.

Disease prevention was also the major focus ot a session de otedto the carotenoid lycopene. m’esponsihle for the red colorof tomatoes.u atermelon and a fl,’v other red vegetables. Epidemiologiealstudies presented that this conference by Dr. Cmos annueei. HarvardSchool of Public Health, have associated a 35( lower incidence oftotal prostate cancer and a 50fr reduction of advanced prostatecancer in men consuming two to four servings of tomato sauce perweek in comparison to mcmi consuming lower amnounts. With thisas a starting point, and the knowledge that laboratory studies inHawaii had suggested a cancer preventive role mr this earotenoid,Dr. Kucuk and colleagues at the Karmanos Cancer Center in Detroitassessed the effects of Iveopene supplementation on individualsrecentl diagnosed with prostate cancer. A\ dose of 30 milligrams ofI copene/das derived from tomatoes t five to I (I times normaldietar exposure) was administered three weeks before radicalprostateetomy. In comparison to controls who received no intervention. pathological examination of pm-ostates from the Iveopene—supplemented group revealed less invols ed margins resulting iniouerCjleeson scores.’ Interestingly, malignant tissue from supplemented individuals were found to express higher levels ofconnexmmi43. a gene responsible for intracellular communication through gapjunctions. Connexin 43 has been firmly established, in part by workby- this author at the Cancer Center of Hawaii, to he a tumorsuppressor gene.’ A possible explanation for the reduction insurgical miiargins was presented by a group from the University ofIllinois at Chicago. who shi u ed the induction of apoptosis (pro—granimed cell death in I copene treated prostate cancer cells eros ii

in culture, These clinical studies are being pursued both in Detroitand b\ Dr Clinton at the Ohio State University Compm’ehensiveCancer Cemmier. I Iconfmrmed. these studies indicate an important [messstrategy both for nm’evention and treatment of prostate cancer.

I.\ copene may also pla a role in pres enting cardiovasculardisease and stroke, possihl\ because of its stm’ong actis it as a lipid—phase antioxidant, as suggested by recent epidemiological studiesconducted by Dr. Rissanen from the University ot Kupto in Finland.She presented an update on research which indicated that men in thelowest quartile of serum lycopene levels had a 3.3 told increased riskof an acute coronary event or stroke as compared with men withhigher F copene levels. In high—risk individuals the mitima—Tnediathickness of the common camot id artery was found to be I SU- greater.

77

as assessed by ultrasonic measurement, than in men with higherlycopene levels at lower risk of coronary event or stroke. These

correlations did not hold for s omen who had overall higher lvco—pene levels indicative of a better diet.

One of the biggest disappointments in the cancer pies entioncommunity ss crc results presented in the I 990s of a lack of protec—tin e action of beta—carotene against lung cancer and cancer in

general. Epidemiological studies had strongl\ supported such a role

for beta—carotene in smokers, vet in two intervention trials insmokers beta-carotene actually increased lung cancer rates vs.

placebo controls, while in the Physicians Health Study. which

contains few smokers, no protection was obsern ed, Dr. Mayne. Yale

l,tniversit. presented new results on the efftrc ts of beta-carotene onthe incidence of upper aero-digestive tract cancer, which predomi

nantly appears in smokers. Interestingl\ . a protectine effect against

cancer at these sites was observed which nn as balanced by an

increased cancer rate in the lung: In all the studies shos inst adeleterious effect on the lung, beta—carotene was supplemented atdoses approximatel I O—llLl higher than nornialit achieved in the

diet. Clearly, supplementation with pharmacologic doses of beta-

carotene should be avoided, especially in smokers, In an attempt to

explain these findings, the research group led by Dr. Russell, at the

Center on Aging at Tufts University, found that exposure ofexperi

mental animals to pharmacological doses of beta-carotene together

with cigarette smoke resulted in decreased expression of a putatin etumor suppressor gene in the animals’ lun L’s together with increased

cell proliferation and metaplasia. lit contrast, in animals fed anamount of beta—carotene producing comparable tissue len els to

those obtained in humans consuming a “healthy diet’’, some protec

tion against cigarette smoke damage was observed.A These studies

imply that at high concentrations of beta—carotene, interactions

between oxygen/tobacco smoke produce lung toxins.The carotenoids produce a colorful environment by providing

pigments to leaves, flowers and fruits. They are also synthesized bymicroorganisms. which when consumed by animals. are responsible

for the coloratit m f shrimp ai it1 salmon, the hi-il h ant p1 umage of

many birds and the yellow coloration of egg yolk. With the ads ent

of shrimp and salmon farming. a major industrt has developed tosupply the earotenoid astaxanthin necessary both br the coloration

of these animals and for their health. The State of Hawaii has twocompanies producing carotenoids from the growth of microalgae,

and delegates to this conference heard details of the commercialprocess from representatis es from Ct anoteeh. on the Big Island. and

a Japanese companc . Micro Gaia on Maui. This session was

organized by Dr. Boussiba from Ben—Gurion Universitt . Israel nhopresented his own experience in carotenoid production from

microalgae in a desert ens ironment.With increasing demand for carotenoids br aquaculture. in egg

production and as namral colorants for processed foodr. it is appar

ent that the commercial importance of earotenoid production inHawaii will increase. Moreover, it is expected that a rowingrealization of the importance of adequate amounts of key earo—

tenoids in the human diet to maintain health, will also increase

demand for carotenoid supplements. Hons ever, lessons learned

from the beta—carotene intervention trials discussed earlier wouldindicate that prudent advice would he to obtain earotenoids from the

diet rather than from dietary supplements Eat up yours egetablec”

has taken on new meaning.

References1 Bemxte P S KhacNk F Ca aiho L S Mu r C J Zhv C V rd Katz N B 01 idnhhca vs

and quanhtahon of carotenoids and their metabolites in the tissues of the human eye. Exp.Eye Rex.72, 215223,

2. Bernster.P SYoshidaM.D Ka:z,N.3McCianeR W ancGeitermann,W.(t998. Ramandetechonof macvim carotenoid pigments in ‘tact human rehna. invest Opirfhalmol Vs Sc 39 2003-2011

3. Siechenso.LSLaft.a’rn.t1.C arogtteser PA 2007-Gobs nwurr0o Pamvsorogv.121 SuppiS5-22.VeX Af BaSiL S Kim.A Zvanc..j Ljcca.P. Sever 7- usc Poz’acus.t. .2000 Ens neenrc. thenros6amn A beta-carotene oovyntbetic pathway nyc curotenoin-freer rice endosoerm. Sc, 287.303-305

5. Gann,P.H., MaJ Gicvarrnucc .E WiLatOW.,SacRs Ft.!. He’r’reker’s.C.H..anoS:amofer M.J. 1007-

Lower prostate cancer “s ‘neC ut— eievatv5 oasma ixcoosne 7-vets. Resu rs of a prospect-acanVycs Cancer Research, 59 t 225-t 230,

6. Kucuk,C., Sarkar,F,H.. Sakr,W Dj.r(c 2.. Potiak,M,N., Kf’chik.F,. Li,Y,W,, Banerjee.M Grignon.D..Bertrxrr iS,, Crisamanj,D,. Pc’tns,E.J., and Wood.D P 2O01l Phase 0 randomzed clinicaitrialof lycopene supplementation betore radical prostatectomy. Cancer EpidemioLBionrarkers Prey,, 10.86t -868

7. lGng,T.J.. FukushimaL,H,, Hieber,A.D., Shimabukuro,K.A,, Sakr,W.A.. and Bertram,J,S. (2000)Reducao macis of conneain43 in cervical dysplasia: inducbie expression w a ceruica carcnoma chitOne decreases neoplaatic potentia: with implications for tumor progression. Carcinoaenesie. 21 t 097-

8. Masse 5T. CaOmei.B.. Becnr.!,1.. Snor-°osrer C Fa’oy B.C. Brrssu.K . Beao.J Zheno.T Z.Cocer,D . Freaman.C. ann Gcodw r 7-i.. i’. 206’ Randcmzxd slat of suopee’ta b-caroteneto omuent vecono than arc rem cancer. Cancer Researc”. 61. 0057-1003

9. Lu C Wana.X.C. Broraos.R.T Smtfr.D.F.. KrnsRv.i(... and Rusaeil.P.M. .2000. Effects or

p—ar’nacc’cocm Oets,-caroterte ecDp:enetat Or’ Or’ CCL pm ieratO- ann5ntooat’rc-S C “ ‘ ‘k 21’

78

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Va0e5 . A:vare: 0 Pose A. et a. thr’rcsiszt:-e a’ excea:C’-a caseC Cv CThc,av:wc cases. Reso’,c 1925:9751-92.Rome’s S Mac— C. Hemarcez L. at a Cbaoz’a c”—.cs.v a’ t’-e ye’. ar’avss c cv trecency amCt’ee 998 ‘‘

6. Dc’a— C’o:’-oa’ a’-d c-cr’s; c. c’c’v AliA ‘965:a. se F. L ‘-sc-eer W. c ‘ c’, c_s sac :eamoaae:s a e c’”ms a

P:ec’c’W SDc—:a’-ac_scnvc_sasc.’escc’r’-csy jC”GySDeie’C359Durnoal AE. a5 JH. FV.w rate and aomccsaor CT thoracc ductcynrc.h in, oar v—ta w:rh V rrhosis. NEJM Iuebrn’a F e0—- P “°e A a ° a d °amero1 —re am rbns:s A ft o’9o

64:Rubinstein D, Mc]rnes IF. Dudley F. Hepatic hydrorCorax lathe absence at clinica ascites: diagnosis and management.Gastroenterol 1995: 88: 188-191.Lieberman FL, Peters AL. Cirrhotic hydrothoras. Arch Intern Med 1970: 125: 1141, 7.Van Pernis. Varlat:ons at the thoracic duct. Surgery 1949; 26: 806-809.Cha EM, Sirijintakearn P. Anatomic variation ot the tncracic duct and visualization at mediastinal i.ymph nodes. Radioiogy 1976; 119: 45-48.Foresti V, Villa A. Scolad N. Chylothorax in liver cirraosis Iletter; comment], Reso Med 1, 997:91 i2i: 1 t8-9.Sn P cash F Cu dj’- L N no tr A My h thhorax ompvca a th °r Sos herr M J r 8° 19 v2

930.

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Locum Tenens

BOARD CERTtFIED FP— available for summer LocumTenens office coverage. HI license. ACLS. NALS.Itability insurance provtded. Please call 91 3(685-7494.

For Sale

TREADMILL:EKG— Burdick Spacelabs Quest StressSystem w,.’CPU, monitor, treadmill & cart. 1 yrold rarelyused-Assume low monthly lease or buyout @ $16,500.SIGMOIDOSCOPY— Olympus Unit complete w!cart &supplies. $2,800. For questions call Terry (808> 885-9606 Big Island or e-mail; drlamlava.net.

FOR SALE— ConBio Erbium;YAG 2.94 Laser. VeryLow Usage. Protective eyewear included. Call 596-0955 or 375-5288.

Physician Wanted

PRIMARY CARE PHYSICIAN— Position Available.Half-time. Universif.y Health Services. UH Man.oa. Contact Dr.Liiy Ning. 1710 East West Rd., Honolulu. Hi96822. (808> 956-8965.

Until There’s a Cure,

There’s the

American Diabetes

Association

81

The Weathervane Russell T. Stodd MD

At HHS They Forgot To Pay The Brain Bill.In August 2000 our beloved Department of Health and Human Servicesprovided cuidelines that all physicians ss ho recei’ c tederal binding mustprovide at the]r 055 n expense. a trained clinical interpreter br ill theirpatients ts itlt lmnimted English skills. The rulinu cosers all patients. eventhose w t h p0 ate nsuranee. Many ph sicia mis are enraged, point no ‘at thatthe rcimhu rsenme nt br a \ ledicaid office S isit i’ about ofthc i nterpm ctcr’ s

t NI ‘0) to \t “0 \mn m in \1,dm l \ o m tm m 55 on b mdabout t I ie absurd tnanda te regardmng translators, stating. “1 he association isstrongly opposed to allowtng the burden of funding written and oralinterpretation services Fir limite&Englishproficiencv patients to fall onphysicians.” Perhaps when enough physicians give ttp accepting I4deraldollars our great social platmers will ss ake rtp.

Someday Well Look Back On All This And Crash Into AParked Car.Pitx th ise cm istunied pe ‘to rmers wli i appear at athletic es eats dressed asmascots t ir the team. Edward McFarl ane. M - I). repiirti ng tor the Johnshopkins Sports Medicine I)epartment. urs eyed 4 mttascots tor pu base—ball. basketball and football teams. 5t0 reported that they had experiencedheat illness from donnine their fur or leathers. Half of them required IVfluids They endured mnlurmys e tu ed hs I dIm,, on stars ettmnv tn tm,thtsand even being run over by golf carts. 4454 developed chronic lo er hackpain, 1754 suffered knee injuries, 13’ had ankle damage, and additionalinjuries ssere tohands. 0 rists andfingers. In all, the4S nmaseotsreported 179

nurmes and 22 (it those req ui red surger. Rah. nih. sms boom aaaughhh

Nobody Is Interested In Sweetness And Light.Jmmatrists sa it is unltealth behas iir and pro ae\ adsoeates are scry

distressed. hut n smo paranoia is- dri lily immore and mote .-\mermeans 01

on each other, on their neighbors, and even on their own families. SinceSeptember II” sales of surveillance devices have increased by 30 to 6054.Fears of anthrax and other terrorist activities has caused people to installminiature cameras in mimi I boxes, anti—bug devices on their phonesV• mrinia—tare recorders for phcne conversations, and some has e even purchasedii mght— vision goggles. A huger sized high quality microphone can be slippedin a slim r pocket. and a backpackc1i can be attached to transmit unii irs i or

a spouses whereabouts, Many of t[iese snooping ti iols are remarkablycheap and many are not illegaL You could ask Frank lb ft omd. You can evenpurchase a high tech pai slc\ necktie installed with atm n s ideo camera. Spy

stores are quick to poi it tmlmt that tIes merely sell the goods, and it is up tothe customer how they arc used.

When Choosing Between Evils, Take The One You Haven’tTried Before.The tobacco people are amotig the most creative in our societ . The makersif snuff, that delicious ‘i sad of uk bctoeen cheek and gum. asked the

hLd’miI Trade Commissioim br pcm’misioim to say in ads that its priiduetscould he a sal’er way to c’n same tobaee i than ciarettes. [SE Inc.. niaker

Sb ml mad ( nIian p mt ut tli it ohilu 30mm tOO I ‘a,, Lrmmi sm mm ttusmokers sIte each year. onE ‘),i’fii) die Ironm oral cancer. ,uid m’st it those(eaths are Ii nked to cigam’ette use, Mete I 901107 That’s ‘ ntlv three times theWorld Tm’ade Center hom’ror, Gee. let’s have a party with awards for foulest

halitosis and longest expectoration.

If You Don’t Know Where You’re Going, When You Get ThereYou’ll Be Lost..-\I Cois’ and tin’ PrOpsoieflts. ililist beunhappsahmut the re:s tom Jap.mn .‘sv’. the Jaranee go\ernmmieimt hasilmopped naiidamory ncs ie’trictions on grc’emml’mouse O,i emissiorms. iii1lieut-inc Japami s’ n’m he able to macct t.mccts mim,mnsjated tinder t he Tm’eamr l’hcrestrictions pmo\eu too e\peimsise tot’ Japanese indu’.tm’s. one part ol thereass its the F S . Senate unaammouslr mc’ected the ‘l’m’eats ma 1997. 1 he teel—oood Kys.>to Treaty l.ac.ks scientific’ es ide.nc.e for grcenh.ous.:e g:ases tms.’ thecause- for “g.bohal wartning.:s and ni.oreover it is.- simply not worth the.expense. Further, current studies of Anmam’etica reveal hat the Ross Ice Shelfhas grossmm ses eral mniles m the past too decades.

You Know You Can Trust Him. He Owes Money To Every.body.In I 9%. a studs was published in mIme li-/m/mi’s 7 Inn i’i!st/ .-W dniimi ahommt,immc lo/emmoes which eonebmmdcd that “sesei’ai possible maechammisimis nayamake /mmme ,mmm e[t4ctise ii’eatmmmcmmt, Suhsequermihr. it becammie kmmoss mm timat

before puhlicatioit. omie of the ammthors purchased stock in the eomitpammy thaimade the lozenges. 1,.ater whemi tIme stock soared, the author sold some shares

amid muade a prot’it of S I 45.00)). A survey’ hr the Jommma/ of i/me Aomeris’s:ms

I-li-/i 0/ il,s’so -jail mm revealed that mmearlv L) of Ii) mm medical experts ss ho o motetlme guidelines lam other doctors tim use in rese,mrelm, Imad a ‘inamicial tie ssimlm

drug eampammies sshen thes- ssrote themmi! \-Ismre thamm 5i of the 11)0 expemtsreeem ed limmmmneial support tim m’eseam’efm .3X’ served as emmmplos-ceseiiimsultants tom a pharmmiaeeutiesml eommipanr . aimd amm imtcredible 59’s h.mdI’m mianemal relat momms[m ups wmth commmpanies v hose drugs ys crc ci mmsmdered 1mm thegumdclmnes they authored, No one is suggestimme these sciemitists and el immiciamis are for sale, hut the problem of uncommsc ous huts miiust be recogmiized.honest diselosrire and appropriate clinical practice guidel imies must bedel’mmmed, amid scientific jotimnals niust tighten policies about conllicts at

intcm’est,

Warning! Driver Only Carries $20 In Ammunition.A surgeomm wmt,h 25 sears experience. sers ed as a consmmltammt on a case wherea paticmmt died folloss iimg a rmuptmmred appemmdi\. .-\ law suit. mmmcd mite surgeon.

a hong others. fur aegileenee. The slmrmmeon 55 as later dropped from theeommmplaint. hot a ci ml league ss as found mieg I gent, and the .1 urn awarded ajudnmenicnt of S I 59.000. The sum’geon svasamsgrr . Hedistrihutedalettertohifellow physicians in the cotnmiiunity natning the plaintiffs, the juror’s names

and addresses, as svell as the miames and addresses of four svitnesscs for theplaimmtiffs. His letter included statements suggesting these svere people who‘‘foumid a doctor gmmm Its’,’” and ‘‘others 01 whom I am leers .‘‘ The letterbackt’mm’ed. Emghm of the jurors brought a lass smumm against tIme surgeon allegingits asmon of prm tier, emotional distm’ess. ohstnmmetiim of justice, and ititemi -

tmommal mind mmimmliemotms actions. l’he initial slmit ss’mms dismissed, bitt the Cotmm’iil Appeals rem mi stated the complaimit which is pending belt ire the state

Smiprenue Cotmrm . Because the surgeon’s act on ss as an mrmtent monal act amid mutt

a niatter of mnedieal liability’, tIme doctor is persorma lly at risk for mmtiy penaltieswhich may’ emismie. Without exceptiomi. all phn’sicians are hurt, angry andsvant vindication svhen svronglv accused. bnit if the issue dies, let it die!Retribnmtion sirnplr doesn’t work, and vengemmnee has been clainied by’ theCreator. so l’i Ic it tmnder ‘‘crapola’’ amid get on ss Oh life.

Talent Is The Infinate Capacity For Imitating Genius.Fach seam’ at hEirs mmmd Ummiversmtn the ig,_Nyibsm,l awards mime preseimted tonaeli es emnenmts ‘ilmmmt can not or should not he reproduced. G mr Biology. t lieass mud goes to Buick Weimer it Pueblo. C’ ilorado. for inventing F-mu/i’m’-1% iNc. airtight imimdem’wear with a replaceable ehaiei al filter that remiioves bad—smellimmg gases betimme they’ esemipe. For Public Health, atm lyNohel awardgoes to Amidrade and Srihari of the National Immstitute of Mental Health atmdNeuroscienees, Bangalore. ladimu. for their discovery that nose picking is mmcommmmmmon activity’ mimmmong adolescemits. Amid mcst enlightening, the award ft

mmstmoplir sics coc’ to Dr. Jack and Rexella \mmn hope mf Jack Van Irnpc\Iimiistrmes. t’or sliscosermmie that black holes tmmht’mIl mmll the technical require—mmmemits to be the Iiemmmioii at’ hell,

A Newspaper Is A Circulating Library With High BloodPressure./)/ira/ Indu,sIi’r, a ji nirnal mhat tmmmcks piiblcmuti

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