The projects, listed below, were either part of the Community Medicine Courses (BIOM 581, 582, 583) or the Community Medicine Research Project (BIOM593). The Community Medicine courses were completed between August 2000 and June 2001. Clicking on the student's name will take you to the sponsoring organization's website. The Research Projects were completed between July 3 and September 4, 2001. Clicking on the student's name will take you to the project's abstract. A special mahalo to the faculty who reviewed the BIOM594 project reports: William Gosnell, PhD, Shannon Hirose-Wong, PhD, Al Katz, MD, MPH, Dave Lally, PhD, Jon Martell, MD, Howard Mower, PhD, Neal Palafox, MD, MPH, and Karen Yamaga, PhD. The Student Research Program was formed through the dedication and commitment of Bill Johnson, Jeff Gertsch and Haven Malish to improve student research opportunities at JABSOM.

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Attitudes Regarding Tuberculosis in Immigrants From American Samoa to the United States

Background and Objectives: More than two thirds of the cases of tuberculosis (TB) in the United States occur in non-white minorities and immigrants. American Samoa is a United States Territiory in the South Pacific with a TB incidence rate of 8 per 100,000 similar to the U.S national incidence rate of 7.8 per 100,000 as reported in 1993. In the 1920s through 1990s, the American Samoa TB incidence rate has dramatically decreased from 347 per 100,000 population to 8 per 100,000. This paper explores Samoan knowledge, attitudes, and practices concerning TB. Methods: A focus group of Samoan immigrants was convened to discuss the participants' explanatory models regarding TB. The results of this group was reviewed by a panel of Samoan health workers. Results: The focus group participants expressed a belief in the extreme contagiousness of TB. This leads to social stigma and isolation. Many agree that biomedical treatment is necessary. Conclusions: If explanatory models of illness are elicited from individual patients, an understanding of the shared beliefs regarding tuberculosis in Samoans may contribute to treatment of these patients.

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Enhancing Assessment and Communication in a Rural Context: A Quentin Burdick Project

The goals of the Quentin N. Burdick Rural Health Interdisciplinary Program generally focus on forming partnerships with rural health associations and increasing the health care capacity of rural communities including the island of Molokai, Hawaii. The four projects that were completed this summer through this program reflect these goals in relation to prevention and education of diabetes and other health care issues of concern to the Molokai community. The prevalence of type II diabetes in Hawaii varies among ethnic groups, of which the highest include Hawaiian, Filipino, and Japanese. However, mortality rates for Hawaiians are more than twice as high as the rate for other ethnic groups. Molokai is the only island (except for Ni'ihau) where Hawaiians comprise the majority of the population at ~50%, followed by Filipino at ~20%. Thus, diabetes is a serious health problem for the community of Molokai. As the first project, Quality of Life/Mental Well-Being Questionnaire items were compiled in order to assess psychosocial issues affecting those living with diabetes. Items were compiled primarily from two well-validated quality of life questionnaires, Diabetes Related Quality of Life and A 12-item Short-Form Health Survey. Items were reviewed and revised by the staff at Na Pu'uwai, a community based Native Hawaiian health care organization on Molokai. With anticipation of improving their case management services, these newly created items were recompiled in final form and submitted to Na Pu'uwai. An Evaluation Tool for Knowledge of Diabetes, developed as the second project, is a multiple-choice assessment tool to identify gaps of knowledge, both prior to and after a diabetes-related educational curriculum. A representative sample of multiple-choice items were drawn from Life With Diabetes, the primary curriculum for Lamalama Ka 'Ili, a community health center on Molokai. Items were reviewed and selected by the primary diabetes educator to enhance cultural and community sensitivity. The third project, funded through Na Pu'uwai as the Laulima Project, focused on creating an internet-based informational system for the networking of health and human services on Molokai, accessible to the broader community and having the capacity for local management. The original directory, however, contained obsolete services and lacked maintenance. Thus, a new website directory was created, incorporating more community health providers, with updated information. A staff member at Na Pu'uwai, who is currently locating a server to host this site, will maintain the site. A Dental Care Coloring Book was the fourth project developed to target dental health education of the Molokai youth. In addition to diabetes, poor oral health is a documented concern for the children of Molokai. Suitable black and white figures from Microsoft Office 2000 Clip Art were chosen to outline oral health in terms of dental function, nutrition, and self-care. The coloring book was also submitted to Na Pu'uwai, targeting their mission of health promotion and disease prevention.

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Avoiding Exercise-Induced Hyponatremia in the Face of Cystic Fibrosis: A Case Study

W. Douglas B. Hiller M.D., Laura Dierenfield. Labman Hawaii Inc., North Hawaii Community Hospital, Kamuela, HI
Damien A. Arafiles

Dehydration and electrolyte balance, particularly hyponatremia represent a major health problem in ultraendurance athletes. The addition of a disorder in a balance maintaining mechanism, like the elevated sweat NaCl concentration of an athlete with Cystic Fibrosis, requires that the affected athlete have a personalized regimen of water and salt balance. Recommendations are made through a one-on-one study measuring the potential sodium loss and the estimate water loss the individual is likely to encounter. These recommendations will help the athlete avoid the performance deteriorating manifestations of exercise- induced hyponatremia and should be a valuable aid in race planning.

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Urologic Complications of Placenta Percreta Invading the Urinary Bladder

Robert Washecka, MD, Department of Surgery, John A Burns School of Medicine
Amanda Behling

Placenta percreta invading the urinary bladder may cause hemorrhagic shock, hematuria and urologic complications at parturition. This retrospective survey of 47 patients reviews maternal characteristics, presentations, urologic complications, and management. Methods: A new patient is presented. 46 additional patients were identified by medline search and literature review. Results: Hematuria was present initially in 30% (14 /47) patients. Of these, 6 of 14 required transfusion support. A preoperative diagnosis was established by ultrasound or MRI in 28% of patients. Cystoscopy was performed in 9 patients and did not make a preoperative diagnosis in any patients. 37 urologic complications included bladder laceration 28%, urinary fistula 13%, gross hematuria 11%, ureteral transection 6%, and small capacity bladder 4%. Partial cystectomy was performed in 43% (20/47). Three maternal deaths and 9 fetal deaths occurred. Only 1 patient subsequently had a delivery. Conclusion: Readily identifiable risk factors by history are important to suggest placenta percreta in pregnant patients with gross hematuria. Ultrasound not cystoscopy can establish a preoperative diagnosis. Partial cystectomy is commonly required for extensive or deep bladder invasion.

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The Ontogeny of Murine Natural Killer Cell Receptors

Wayne Yokoyama, MD, Washington University Medical Center, St Louis, Missouri
Laura Belorgey

Murine natural killer cells express lectin-like activation and inhibitory receptors including the CD94/NKG2 family and the Ly 49 homodimers. This project looked at the ontogeny of expression and co-expression of various receptors, including the inhibitory receptors ly 49 A, ly 49 C/I, and ly 49 G, the activation receptors ly 49 D, ly 49 H, NKG2D which, unlike other NKG2 molecules, does not pair with CD94, and Mac-1 whose function in NK cells is unknown at this time. The data for ly 49 receptors was consistent with previous ontogeny studies, demonstrating that ly 49 receptor expression increases with age, and that the activation receptors ly 49 D and ly 49 H are expressed later than the inhibitory receptors. This project was also the first to employ the recently developed anti-NKG2D antibody, demonstrating that, unlike the ly 49 receptors and Mac-1 whose expression is an all or nothing phenomena, the expression of NKG2D is a gradual process, with the density of expression increasing with age. Lastly, this project demonstrated that the expression of Mac-1 in spleen NK cells is at close to maximum as early as one week after birth, thereby supporting a theory that Mac-1 can serve as a marker for mature NK cells. (This research was supported by a Howard Hughes Medical Institute Research Fellowship awarded to Dr. Yokoyama).

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The Role of Board Certification in a Patient's Selection of a Physician

Stanley Tseng, MD
Heath H. Chung

Purpose: To determine whether or not patients use a physician's Board Certification status as a factor in physician selection. Methods: Internet Web site was used to educate browsers on the Board Certification process. After browsers viewed information on the certification process they were directed to a questionnaire that they were asked to complete. Results of the questionnaire were then automatically sent via the Internet to a storage area on the Web hosting site's server. The total number of responses was 27. Results: Approximately 93% of those queried responded that board certification is a deciding factor in their choice of a physician. Interestingly, only 33% of the study population knew for certain that their current physician was board certified in his or her field. Conclusions: Board certification is a criterion used by patients in their selection of a physician.

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Prevalence of Diabetes Mellitus and Impaired Fasting Glucose in Marshallese Adults Living on Ebeye, Republic of the Marshall Islands

Seiji Yamada MD, MPH, Kay Bauman MD, Sheldon Riklon MD, Tin Soe MD, Department of Family Practice and Community Health, JABSOM
Anna L. Dodd

Objective: To evaluate the prevalence of diagnosed and undiagnosed diabetes mellitus and impaired fasting glucose in Marshallese adults by age, based on data from outpatient medical records from the Ebeye Field Hospital (EFH), Republic of the Marshall Islands. Methods: A cross-sectional epidemiological survey was done to assess the prevalence of diabetes mellitus in Marshallese living on Ebeye. Seven hundred thirty-four (17.38%)out of 4,223 outpatient medical records of patients >30 years of age at the Ebeye Field Hospital (EFH) were reviewed to ascertain a medical history of diagnosed diabetes, undiagnosed diabetes, and impaired fasting glucose. Patients were categorized based on medical records and laboratory results of fasting and random plasma glucose levels. Information from 42 medical records was thrown out because of incomplete information, age, or non-Marshallese ethnicity. Prevalence of diagnosed diabetes, undiagnosed diabetes, and impaired fasting glucose for the remaining 692 patients was calculated using the 1997 American Diabetes Association fasting plasma glucose and random plasma glucose criteria. Results: Of the 692 patients, 302 were 30-39 years of age, 206 were 40-49 years of age, 110 were 50-59 years of age, 52 were 60-74 years of age, and 22 were >75 years of age. The prevalence of diagnosed diabetes was estimated to be 12.72% for Marshallese outpatients >30 years of age (537 people when extrapolated to the total number of charts). Using American Diabetes Association criteria, the prevalence of undiagnosed diabetes (fasting plasma glucose >126 mg/dl or random plasma glucose >200 mg/dl with symptoms) was 6.94% (293), and the prevalence of impaired fasting glucose (110-125 mg/dl) was 2.46% (104). Based on American Diabetes Association criteria, prevalence of diabetes (diagnosed and undiagnosed) was 19.65% and glucose intolerance (diagnosed and undiagnosed diabetes plus impaired fasting glucose) was 22.11% for Marshallese outpatients >30 years of age. Total prevalence of diabetes (diagnosed and undiagnosed) increased with age from 5.30% at age 30-39 and leveled off to approximately 46.00% after 50 years of age. Total prevalence of glucose intolerance increased from 5.96% at age 30-39 to 59.09% at age >75 years. Conclusions: The rates of diabetes in Marshallese outpatients >30 years of age are similar to those found in native Hawaiians (Grandinetti). Both are significantly higher than the worldwide prevalence. Because there is a correlation between westernization and increases in prevalence of diabetes (Zane, Collins, Ebbesson), it is essential to follow the rise and fall of the prevalence of diabetes in the RMI over several generations. In addition, there are many cases of undiagnosed diabetes in the RMI. Because the complications of diabetes can be postponed with good glucose control, it is imperative to implement broad reaching testing.

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A Preliminary Study of Renal Risk Factors in a Pacific Island Population

Objective: a preliminary analysis of data collected by the National Kidney Foundation of Hawaii (NKFH) was done to examine renal disease risk factors in a targeted high-risk population. Methods: the NKFH conducted screenings for enal disease in this community-based sample using a standardized questionnaire, blood and urine samples, and blood pressure. A descriptive analysis of demographic and clinical variables was done using data from 283 participants. Results: females made up 63% of the population, Pacific Islanders 51%, and Asians 23%. Diabetes was present in 32% of the sample, hypertension in 62%, and a history of cardiovascular disease (CVD) in 76%. Fifty-one percent met the criteria set-up for Renal Disease/Insufficiency (RD). Associations of risk factors with RD was shown with diabetes P < 0.001, hypertension P = 0.002, and a history of CVD (used as a proxy for hyperlipidemia) P = 0.013. Conclusions: the majority of this population satisfied the criteria used for RD and at least three risk factors for RD were present. About 1/3 of the population met the criteria for diabetes, about 2/3 had hypertension, and more than ¾ had a history of CVD. Associations of these known risk factors with RD were shown with significant P values. Because Asians and Pacific Islanders together made up 74% of the total population, in the future, as this database grows, it might be possible to determine the risk of RD in these minority groups.

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HIV/AIDS in Nepal and Hawaii: Prevention, Diagnosis and Treatment

Daisy Lynn A. Galario

HIV has claimed over 16.3 million lives worldwide. Over ninety percent of the current cases occur in developing countries. It is important to understand how a developing country prevents the transmission of the AIDS epidemic in comparison to a developing country. A visit to the country of Nepal was made and research in regards to the AIDS epidemic in the country was conducted. Information about Hawaii and Nepal was obtained via contacting directors and workers of various AIDS service organizations, and reviewing articles and books. The literature review showed that poverty, illiteracy and ignorance are major factors in the transmission of HIV in Nepal. Prevention programs aren't effective, diagnostic procedures are modified and adequate treatment isn't available. Hawaii, in contrast, has a well developed and organized AIDS prevention program.

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The Health Status of Filipinos in Honolulu Today

Kamal Masaki, M.D., & David Johnson, Ph.D., Department of Medicine, Geriatrics Program, JABSOM
Glenn M. Garo

Objectives: This report studies differences in health status and health habits among young and middle-aged Filipino Americans. Also, this report determines relationships of traditional risk factors, positive and negative, to cardiovascular disease. Methods: Data is from the secondary data analysis of the Filipino-American Community Epidemiological Study (FACES). The respondents were in the age bracket of 18-65 and were divided into two groups, young (18-49) and middle-aged (50-65). Data collection included demographic information, health habits, self-report of chronic diseases, and self-perception of physical and mental health status. Chi square analysis was used to compare differences in categorical variables. T tests were used to compare means of continuous variables. Univariate and multivariate logistic regression analyses were used to study associations between risk factors and both heart failure and coronary artery disease. Results: Cigarette smoking was found to have no significant difference between the two age groups (p = 0.26). The middle-aged exercised more than the young by 8%. Logistic regression analysis showed that age, immigration status, diabetes, and hypertension were statistically significant and positively correlated to heart failure and angina. This was further analyzed with remaining variables being controlled for while one was being tested. All remained significant except hypertension in its relationship to angina. The young (53.2) perceive their physical health to be better than the middle-aged (51.2). Meanwhile, there was no difference in self-perception of mental health between the young and middle-aged, 53.3 and 53.1, respectively. Conclusions: As age increases, self-perception of good physical health decreases, whle that of good mental health is unchanged. The middle-aged are more susceptible to health risk factors and are exercising more. Increasing age, being U.S. born, diabetes, and hypertension are all associated with heart failure and coronary artery disease.

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Prevalence of Juvenile Rheumatoid Arthritis and Systemic Lupus Erythematosus on Oahu and the Neighbor Islands: Comparison of Outcomes of SLE on Oahu and the Neighbor Islands Due to Geographic Barriers

Dr. David Kurahara, Department of Pediatrics, JABSOM
Marie Han

Both JRA and SLE are not rare diseases. However, there have been very few studies on the prevalence of childhood rheumatic diseases, especially in the state of Hawaii. Understanding the prevalence of JRA and SLE will allow for better planning for medical resources. As of now, there are no childhood rheumatic specialists on the neighbor islands. Rheumatoid specialist from Oahu offer visiting specialty clinics about once a month to the neighbor islands. The outcomes of SLE may be worse on neighbor islands due to geographic barriers. The prevalence of JRA and SLE on Oahu and the neighbor islands was determined by counting the number of patients diagnosed with JRA and SLE on each of the islands. This was a retrospective study of a population of rheumatic illness in children based in Honolulu with outreach clinics to all major islands. The outcome of SLE patients on Oahu compared with the neighbor islands were measured in the number of hospitalization days. The prevalence of JRA and SLE was generally higher on the neighbor islands. The number of hospitalization days per patient was slightly higher for neighbor islands patients versus Oahu patients but the results did not show a significant difference.

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Distance Delivery in the Yukon-Kuskokwim Delta: Model for the Western Pacific?

Geoff Jones, MD, Alaska
Donald Persons, MD, Tripler Army Medical Center, Honolulu, HI
Thane Hancock, MPH

Providing quality health services to rural, remote and culturally distinct populations is a difficult task. In the Yukon-Kuskokwim Delta of Alaska, a Native Alaskan health corporation has established a policy to deliver care to this type of population. It employs a four-tier system of village clinics, sub-regional clinics, regional hospital and a full service facility in Anchorage to provide care to its indigenous populations. To connect these tiers of care providers, technology and transportation are heavily relied upon. This distance delivery policy is examined and analyzed in hopes of finding successful characteristics that may be employed in other similar populations of the world, especially in the Western Pacific.

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An Analysis of the Effectiveness of the Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP) for the Diagnosis of Osteomyelitis, Septic Arthritis and Acute Rheumatic Fever

Loren Yamamoto, MD, Department of Pediatrics, JABSOM
Michael Hayashi, David Park

The ESR and CRP are both sensitive indicators of inflammatory conditions such as ARF, osteomyelitits and septic arthritis. Although both are non-specific acute phase reactants, a normal value is useful to assist in ruling out such highly inflammatory conditions, and a highly abnormal value raises the suspicion of these conditions, encouraging additional diagnostic testing. Since ESR is based on the gravitational settling of erythrocytes, the size of the erythrocytes and/or their surface area to volume ratios may affect the drag force in the fluid media and hence, possibly the ESR. While it is commonly stated that the CRP is a better test for this clinical indication since it supposedly rises faster, studies comparing the twofor these clinical conditions are lacking in the literature. The purpose of this study is to compare the sensitivity and negative predictive value of the ESR and CRP in the early identification of ARF, osteomyelitis and septic arthritis. We hypothesize that 1) both the ESR and CRP are equally sensitive in identifying these conditions, 2) both the ESR and CRP have similar negative predictive values to help rule our these conditions and 3) microcytic erythrocytes affect the ESP, but not the CRP.

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Comparison of the Serological Response of Small Cell Lung Cancer Patients Against Vaccines Containing Two Different Polysialic Acids

Philipo Livingstion, MD, Memorial Sloan-Kettering Cancer Center, NY
M. Scott Hickman

Polymers of alpha2-8-N-acetylneuraminic acid residues are found at the cell surface of small cell lung cancers and in capsules of N. meningitidis group B. On SCLC, these polymers are attached to neural adhesion molecules (NCAM) where they act as carcino-embryonic antigens being expressed on fetal NCAM, but not adult NCAM, except as a consequence of oncogenesis. Standard vaccines against this polysialic acid polymer for prevention of meningococcal disease have been poorly immunogenic, most likely as a consequence of tolerance due to the expression on embryonic tissues. We have conjugated this antigen to the carrier molecule keyhole limpet hemocyanin (KLN) and mixed it with QS21 adjuvant as the optimal approach to inducing antibodies against poorly immunogenic antigens.The goal of this project is to ID a consistently immunogenic polysialic acid vaccine for inclusion in a polyvalent vaccine against small cell lung cancer and possibly for future testing against N. meningitidis. (This research was supported by an award from the Sloan-Kettering Cancer Center).

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Radiology Cases in Pediatric Emergency Medicine

Loren Yamamoto, MD, MPH, MBA, Department of Pediatrics, JABSOM
Kevin Higashigawa

In patients with complex clinical presentations, a diagnosis may be difficult to make without the help of laboratory work-up. In particular, radiographs tend to be helpful in confirming or excluding the preliminary diagnosis or to help identify new, alternative diagnoses. However, many clinicians may find radiographs difficult to interpret. Radiology Cases in Pediatric Emergency Medicine is an ongoing project which presents unique clinical vignettes with special attention to radiographic findings. The goal of this project is to provide continuing medical education for physicians. As such, Radiology Cases in Pediatric Emergency Medicine can be found on the internet at www.hawaii.edu/medicine/pediatrics and will also be made available on CD. "Forearm Swelling, Pain, and Numbness Following Trauma" (Volume 7, Case 6) provides a detailed discussion of compartment syndrome and "A Toxic Infant with Aseptic Meningitis" (Volume 7, Case 9) presents a case of a neonate with herpes simplex virus encephalitis.

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Improving Accuracy of Gestational Age Assessment in the Extremely Low Birth Weight Infant: Clinical Validation of Gestational Age Using Foot Length Measurements from the Delivery Room Record

Sherry Loo, MD, Department of Pediatrics, JABSOM
Colin T. Higuchi

Accurate assessment of gestational age is very important in the management of the extremely low-birth-weight infant. In these infants near the limit of viability, counseling the family for resuscitation, mortality, morbidity, and ongoing hospital course rests with birth weight and gestational age determination. While birth weight is objective, gestational age assessment is not, and many methods have evolved with various degrees of satisfaction and accuracy. The developments of obstetric ultrasonography and reproductive technology (i.e. in vitro fertilization, artificial insemination) have allowed a better gold standard than the LMP by which to measure accuracy. Consequently, fetal foot length regained attention as a robust parameter, with both anatomic and ultrasonographic bases as an indicator of gestational age. Since there is much evidence for fetal foot length as a viable parameter for gestational age evaluation, this study explored the validity of neonatal foot length by which to assess gestational age in extremely low-birth-weight infants. Gestational age and foot lengths based on newborn footprints were obtained from 100 delivery room medical records of infants weighing less than 1,250 grams. A scatter diagram of foot length versus gestational age was constructed, and using linear regression analysis, foot lengths from 21 additional records were used to predict gestational age. The results were compared to gestational age predictions based on data obtained from Mercer et al and gestational age estimates found on medical records. The outcome of this study showed that neonatal foot length has a strong association with Mercer et al foot length data, and so is an accurate, statistically significant, and simple method for assessing gestational age for preterm infants.

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Diarrheal Disease: Cholera and Typhoid Fever in a Rural Hospital in Nepal

Helen Hansen, MD, David Rogers, MD, Phil Stiver, MD, Dave Stengel, MD, Sobha Nani Gurung, RN, Digby Hoyal, MD, Olak Jirel, MD, Nepal
Jennifer Holzman

This paper introduces the topic of environmental factors as they relate to the global burden of diarrheal disease using two case studies from a rural hospital in the Gorkha district of Nepal. Two diseases were looked at specifically, cholera and typhoid fever. The cases were presented and the nature of the disease analyzed, specifically epidemiology, etiology, transmission/pathogenesis, clinical presentation, diagnosis and treatment. A comparison was made with the nature of the disease in the United States and the similarities and differences surrounding them assessed. By looking at two of these diarrheal diseases in depth, the public health issues surrounding them are more clear and are discussed in this paper.

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Geriatric Cooperative Health Care Clinic, Kaiser Permanente, Lahaina Clinic: A Quentin Burdick Project

Eileen Exton, MD, Jane Bartlett, RN, Kaiser Permanente, Maui
Dan Hudak

Cooperative Health Care Clinics (CHCC) incorporate individual primary care physician visits with group health education and socialization. The CHCC concept is relatively new beginning in the early 1990's in Kaiser Permanente clinics in which patients deemed "high utilizers" of the clinic replace individual PCP visits with group CHCC visits. A CHCC was implemented in the Lahaina, Maui community in order to better health care delivery in a sub-population of Lahaina - "high utilizer" patients over the age of 65 without serious disability. A Lahaina PCP agreed to incorporate her patients into the CHCC. The actual invitees to the CHCC included those patients over 65 who had visited the clinic at least 10 times within the past year. Following past CHCC guidelines the initiation of the group clinic was achieved and infrastructure built to perpetuate the CHCC meetings on a monthly basis.

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Student Participation in Biomedical Research Activities: An Administrative Proposal

Kenton Kramer, Ph.D., Leslie Tam, Ph.D. Office of Medical Education, JABSOM
E. William Johnson, MPH, Jeffrey Gertsch, Haven Malish

Objective: Every JABSOM student should become aware of the role of research in medicine and have an opportunity to participate in research. Description of Proposal: 1) the Student Research Link website will organize current research opportunities available to students. Faculty and community researchers will be asked to electronically submit general descriptions of their research and how students might participate. Students who are interested in visiting a research site or organizing an elective or summer research can browse this website. Students must initiate contact individually. The Student Research Link will also catalog student comments after their experience is completed and provide a list of grant options. Second, a ten-hour "Research Exposure Short-Course" will be offered twice per year. Students are asked to visit faculty and community researchers to complete an overview of research prior to beginning their traditional summer research requirement. Third, students wishing to pursue a more in-depth research experience may enroll in a Research Mentor Elective or choose a summer option with a research focus. The proposed Student Research Committee of the MD Program Committee will oversee and evaluate the Student Research Link, Research Exposure Short-Course, and Research Mentor Elective. This proposal was unanimously approved by the MD Program Committee in 1999.

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Radiographic Cases in Pediatric Emergency Medicine: 1) Discitis, 2) Kidney Stones

Dr. Loren Yamamoto, Dr. Lynette Young, Department of Pediatrics, JABSOM
Daniel Kidani

Radiographic evidence is sometimes the key in diagnosing certain medical cases. This project centered around radiographic findings to present and discuss cases of discitis and kidney stones in children. The project entailed performing literature searches to provide background information on the two topics. The information was used to write a section descibing the epidemiology, etiology, clinical manifestations, laboratory results, radiographic findings, and treatment of the topics at hand. This information was then used to present and discuss the different cases such that one would be better able to visualize the medical history and clinical manifestations of discitis and kidney stones so as to better recognize these entities when encountered in the real world. The documents generated from this project, one on discitis, the other on kidney stones will be part of a continuing medical education CD-ROM, as well as posted on the net, by Dr. Loren Yamamoto.

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Determinants of Successful Adaptation to Bereavement in Elderly Japanese American Women in Hawaii: A Pilot Study

Linda Tom, MD, Kamal Masaki, MD, Carolyn Murdaugh, Ph.D., Lon White, MD, Ph.D.,Patricia Blanchette, MD, MPH., Department of Medicine, Geriatrics Program, JABSOM
Cecily Ling

As the geriatric population continues to grow, so does the need for caregivers for these elderly. Adverse effects of long-term caregiving have been well studied, but relatively few studies have examined bereavement, particularly in minority groups. This pilot study addressed factors affecting long-term bereavement in caregivers. A follow-up questionnaire to a prior Honolulu Heart Program (HHP) case-control study, which looked at dementia vs. non-dementia caregiving (1991-1993), was used to collect information from widows of HHP participants. All subjects were Japanese American women. 15 subjects from each group (demented and non-demented) were interviewed. Current grief and depression scores were used to define bereavement patterns (High or Low), and were compared against various factors that may affect bereavement. Significant positive correlations were seen between present depression and 1) lack of social satisfaction in the caregiver, and 2) presence of more bothersome dementia-related behaviors in the decedents prior to death. The data showed trends suggesting that present grief was higher in those who cared for husbands who 1) did not have dementia, 2) experienced pain before death, had a 3) sudden or 4) unexpected death, 5) died someplace other than home, and 6) showed more bothersome behaviors prior to death. Trends also showed present grief to be higher in caregivers who 1) presently live alone, 2) had less education, and 3) provided a shorter duration of care. Identification of determinants of successful of unsuccessful long-term adaptation to bereavement may have future implications in defining preventative intervention strategies. Efforts can then be made to optimize the caregiver's health and well being after bereavement.

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A Study of Creutzfeldt-Jakob Disease in Hawaii

John Hardman, Department of Pathology, JABSOM
Steven J. K. Lum

The family of transmissible human spongiform encephalopathy includes Creutzfeldt-Jakob disease (CJD), Gerstmann-Staussler-Sheinker syndrome (GSS), and kuru. The transmissible agent responsible for the typical neurohistological triad of spongiosis, astrogliosis, and neuronal degeneration is an infectious protein, termed a prion (for proteinacious infectious particle). To date no nucleic acid has been found. CJD manifests in four variants, sporadic, familial, iatrogenic and the recently discovered variant form. In this study of retrospective cases of neuropathologically verified CJD cases from Kaiser hospital on Oahu the most common form of CJD was sporadic. This form affects men and women equally at a mean age of 60 with a worldwide incidence of 1 per million per year. Retrospective medical records detail CJD patients manifesting progressive mental deterioration, pyramidal signs, visual disturbances such as diplopia, and cerebellar dysfunction such as myoclonus spastic contractions. A useful tool in diagnosis, although not pathognomonic for CJD, is electroencephalography (EEG) that displays periodic patterns of 1-2 cycles/sec triphasic wave activity. CJD diagnosis is important to diagnosis as these patients quickly deteriorate and die within a year. Additionally, as there is no current treatment for CJD the diagnosis is important to alert both physicians and pathologists to the risks of infection during biopsies, surgeries and autopsies.

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Induced Apoptosis in Cultured PtK2 Cells by Enteropathogenic Escherichia Coli (EPEC)

Haven Malish

Two strains of Enteropathogenic Escherichia Coli (EPEC), JPN 15 and wild type E2348/69, induced apoptosis in cultured PtK2 cells in 10-12hours. Wild type E2348/69 induced apoptosis in Caco-2 cells in 21-36 hours. Apoptosis was detected in the cells by a fluorescently labeled ntibody that reacts against bromolated deoxyuridine triphosphate nucleotides (Br-dUTP) that incorporate into the 3'-hydroxyl ends of DNA fragments created during apoptosis. We modified the detection procedure for use on adherent cells. Disruption of the actin network, probed using rhodamine-labeled phalloidin, accompanied EPEC induced apoptosis in PtK2 and Caco-2 cells. Placement of chemically fixed, i.e., dead, EPEC does not induce apoptosis or the loss of stress fibers in PtK2 cells. In contrast to EPEC infections, infection of PtK2 cells with Listeria monocytogenes (L. monocytogenes) did not induce apoptosis in PtK2 cells. When EPEC (E2348/69) were grown in protein-free medium and the medium was then filtered to remove the EPEC, apoptosis and the loss of stress fibers were induced in both cell lines by the filtered medium. A larger volume of EPEC (E2348/69) was grown in protein free medium. When the medium was fractionated, concentrated and then added to PtK2 cells, apoptosis and the loss of stress fibers were also induced. When the concentrated medium was analyzed by SDS-PAGE, the bands on the gel corresponded to the molecular weights of proteins that are known to be secreted during EPEC infection. Another portion of the bacterially conditioned medium was processed through a 10-kDa filter. Whereas the lower molecular weight fraction produced levels of apoptosis lower than 1.5 percent in both cell lines, the fracion containing molecules greater than 10-kDa induced apoptosis in at least 99 and 39 percent of PtK2 and Caco-2 cells, respectively. Keywords: apoptosis, stress fibers, actin, Enteropathogenic Escherichia coli, Listeria monocytogenes, cytoskeleton, cell death, Type III secretion.

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SunSafe for Kids: A Pilot Sun Safety Education and Awareness Program

Ivy Nip, MD, Department of Medicine, JABSOM
Pamela Monzon, Brent Ogawa, Kimberly Siu, William Wilson

Sun exposure during childhood accounts for about 80% of total lifetime exposure, putting children at particular risk, making early detection and prevention efforts crucial for all skin cancers. Reducing lifetime exposure to ultraviolet radiation and eliminating severe overexposure prior to age 20 may substantially reduce the risk for nonmelanoma skin cancer and melanoma. A sun safety awareness program titled, "SunSafe for Kids," was a pilot study developed to target second and third-grade children for a private school. The goal of "SunSafe for Kids" is to enhance knowledge and understanding of sun protective behaviors in order to promote positive attitudes and practices in the area of preventative care. 136 children, ages from 7-8, were studied. One week prior to the instruction, the children were given a multiple question Pre-Test which consisted of 10 number of questions. The test questions were conducted at school and evaluated the children's perceptions of the sun, their knowledge of its effects, and their behavior when preparing for the sun. The SunSafe program taught 15 classes of children in 4 days. The program was interactive and the curriculum consisted of discussing sun safety such as sunscreen use, protective clothing, and some of the consequences of sun exposure. At the conclusion of the fourth day, there was a SunSafe Fair, which was held for 60 minutes in the courtyard of the school. 13 days after the completion of the SunSafe program, a post-test, consisting of the same 10 multiple choice questions as the pre-test was given. Significant differences in pre and post-test scores exist for questions regarding sun protection factor (SPF), wearing sun protective clothing, ethnicity risk for sunburn, and sunscreen use. Differences in these questions showed a higher number of students selecting the appropriate answer in the post-test. A total correct score was tabulated as the "Sun Safety IQ" in which questions with regard to enhancing knowledge and understanding protective behaviors were selected as a measure of the children's basic understanding of sun safety. Sunscreen IQs were significantly higher across age groups and sex in the post-test. In summary, the Sun Safe for Kids pilot program was successful in educating the target population on sun safety awareness. The results showed validity and potential of a sun safety program being incorporated into a school curriculum.

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Echocardiographic and Cardiac Catheterization Predictors in Pediatric Heart Transplant Patients Without Rejection

Jeffrey A. Feinstein, M.D., M.P.H., Daniel Bernstein, M.D., Clifford Chin, M.D. Department of Pediatrics, Stanford University School of Medicine
Kyra A. Nishimoto

Background: Endomyocardial biopsy is utilized to detect rejection in pediatric cardiac transplant patients. Although the risk associated with endomyocardial biopsy is low the procedure is invasive, therefore echocardiography is a potential noninvasive means to detect cardiac rejection. The purpose of this study was to investigate the possibility of using echocardiography or catheterization measurements to predict biopsy findings.Methods: This was a retrospective study that reviewed the transplant databases for biopsy results, catheterization, and echocardiography measurements. The study time frame was from 1/1/99-6/30/00 in which 281 biopsies were performed on 50 pediatric patients. Results: When attempting to identify episodes of >grade 1A rejection, the RVED, RAp, PAsys, PAmean pressure measurements were significantly lower in those with positive biopsies compared to measurements made during a negative biopsy. The negative predictive value of six of the catheterization (RVED, MVsat, PAsys, RAp, PAmean, and PVR) measurements and three of the echocardiography (%FS, VCFc, and M1) measurements were >83% for predicting a rejection episode of grade 2 or greater. However, the sensitivity, specificity, and positive predictive values were low for these pressure measurements. Conclusions: endomyocardial biopsy should continue to be utilized to diagnose rejection in pediatric cardiac transplant patients because the sensitivity and sensitivity of cath and echo values were low. Negative predictive values, however, for these pressure measurements were high, therefore if a patient has normal echo and cath values it is unlikely that they are experiencing a rejection episode of grade 2 or higher.

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A Quentin Burdick Project, Hamakua, Big Island

Bev Cypirano, Hamakua Health Center
Jason Nomura

The Quentin N. Burdick Rural Health Project focuses on community capacity building in rural areas. The particular focus in Honoka'a was in health education for the community. A need assessment of the community was conducted using survey and interviews to determine health needs, concerns, and assets of the community in the health area, as well as a possible location for a health education center. The results show an interest in increasing services in the area and would welcome a health education center. The community has a wealth of local talents and a strong interest in sharing through community service. Health education in Honoka'a should focus on the top three identified concerns, drug and alcohol abuse and teen pregnancy. Recommendations include developing alternative transportation strategies, establishing a network of health education resources through the Hamakua Health Center and establishing a monthly calendar of activities to better inform the community of opportunities for enhancing health and wellness.

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The Effects of Abdominal Paradox on Vital Capacity During Inspiration

Drs. Lyn Silbert, Richard M. Smith, David Lally, Department of Physiology, JABSOM
John Sheehan

We measured vital capacity (VC) in 12 healthy normal subjects (NS) and 6 athletes to determine if voluntary contraction of the lower transversus abdominis (TA) in conjunction with latissimus dorsi muscle (LDM) recruitment to enhance lower rib cage expansion during inspiration would increase VC compared to their natural breathing mechanics. The NS had participated in structured 1 hour strength training classes 3 times per week for 1 year where they learned the above experimental breathing mechanics (EBM) and weight training exercises. All subjects performed 3 VC tests with the lower abdomen pulled in maximally while recruiting the LDM (VCEBM), and 3 VC tests utilizing their natural breathing mechanics (VCNB). Protocol order was random and subjects were naïve as to the intent of the study. We found that VCEBM was larger than VCNB for all subjects. The mean VCEBM for the NS was significantly greater (5.6%) than the mean VCNB (4.72 + 1.27 vs. 4.47 + 1.17L) by paired t-test (P < 0.0001). The mean VCEBM for the athletes was also significantly greater (4.6%) than the mean VCNB (4.74 + 1.43 vs. 4.53 + 1.51L, P < 0.01). The mean rib cage circumference (RCC) at maximum inspiratory volume VCEBM was significantly larger than the mean RCC VCNB for both groups (P < 0.03). We confirmed that the mean waistline circumference (WC) VCEBM was significantly smaller than the mean WC VCNB for both groups (P < 0.0001). The results suggest that inward contraction of the TA in conjunction with LDM recruitment increased VC and RCC in both athletes and NS.

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Diversity of Marine Biotoxins in the Near-shore Ocean Area: Presence of a Palytoxin-like Entity at Barbers Point Harbor, Oahu

Yoshitsugi Hokama, Department of Pathology, JABSOM
Kelly M. Wachi

The presence of palytoxin or palytoxin-like compounds in fish extracts has been presented in this study. The hemolytic assay with sheep erythrocytes demonstrated the occurrence of hemolytic factors in fish extracts of Hawaiian reef fish from Barbers Point Harbor, Oahu. The rabbit anti-palytoxin inhibition assay with fish extracts and sheep erythrocytes demonstrated that palytoxin or its congener contributed to the lysis of sheep erythrocytes. From these results, it was concluded that sheep erythrocyte hemolysis was caused by palytoxin or palytoxin-like factors present in the fish extracts. Moderate correlation (R2) between mouse toxicity and sheep erythrocyte hemolysis was shown with 50 µg (R2 = 0.48) and 100 µg (R2 = 0.45) extracts. An inverse correlation of R2 = 0.64 was shown between hemolysis and MIA endpoint.

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Human Immunodeficiency Virus Type-1 Accessory Protein Vpr Binds to p300 and Enhances Nuclear Receptor Coactivator Activity

Tomoshige Kino, M.D., Ph.D, George P. Chrousos, M.D., NICHD/PREB
Jeffrey J. Wong

Glucocorticoids are steroid hormones that help maintain homeostasis in higher organisms. They play a significant role in the alteration and control of metabolism, and the response to stress. They are also one of the important therapeutic compounds for inflammatory diseases. Glucocorticoids act through binding to the glucocorticoid receptor. The glucocorticoid receptor is a ubiquitously expressed, cytoplasmic, ligand-dependent transcription factor. It binds to its responsive element in the glucocorticoid regulated genes, and interacts with recently described coactivators such as p300/CBP, P/CAP, and SRC-1 to stimulate transcription. Through a complicated series of events, this hormone-receptor complex causes transcription to be greatly enhanced. Many different diseases can occur when there is a disruption in tissue sensitivity to glucocorticoids. Interestingly, some of the symptoms found in AIDS patients such as immunosuppression, myopathy, central obesity, and muscle wasting may be related to increased sensitivity of glucocorticoids. The HIV-1 virion-associated accessory protein (Vpr) affects viral replication, cellular transcription, proliferation, and differentiation. Interestingly, Vpr has recently been found to act as a nuclear receptor coactivator, and it may increase tissue sensitivity to glucocorticoids. Vpr binds to the ligand-activated GR as well as the general transcription factor TFIIB, providing a link between the nuclear receptor and the transcriptional machinery. Our goal was to further elucidate the role and mechanism that Vpr plays in the coactivation of ligand-bound glucocorticoid receptor complexes.

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Anticonvulsant-Drug Therapy with Hypertonic Saline for Hyponatremic-Induced Seizure

Dr. Jinichi Tokeshi, Department of Family Practice and Community Health, JABSOM
Kristi Youn

Although seizures are uncommon manifestations of hyponatremia, when they do occur, they can lead to permanent brain damage and even death.1, 2 In patients with hyponatremic-induced seizures, 3% hypertonic saline is the standard treatment. A rapid rate of correction, however, may result in central pontine myelinolysis, a severe neurological disorder. Based on the available data in this case, Diazepam 5mg, Dilantin load of 750mg over 20 mins, and 3% hypertonic saline 25 cc/mL, resulted in correction of hyponatremia without subsequent seizures of myelinolysis.

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