The projects, listed below, were either part of the Community Medicine Courses (BIOM 581, 582, 583) or the Student Research Project (BIOM594). 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 Student 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.

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The MMR Vaccine and Misinformation on the World Wide Web

Randy Alejo, Marc Miyasaki, and Loren Yamamoto M.D.

The World Wide Web (WWW) is a rapidly growing resource of information available to the public. Patients and parents are increasingly turning to the web as a source of medical information. But how reliable is the information disseminated over the WWW? To determine this, we analyzed 320 websites that dealt with the MMR vaccine. The MMR vaccine was chosen as the focus of our study due to the significant amount of existing controversy surrounding the vaccine's safety. A 1998 article published in The Lancet sparked concern over a possible link between the MMR vaccine and autism. Using the Yahoo Search Engine, we conducted searches on eight different search terms, e.g. MMR Vaccine Adverse Reactions, related to the MMR vaccine and analyzed 40 websites per search term. These sites were analyzed and graded on two criteria: 1) does the site favor use of the MMR vaccine and 2) is the site consistent in regards to adverse reactions as stated by the Advisory Committee on Immunization Practices, Red Book 2000, The Centers for Disease Control and Prevention, and American Academy of Pediatrics. Our results, although not complete at this time, show that while there is accurate information to be found on various websites, a significant amount of misinformation about the vaccine exists on the web. Of the sites that were spreading misinformation, nearly all of them dealt with the MMR vaccine's association with autism. However, the search term used affected the number of inconsistent sites to be found. The implications of our results are that if patients were to do their own medical research on the internet, there is a good probability that they could be misinformed, not only about the MMR vaccine, but on other medical topics as well.

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Comparison of Medical Malpractice Rates Between the Graduates of a Pre and Post Problem Based Learning Curriculum Change at the John A. Burns School Of Medicine

David Behling, JD, Kristen Low, John Hardman, MD, and R. Severino, MS

Authors hypothesized that physicians trained in a problem based learning (PBL) format as opposed to traditional lecture based formats would develop stronger physician-patient relationships. This hypothesis is premised on the fact that PBL training places a greater emphasis on a patient centered approach to medical treatment. If PBL does indeed foster stronger physician-patient relationships, one objective measure of this phenomena may be through the filing of significantly fewer malpractice claims against PBL physicians compared to traditionally educated physicians in individual postgraduate years. Rates of malpractice filings against the1969 graduates for the John A Burns School of Medicine were compared between the school's two populations of graduates: 1084 graduates from a traditional format (1975-1992) and 385 from a PBL format (1993-1999). Due to the comparatively small population of PBL graduates and the fact that medical malpractice claims are relatively rare events on an annual basis compared to the number of physicians in the two populations, a statistically significant difference was not found. However, power analysis demonstrates that with the graduation of 10 more classes of PBL trained physicians a difference of 5% between the two populations rates of malpractice would demonstrate a statistically significant difference.

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Service-Learning in Hawaii Public High Schools: Community-Based Training for JABSOM First-Year Medical Students

Christina Bertao, Malia Haleakala, Scott Kawamoto, Kayla Nguyen, Chad Sparks, and Mike Fukuda, MSW

Contemporary literature comments on the lack of compassion and commitment for public service by Generation X. The 1960's ideal of working for the betterment of society has been replaced by individualism and the pursuit of personal gain. This has left medical students in a quandary: they chose medicine believing they could better society through health; however they do not have the experience or venue to fulfill this altruistic principle. Service-learning provides a structured experience that allows students to integrate scientific principles via problem solving on real life community issues. Our program, which is a collaboration of a private hospital and State University, provides health care to the underserved and community-based training to first-year medical students from the University of Hawaii John A. Burns School of Medicine. Teachers from two local high schools attended a lecture on the training needs of future health care sector workers, and requested assistance with their health education curriculum. We felt this presented an opportunity to forge a connection, which could provide long-term benefits to the community while providing a service-learning opportunity for students. Hospital-based Senior level faculty reviewed problem based learning for the teachers, and demonstrated how problem based service-learning could benefit their health curriculum. The Roosevelt High School faculty submitted a curriculum outline on health education topics that required content experts. First-year medical students used the high school curriculum as the basis for their problem-based learning, with hospital-based Senior faculty acting as facilitators. Our medical students presented the reproductive anatomy through traditional lecture; however moved to small interactive groups to review the birth process, contraception and sexually transmitted disease. This facilitated comprehension of complex health information, and allowed the high school students immediate feedback if unclear on the topic. A one-group pretest-posttest design was used to determine if the reproductive health education presentation met the curricular goals for the high school students. Two physical education classes attended the presentation. The two classes improved their mean score of correct answers after the presentation, demonstrated by a significant increase from pretest to posttest (class one: t = 3.63, df = 49, p < .05; class two: t = 5.8, df = 53, p < .05). Service-learning is a mutually beneficial and rewarding curriculum. Our data demonstrate that service-learning can improve the knowledge of high school students through medical student content experts. In addition, in conjunction with the University of Hawaii John A. Burns School of Medicine's mission to form and foster interactive community partnerships and alliances, this experience allowed the medical students to recognize and fulfill a social responsibility to their community. (Reviewed in Hawaii Medical Journal. January 2002)

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The Usefulness of the Hospice Experience for Medical Students

Christina Bertao, Kayla Nguyen, Reiko Kayashima, MS3, and Kathryn Braun, DrPH

Although end-of-life care has become a topic of receiving increased attention over the past 25 years, education in this field is lacking in most US medical school programs. To begin to address this deficiency, the current curricula of John A. Burns School of Medicine at the University of Hawaii includes a 12-week hospice rotation during the 1st year of medical school (MS1). The purpose of this study was to evaluate the usefulness of a required rotation in preparing MS1s to care for terminally ill patients in their clinical years. We administered a 2-page anonymous survey to 111 students in the first and fourth years (MS4) of medical school (100% response rate). We compared MS1s and MS4s regarding attitudes and comfort level in providing various aspects of end-of-life care (EOL). Data were analyzed using SPSS. We found that MS4s valued the hospice experience more than MS1s (90% vs 68%, p <0.01). This difference may be due to the clinical experience of the MS4s. In contrast, we found few differences in comfort levels with EOL care skills between the classes. Almost 90% felt comfortable with their listening skills. About 50% of students from both classes rated themselves as comfortable with their knowledge of grief/bereavement, symptom control, physical needs and psychosocial needs. About 25% of each class felt comfortable discussing a patient's terminal illness with the patient and family. Although students did not link their hospice experience with large improvements in their comfort of caring for dying patients and families, 81% of MS1s and 90% of MS4s looked back on the hospice rotation as a useful experience for them as clinicians. Our finding suggest that this rotation could be improved by 1) increasing patient contact time, 2) adding components that allow students to reflect on and process the experience (complete their own advanced directive, weekly discussions, contact with physician role models), 3) administering pre- and post-tests, to measure change in student knowledge and comfort, and 4) developing a mechanism for students to provide feedback to hospice rotation sites. (This paper was presented in the Community Medicine Category at the First Annual MS2 Research Symposium on October 5, 2001; This abstract has been accepted for presentation in 2002 at the Hawaii ACP and the American Geriatric Society meetings).

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The Perception of Breathing, Exercise, and Alternative Medicine Techniques to Improve Asthma

Benjamina Brown and Roy Adaniya, MD,

As new research begins to study the effects of various non-medicinal techniques for asthma care, new recommendations for the use of traditional drug treatment plans in conjunction with non-pharmaceutical techniques are forming. These new recommendations affect how physicians educate and communicate asthma information to patients. This study utilizes a survey format to look at any pre-existing knowledge and experience asthma patients have regarding these alternative techniques, and correlates their attitudes with degree of asthma severity, years with asthma, ethnicity, age, and medicine use. Results showed the majority of the 24 patients surveyed would like to learn more about various exercises that may improve their asthma symptoms, and all but 4 patients perform exercise or breath work on a regular basis. The survey, although a small one, did reveal both existing interest and awareness for non-medicinal techniques to improve the quality of life of patients with asthma, suggesting that physicians treating asthma should educate both themselves and their patients on any possible benefit or harm that these alternative treatment methods can cause.

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IL-10 Induces Apoptosis in Human Lung Fibroblasts: Implications for Airway Remodeling in Asthma

Owen T.M. Chan, Elizabeth Tam, MD, Claude and Jourdan-Le Sauxl, PhD

Fibroblasts play a key role in the process of airway remodeling, a deleterious event that can follow chronic inflammation in asthma. As a result of tissue damage and repair, fibroblasts upregulate various extracellular matrix products (i.e. collagen), which can compromise breathing dynamics via airway thickening. It is unclear what factor(s) is dysregulated to promote the remodeling phenomenon. To investigate the cytokine-mediated regulation of airway cells, the present work investigated the role of IL-10 on human fibroblasts. We observed that IL-10 induced apoptosis in cultured fibroblasts, as assayed by the TUNEL assay and flow cytometry (annexin V and propidium iodide staining). Our preliminary results show an 82% increase in apoptotic cells by IL-10 treatment, compared to untreated controls. These findings support that IL-10 may play a direct role in remodeling homeostasis through the removal of matrix-building fibroblasts. (This paper was presented in the Basic Science Category at the First Annual MS2 Research Symposium on October 5, 2001; Winner of the Best Overall Poster at the 2002 Biomedical Sciences Symposium, March 22, 2002).

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Adjuvants and a Plasmodium falciparum MSP-1 malaria vaccine: Is growth inhibitory antibody correlated with antibody affinity?

Peter Chang, Yoichi Soma, MS2, George Hui, PhD and Leslie Tam, PhD

Malaria is a leading cause of morbidity and mortality in tropical, developing countries and numerous efforts are underway to develop a malaria vaccine. The Plasmodium falciparum merozoite surface protein -1 (MSP-1) has been shown to completely protect Aotus monkeys against a lethal human malaria infection. The vaccine is believed to be dependent upon the use of Freund's complete adjuvant (FCA), a strong but clinically unacceptable immunologic adjuvant. Hui and coworkers (1991) reported that a combination of synthetic but clinically acceptable, low-toxicity synthetic adjuvants could produce parasite growth-inhibitory antibodies with MSP-1. In this study, inhibition of parasite growth was correlated with antibody titer. It is unknown, however, if growth inhibition is also correlated with antibody affinity. Kenney and co-workers (1989) reported that antibody affinity, in a study of various adjuvants, is not always correlated with antibody titer. The synthetic adjuvant Quil A produced lower antibody titers but higher affinity antibodies to bovine serum albumin when compared with FCA. KinExA is a newly available instrument (developed by Sapidyne, Inc.), which enables rapid measurement of antibody affinity. The instrument is based on a flow injection system and determines the unoccupied binding sites after an antibody and antigen are allowed to react in solution. This study was initiated to investigate the relationship between antibody affinity to MSP-1 (potentiated by FCA and other adjuvants), antibody titer, and the ability of antibodies to inhibit parasite growth in vitro. It is hypothesized that parasite growth inhibitory antibodies have high affinity, while non-inhibitory antibodies have low affinity. Serum samples from the 1991 study in which rabbits were immunized with MSP-1 with various adjuvants were analyzed. The results, discussion, and conclusion are still in progress. (This paper was presented in the Basic Science Category at the First Annual MS2 Research Symposium on October 5, 2001).

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Physician Based Evidence for the Benefit of Research: A Subjective and Objective Study

Lori Murayama, Grant Chen M.S., and Douglas G. Massey, M.D.,

There exists a large amount of anecdotal evidence, but little objective information as to the importance of the research experience in medical education. In order to explore this relationship, we surveyed 203 practicing and retired physicians. As of 8/31/01, we had received 79 surveys back out of 203 sent. Of these, 3 surveys were unfilled due to the physicians passing away, and 5 were undeliverable. The information received was entered into a Microsoft Excel database, and will be analyzed using Excel and SPSS/JMP. As of this date, we have not yet completed statistical analysis due to the lack of the return of all the surveys. Currently, it appears that there is little to no difference between the two populations in regards to objective measurements. However, they appear to have substantially different subjective views on the importance of having research experience, specifically, if having the experience substantially benefits medical students and physicians.

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Reliability of Human Growth Hormone Information on the Internet

Scott Suetsugu, Aaron Choy, Brian Garcia, Max Miranda, Leila Okinaka, Damian Ymzon, and Loren Yamamoto, MD

The use of Human Growth Hormone (HGH) substances that purportedly alter HGH levels is increasing due to the popular belief that increased HGH levels can reverse the aging process, increase muscle growth and improve many other medical and cosmetic conditions. There is, however, no conclusive evidence to support these claims as the purported benefits have only been demonstrated in a small-scale study with a low number of subjects. Because patients looking for medical information often utilize the Internet and this information is not regulated for reliability, it is important for physicians and medical personnel to be knowledgeable about the products and information offered on the Internet. The objective of our study was to evaluate the information and products related to HGH offered on the Internet. During July 2001, a web search was conducted under the headings growth hormone, human growth hormone, growth hormone and anti-aging, and growth hormone and bodybuilding. The first 50 web sites from each category cross-matched for redundancies that resulted in 200 different sites. These were then evaluated based on a set list of criteria to determine the purpose of the web site, the nature of the products sold (if any), and the claims made about HGH supplementation. Of the 200 web sites evaluated. 152 were relevant to our topic. Of those, 119 (78.2%) were commercial sites, 32 (24.8%) commercial sites were selling recombinant HGH while the rest, 75.2% sold HGH releasing products that are meant to increase HGH levels. The majority of the web sites did not list safety claims, disclaimers, side effects or contraindications. Most (53.8%) of the commercial sites surveyed failed to list the ingredients of their products. The most common claims made about HGH are increase in muscle growth, decrease fat/weight loss, increase strength/stamina/endurance, anti-aging, enhanced immune function, and improved sexual performance. The results indicate that there are many HGH supplements being sold on the Internet that claim to benefit individuals in the ways mentioned above, although there is no conclusive evidence to support those claims. Although side effects have been reported, many of these web sites do not mention them or state that there are none. Furthermore, a majority of the web sites did not list the ingredients to their products. Doctors should be aware of the claims being made about HGH on the Internet as well as the products sold so that they may advise their patients when asked about HGH replacement therapy.

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Pain in Elderly Cancer Patients: Assessment and Staff Awareness in an Asian American Population

Sze Mei Chung; Kamal Masaki, MD; Emese Somogyi-Zalud, MD; Kenneth Sumida, MD; Patricia Blanchette, MD

Cancer is a common disease among elderly patients, and pain is one of its most treatable symptoms. Yet 25%-40% of elderly patients with cancer experience pain everyday. Methods: Forty interviews were conducted on patients age > 65 years with a current history of cancer, in the in-patient or out-patient oncology wards at Kuakini Medical Center. The interview included demographic information, medical history, pain assessment (intensity, frequency, duration, onset, quality, and location), ADLs, IADLs, satisfaction with pain treatment, side effects from pain medications, quality of life (QOL), and MMSE. Pain intensity was measured using the Numeric Pain Intensity Scale (0-10), the Wong-Baker face-expression scale, and the Visual Analog Scale. The data from these interviews were compared with the results from surveys on the nurses' perception of their patients' pain. Descriptive statistics, t-tests, chi square, and Spearman models were used for analysis. Results: Forty patients (20 males:20 females; age range 66-85 years) and their nurses participated in this study. The majority of participants (77.5%) were Japanese. During the past 24 hours, 40% reported no pain, 30% had mild pain, and 30% had moderate-severe pain. We found very high correlations (r=0.85-0.94; p=0.0001) among the different pain intensity scales used. There were also high correlations between the patients' and their nurses' reporting of pain intensity (r=0.71; p=0.0001) and frequency (r=0.54; p=0.0004). Correlations between nurses and patients regarding pain intensity were better in those patients who had mild pain compared to those with moderate-severe pain. Patients' feelings of sadness significantly correlated to their pain intensity (r=0.40; p=0.01). The younger age group (65-75 years old) had significantly worse pain intensity compared to the older age group (> 75 years old), p = 0.02. There were no significant differences in reported pain intensity by patient's gender or educational status. Conclusions: Pain is a very common symptom among elderly patients with cancer. We found good correlation among the three different pain scales used in this Asian-American population. Nurses did well in assessing their patients' pain intensity and frequency, particularly in those with mild pain. Future research should study the effect of nurse training on pain assessment. This work was supported by the John A. Hartford Foundation Center of Excellence in Geriatrics, University of Hawaii. (This abstract was accepted for presentation in 2002 at the Hawaii ACP and the American Geriatric Society meetings).

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Children of Immigrant Families: Under Use of Federal Benefits and Resultant Adverse Health Outcomes

Stephen Darling, J. Cook, A. Skalicky, and D. Frank

The purpose of this study was to determine whether US born children of immigrant parents suffer poorer health outcomes and greater food insecurity due to under use of federal public assistance programs such as Welfare, Food Stamps, and WIC. Children of low-income families residing in the greater Boston area were included in a nutrition surveillance study under the Children's Sentinel Nutrition Assessment Project. Interviews were conducted on caregivers of children less than 3 years old in the pediatric ER Department of the Boston Medical Center. Interviews included the USDA Food Security Instrument, demographic, along with Food Stamps and Welfare participation. Medical records review identified hospital admission on the day of the interview. Of 2481 children's families interviewed, 1766 (71.2%) were children of US born parents, and 715 (28.8%) where children of immigrant parents. All analysis was controlled for families receiving public insurance in the form of Medicaid or free care, the child being born in the US and children not receiving supplemental security income for a disability. Compared to children of US born parents, children of immigrant families were less likely to be covered under Welfare (71.2% vs 28.%, p <0.001), and also less to use Food Stamps (72% vs 33.9%, p< 0.001). However, immigrant families were more likely to use WIC for their children (82.4% vs 88.5%, p <0.001). Children of immigrant families were more likely to be food insecure (25.7%) compared to children of US born parents (18.1%, p < 0.001) according to the USDA Food Security Instrument. Children of immigrant families were also more likely to be admitted to the hospital following a ER visit (11.5% vs 7.8%, p = 0.02). Analysis of questions regarding perinatal health revealed that 17.7% of children of US born parents were born premature (<37 weeks gestation) compared to 14.5% of children of immigrant parents (p=0.025). The children of immigrant parents were more likely to be breast fed in this perinatal period than children of US born parents (80.1% vs 47.4%, p < 0.001). While children born in the US to immigrant parents are eligible for federal benefits, the families of these children are not accessing these services. This results in children of immigrant families being more food insecure and at greater risk of malnutrition and subsequent poor health. Therefore, strategies to ensure that immigrant families are accessing the benefits and services for which they are eligible may reduce the negative health outcomes for these children, including the need for expensive hospitalization. The view Steve's poster click here. (This paper won first place in the Community Medicine Category at the First Annual MS2 Research Symposium on October 5, 2001).

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Na Keiki 'O Kauai: A Quentin Burdick Project

Lehua Concepcion, David Jackson, Jennifer Mishima, Amy Marshall, and Nancy Phillion, RN

The Garden Island of Kaua'i is the home of Wai'ale'ale, the wettest spot on earth, Hamura's Saimin and the project site of Quentin Burdick Lihue team from June 18th to July 28th, 2001. David represented clinical psychology, Jennifer, nursing, Amy, social work and Lehua, medicine. Nancy was the site coordinator. Our goal was to develop projects beneficial to the community and to view those projects from our disciplines as well as our team members' disciplines. Although our team was based in Lihue, we were fortunate to work in Hanalei - a truly rural town - for two weeks. Hale Halawai is dedicated to celebrating and increasing the resources and spirit of the people of the Hanalei area. It encourages community participation in all decision-making, and acknowledges that Hanalei's geographic isolation, rural environment and close ties to cultural roots contributes to a community with unique strengths and concerns. We participated in the Halele'a Cultural Exploration Program for children between ages 5 and 13. We taught health related topics such as sun safety, dental hygiene, first aid and nutrition. The latter part of our project involved the Summer Health Academy. This is a summer program designed to introduce 7th and 8th grade students to the health care field. We organized each day to include both active participation and learning down time. Some of the activities included: CPR, violence prevention, visiting the local hospital and meeting the EMS team. They also learned about diagnostic specialists, nutrition, community nursing and microbiology.

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The Use of Biological Markers in Identification of Aggressive Tumors among Native Hawaiian Breast Cancer Patients in Hawai'i

Rosalyn Enos, Jeanelle Kam, Clayton Chong, M.D., and Kathryn Braun, DrPH

Breast cancer is the most common solid tumor in women and the second leading cause of breast cancer death in females in the United States. (1) Although Caucasians have a higher incidence of breast cancer, Native Hawaiians have a higher mortality rate from breast cancer than any other ethnic group in Hawaii. In explaining cross-ethnic differences in breast cancer survival in Hawaii, Meng et al (11) propose that histopathological differences may exist. An important research question, then, becomes: " Is the higher incidence of late-presenting breast cancer in Native Hawaiian women due to a significantly more aggressive biologic cancer leading to a more advanced stage of breast cancer at diagnosis?" If so, changes to screening frequency and treatment regimes may be indicated. If not, perhaps later presentation is due to delayed screening and diagnosis, indicating the need for more interventions targeting health knowledge, behavior, and access. In an attempt to begin explorations in this direction, this study will examine the associations of various breast cancer prognostic factors (classical and biologic) by ethnicity. This was a retrospective study conducted at a Honolulu oncologist's office who has a broad based population. A chart review was conducted on 192 breast cancer patients who had been diagnosed between 1996 through 2001. Once the patient's charts were obtained, an excel database was created with the following categories: Patient Identification number, date of birth, date of diagnosis, race, and the laboratory that provided pathology and biological markers. The pathology was categorized into the following: tumor size, tumor type, differentiation (histological grade), necrosis, lymphatic or vascular invasion. These pathological categories are classical tumor markers that are used in the diagnosis, staging, and treatment of breast cancer. The biological markers used are: Estrogen Receptor (ER), Progesterone Receptor (PR), Her2neu, KI-67, and P53. The biological markers used are: Estrogen Receptor (ER), Progesterone Receptor (PR), Her2neu, KI-67, and P53. The statistical analysis did not show significant difference among racial groups for the biological markers identified above. There may be a biological tumor marker that may be used to identify the aggressiveness of the tumors among Native Hawaiians when compared to other races. While this study aimed to find the link between race and tumor aggressiveness, the limitations were multi-factorial. In order to adequately explore this connection, there needs to be a standardized protocol, there must be a larger sample size, there must be patients from different oncologists, and a standardized pathological report among laboratories.

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Cancer-Related Ideas and Preferences: A Comparative Study of Japan and the U.S.: A Brief Report

Maxwell Frank and Carolyn Gotay, PhD

The cancer-related attitudes and beliefs of adults living in Japan (N=357) were compared to a Hawaii sample (N=223) consisting of both Japanese (n=106) and Caucasian (n=117) individuals. The majority of U.S. subjects thought doctors should disclose cancer diagnoses to their patients, while a minority of the Japan sample supported cancer disclosure as a general practice. However, the majority of Japan respondents expressed a personal preference to be told, however, should they become ill with cancer. In addition, U.S. subjects rated cancer to be more curable than did Japan subjects, both at the present time and in the future. Finally, word-associations were obtained for "death" and "cancer" in order to explore cross-cultural differences in their definitions. Our findings have implications for clinical professionals who should be aware of how the cultural background of their patients may have important implications with respect to cancer beliefs, expectations and personal preferences.

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The Association of Physical Activity with Depressive Symptoms

Cory Fraser, Kamal Masaki MD and Randi Chen MS

Epidemiological studies describe a negative correlation between physical activity and depressive symptoms in the aged. Randomized clinical trials have shown that exercise therapy is an effective treatment for depression. However, no evidence from any study has shown conclusively that physical activity prevents the onset of depression. This study proposes to determine the protective benefit of mid-life physical activity on the development of late-life depression. In addition, through a temporal relationship, this study proposes to determine the protective effect of physical activity for incident depressive symptoms in late-life. Physical activity index was assessed in the Japanese-American men enrolled in the Honolulu Heart Program (n=8006) in the period of 1965-1968 (Exam 1) when the men were middle-aged (ages 45-68 years). The presence of depressive symptoms was assessed 25 years later at the fourth exam in 1991-1993 when the men were ages 71-93 (n=3741). A second analysis was conducted using Exam 4 physical activity and Exam 7 depressive symptoms (an 8 year follow-up) in which those who demonstrated depressive symptoms at Exam 4 were excluded. Physical activity was evaluated in three ways; on-job physical activity, participation in regular exercise (yes/no), and a physical activity index. Physical activity index was assessed using the number of hours spent per 24-hour period in each of five different physical activity levels. This method has been extensively validated and was also employed in the Framingham and Puerto Rico Heart Studies. Depressive symptoms were assessed using an 11-question version of the Centers for Epidemiologic Studies Depression Scale (CES-D 11 Scale). On job physical activity at Exam 1 showed a strong negative correlation (p=0.02) with the development of depressive symptoms 25 years later. Cross-sectional analysis at Exam 4 showed that regular exercise was associated with decreased depressive symptoms (p=0.04). The 8-year period spanning Exam 4 and 7 in which depressed individuals at Exam 4 had been excluded showed a strong correlation (p=0.005) between regular exercise and decreased depressive symptoms 8 years later. In addition, individuals that walked >1/4 mile/day had significantly less depressive symptoms 8 years later (p=0.0009). There exists a strong negative correlation between physical activity and depressive symptoms. Even after excluding those with prevalent depressive symptoms at baseline, it was found that physical activity protected against the development of incident depressive symptoms 8 years later. This association persisted even after controlling for the prevalence of chronic diseases. Based on this temporal relationship, it may be hypothesized that physical activity may delay or even prevent the onset of depressive symptoms. These findings indicate a need to maintain and improve physical activity in both the treatment and prevention of depressive symptoms in the elderly. (This paper was presented in the Clinical Medicine Category at the First Annual MS2 Research Symposium on October 5, 2001; This abstract has been accepted for presentation in 2002 at the Hawaii ACP and the American Geriatric Society meetings).

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Analysis of Mouse ATF-2 Null Mutants and Possible Role in Natural Killer (NK) Cell Development.

Caron M. Hong, Sungjin Kim, PhD and Wayne Yokoyama, MD

NK cells were originally known to kill tumor cells without prior stimulation or exposure. These cells are a major component of the innate immune system and demonstrate an important role in infection. Patients deficient in NK cells have a higher percentage of recurrent disease and severe infection. Therefore, the identification of factors that regulate NK cell development, which aid in the maintenance of disease and possible curative measures, is essential in the advancement of immunological treatment. Currently, intensive research is being done to identify mechanisms involved in NK cell development as well as activation and inhibitory receptors that determine their physiological function. ATF-2 is a transcriptional factor that may play a role in NK cell development. This hypothesis arose from the results of NK-cell deficiency in homozygous ATF-2 null mutant mice. Originally, these transgenic mice were derived to observe the effects of NK cell deficiency in mice. These mice overexpressed Ly49A, an inhibitory MHC class I receptor ligand, thereby inhibiting NK cell activity. Interestingly, these transgenic mice had the construct inserted within the ATF-2 gene (intron 10), thereby rendering incomplete ATF-2 gene transcription. We explored this aspect to determine orientation of the construct in reference to ATF-2. Rapid amplification of cDNA ends (RACE), cloning and sequence analysis was utilized. The results of our study identified a number of cDNAs with known and unknown sequences. A number of truncated forms of ATF-2 were determined with neighboring construct sequences. Among these isoforms, there was one that was predominant. This isoform and its variations are significant in that they contain the DNA binding region and leucine zipper domains. Therefore, they may bind to DNA recognition sequences and hinder ATF-2 activity. The mechanisms that are involved with ATF-2 and NK cell development have yet to be identified. However, from our findings, there may be some distinct role. In adjunction to the previously mentioned assays, we also utilized Celera database and constructed the entire mouse ATF-2 genomic sequence. We then deciphered prior sequence information with the ATF-2 genomic sequence and determined intron10 to be the region of construct insertion for the main isoform. Primers were then designed for the known ATF-2 and construct (granzyme A) regions. PCR resulted in about a 2.5 Kb product. Sequence analysis verified the organization of the main truncated form of ATF-2. This form included the 3' end construct insertion and transcriptional direction of these segments. With this information, we can create constructs of this isoform and incorporate it into a "gene therapy" assay in mice to determine if this truncated form will inhibit and/or hinder NK cell development. To view Caron's poster click here. (This paper won first place in the Basic Science Division at the First Annual MS2 Research Symposium on October 5, 2001. Supported by a grant from the Howard Hughes Medical Institute Research Fellowship awarded to Dr. Yokoyama).

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Textbook Misinformation on the Significance of Pulselessness and Pallor in Acute Compartment Syndrome

Meituk Hu, Jeanelle Kam, Liana Peiler, and Loren Yamamoto, MD

Acute compartment sundrome prognosis depends upon prompt diagnosis and treatment. Multiple "P" words (pain, paresthia, paresis) describe symptoms and signs of acute compartment syndrome, but pulselessness and pallor are often incorrectly included, since these usually do NOT occur until it is too late. The purpose of this study is to evaluate the accuracy of medical textbooks that describe acute compartment syndrome. Reference texts were reviewed in: pediatrics (PED), family practice, (FP), internal medicine (IM), critical care (CC), emergency medicine (EM), orthopedics (Ortho) and surgery, using a 0 to 4 point score: 0= not covered in text. 1= pulslessness/pallor included as routine signs of compartment syndrome. 2= brief information presented. 3= signs and symptoms. 4= signs and symptoms correct plus a method to measure intracompartmental pressure is described. Fifty-one (51) textbooks were reviewed. The incidences of 0, 1, 2, 3,4 scores (respectively) by specialty were: Ped (4, 0, 1, 1, 1), FP (4, 0, 1, 0, 1), IM (4, 3, 1, 0, 0), CC ( 1, 0, 1, 0, 3), EM (1, 0, 1, 4, 4), Ortho (1, 2,0, 3,4), Surg (0, 0, 0, 1, 4). Mean scores (zeros were excluded) were: Ped 3.0, FP 3.0, IM 1.3, CC 3.5, EM 3.3, Ortho 3.0, Surg 3.8 (p= 0.01 by ANOVA). Five textbooks (3 IM and 2 Ortho) incorrectly implied that pulselessness and pallor are signs of acute compartment syndrome. Since less experienced physicians rely on textbooks when encountering a difficult case, inaccurate textbook may be seriously misleading. (This paper was presented in the Clinical Medicine Category at the First Annual MS2 Research Symposium on October 5, 2001).

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The Clinician and Clinical Trials - "First, Obtain a Valid Informed Consent!"

David S. Inouye Ph.D. and Denis Mee-Lee MD

Informed consent - the process of presenting relevant information in digestible form, as well as the deliberate act of validating understanding of the essential elements of the informed consent - is a cornerstone in clinical research. It is, however, an under-appreciated first step in the process of conducting any clinical trial, regardless of the level of risk involved. This report reviews the steps of the informed consent process from the essential information contained within the document (the "informed consent form") to various approaches of validation of the consent as outlined in the Code of Federal Regulations (21 CFR 50B) and finally, disclosure of new information unknown and thus not contained or covered by the initial consent process. Several case studies are presented to illustrate variations in scenarios and interpretation of the above regulations as applied to the clinician involved in clinical research at various levels.

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Optimization of Pneumatic Compression Use for Prophylaxis of Deep Venous Thrombosis

F. Lurie, M.D., Darrin Awaya, M.D., Erick Itoman, Genie Mefford

Deep venous thrombosis (DVT) is a preventable complication of many surgical procedures. In the absence ofprophylaxis, the incidence of DVT in the lower limb can be as high as 54% following orthopaedic joint replacement procedures. The prominent concern involving DVT is the increased risk of pulmonary embolism (FE), which has reported incidence rates of up to 20% in patients following hip replacement. Approximately 2 out of every 1000 post-operative patients die of PE each year. Factors that are believed to contribute to the formation ofDVT are endothelial injury, venous stasis, and hypercoagulability as set forth by Virchow in 1865.2 Surgery facilitates endothelial injury and blood hypercoagulability, while post-operative immobilization and prolonged bed rest interfere with normal physiologic blood flow in the leg, resulting in a patient at increased risk. Physiologic blood flow in the leg is preserved through a venous pump in the plantar foot that is flattened upon weight bearing, increasing blood flow from the foot to the venous system 7. Unable to bear weight on the lower extremities, post-operative patients are unable to maintain this blood flow, which can result in venous stasis. IPC prevents venous stasis and stimulates fibrinolysis by maintaining normal physiologic blood flow during the inactivity of the anatomical pump. Common prophylaxis strategies for DVT include pharmacological agents and/or mechanical methods. Pharmacological methods such as low molecular weight heparin (LMWH), low-dose heparin (LDH), and antiplatelet agents reduce coagulation. These agents are very effective in the prevention ofDVT, yet they have also been known to induce post-operative bleeding complications in 1.5%-2% ofpatients3. Because of this, mechanical methods such as intermittent pneumatic compression (IPC) have received greater attention. In a comparative study by Borow and Goldstein (1981) involving aspirin, low molecular weight dextran, minidose heparin, IPC, and elastic compression, it was found that postoperative patients treated with IPC had the lowest incidence of DVT (11.9%)4. IPC is believed to be as effective as the pharmacological agents aforementioned, yet free of any hemorrhagic complications3-6. Although the utility of IPC as prophylaxis against DVT is extensively documented, the impact of limb positioning during pneumatic compression has not been thoroughly investigated. The purpose of this study is to determine whether limb positioning during IPC alters its effectiveness, and if so, what is the optimal positioning of the leg and placement location of the cuff during IPC.

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Measures for Health Care Quality for Children

Jeanelle Kam, JP Co, and A Beal

Public Health is a discipline that "addresses the physical, mental and environmental health concerns of communities and populations at risk for disease and injury." Within the realm of public health, health policy participates in "formulating public policies, in collaboration with community and government leaders, designed to solve identified local and national health problems and priorities." To implement policies, one aspect researchers study is the measures of health care quality. In 1990, the Institute of Medicine (IOM) defined health care quality as "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and consistent with current professional knowledge." In the US, the measures of health care quality has been improving and will continue to improve as a result of the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry. In 1998, the Commission issued recommendations that led to the passage of Title IX of the Healthcare Research and Quality Act of 1999. The purpose of this study is to assess the state of science for quality measurement in children's health care by identifying what the current state of measures (reliability, validity, scientific evidence), feasibility for widespread use and balance/comprehensiveness of the measures. The current measures (surveys) were identified by a consensus among the MGH Center for Child and Adolescent Health Policy and AHRQ. A total of 20 measures were collected via internet searches, and direct retrieval from the developers of the measures. A literature review was done on each measure for the psychometric analysis. A preliminary classification was conducted on one measure (Consumer Assessment of Health Plans Study - CAHPS) using the IOM framework for the health care quality report. The two categories for the IOM framework included: Components of Health Care Quality [Safety (S), Effectiveness (E), Patient-Centeredness (PC) and Timeliness (T)] and Patient Perspective, [Staying Health (SH) Getting Better (GB), Living with a Disability (LD), Coping with End of Life Issues (ELI), and Equity (E). Excel was used to classify each item with the measure and to chart and graph the percentages of questions that related to each category. Out of 40 questions in the CAHPS survey, the incidence of S, E, PC and T were 0%, 20%, 40% and 33% respectively. Health Care Policy research on children is critical to determine the quality of health care and subsequent improve the health care of this population. MGH is responsible for providing the information about the current available quality measures for children to decipher the areas in need of future attention, research, and funding. The preliminary analysis of CAHPS survey shows a paucity of safety measures.(This paper was presented in the Clinical Medicine Category at the First Annual MS2 Research Symposium on October 5, 2001).

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Possible Effects on Native Hawaiian Health Care: Taking a Closer Look at Hawaii Physicians

Jerem Nohea Kaawaloa, Eric H. Kajioka, and Shannon Hirose-Wong, PhD

Although the life expectancy of those living in Hawaii is among the highest in the U.S., Native Hawaiians, have a short life expectancy and high mortality rates for heart disease, cancer, stroke, accidents, and diabetes. Studies examining the causes of these disparities remain sparse. Identifying the characteristics of physicians in Hawaii may shed some light on health care delivery and causes or ways to address this health disparity. We surveyed 2,719 physicians in the state of Hawaii to examine the relationship between physician ethnicity, medical specialty, and location of practice. Our findings show that most physicians in the State of Hawaii are male (77%), Caucasian (39.53%), and practice in non-primary care fields (50.03%) in the county of Honolulu (80.77%). Native Hawaiians comprise 12.5% of the state population, but only 5.06% of the physician population. In addition, in areas with >15% Native Hawaiian population, only 4.58% of the physicans are Native Hawaiian. When examining Native Hawaiian physicians in particular, most practiced in Honolulu county (85.00%) where only 66.29% of the Native Hawaiian population resides. However, Native Hawaiian physicians were more likely to practice in a primary care field than other ethnicities (p<0.05). This study sample indicates that Native Hawaiians are underrepresented among physicians in the state of Hawaii, and that the majority of Native Hawaiian physicians are not practicing in areas of high Native Hawaiian populations. Improving cross-cultural communications and increasing Native Hawaiian physician representation may hold the key to better health care and health care outcomes for Native Hawaiians. (This paper was presented in the Community Medicine Category at the First Annual MS2 Research Symposium on October 5, 2001).

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Changes in the Association of Low Birth Weight with Socioeconomic Status in Hawaii: 1970-1990

Myron L. Kung, Drs. Eldon Wegner, Gregory Loos, Alvin Onaka, David Crowell, Yuangquing Li, and Helen Zheng

This study examines the rates of low birth weight (LBW) in the state of Hawaii and changes in the association of LBW with socioeconomic status from 1970 to 1990. The analysis is based on aggregate data for census tracts. Rates of LWB were calculated for each census tract. Relative socioeconomic scores were calculated from average household income and years of education. The results show that: 1) there was a decrease in the rate of LWB infants in Hawaii, and 2) that the correlation between socioeconomic status and LBW was substantially reduced, though a significant correlation remains. This study suggests likely ceiling effects, but that the progressive public health policies and expansion of access to primary health care in Hawaii during this period played a major role in reducing the rate of LBW infants and in decreasing socioeconomic inequality on this important health indicator.

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Nitrate, Nitrite, and N-nitroso Compounds and Cancer

Khoi Le

This paper reviews the literature, focusing on relevant findings, and explores the contemporary position of the scientific community on the role of nitrate, nitrite, and N-nitroso compounds in the development of cancer in humans. Dietary exposure to these compounds, their metabolism and biotransformation in the body, their possible carcinogenic mechanisms, and results of epidemiological studies and their implications are discussed. A possible solution for reducing cancer risk from nitrate and nitrite exposure in the diet is also discussed in the paper.

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In-hospital transfer patients with acute myocardial infarction: How do they compare with direct-admit patients?

Sterling Malish, Todd Seto, MD, MPH, and Kamal Masaki, MD

The objective of this study was to assess characteristics, management, and outcomes between patients with acute myocardial infarction transferred in from another hospital and patients directly admitted to the hospital. The study was designed as a retrospective cohort study, using data from the Third National Registry of Acute Myocardial Infarction. All patients admitted with an AMI diagnosis to a large tertiary care hospital in Honolulu, Hawaii from April, 1998 to June, 2000 (n=1184) were analyzed. Outcomes measured were patient demographic and clinical characteristics, utilization of two procedures (coronary artery bypass grafting [CABG] and percutaneous coronary intervention [PCI], and angiography), administration of 4 recommended medical therapies within 24 hours of admission (Aspirin, beta-blockers, ACE-inhibitors, and lipid-lowering agents), and 4 in-hospital outcomes (mortality, recurrent angina, stroke, and congestive heart failure). 546 patients were transferred-in and 638 patients were directly admitted to the study hospital. Patients transferred in were younger, more often male and Caucasian, and had lower rates of prior CABG and stroke. Transfer-in patients also had higher left ventricular ejection fractions and had higher rates of ST elevation infarcts. After adjusting for confounders, transfer-in patients had higher odds of undergoing angiography (odds ratio, 2.1 [95% confidence interval (CI), 1.6 to 2.7]), PCI (odds ratio, 3.2 [CI, 2.4 to 4.4]), and CABG (odds ratio, 2.9 [CI, 2.1 to 4.1]). Crude in-hospital outcomes for transfer-in patients were generally better. Transfer-in patients had lower rates of CHF (40% vs. 46%, P=0.03) and mortality (11% vs. 17%; P=0.002). Rates of recurrent angina (32% vs. 23%; P=0.002), however, were higher in transfer-in patients. After adjusting for confounders, the likelihood of CHF(odds ratio, 1.2 [CI, 0.9 to 1.6]) and CVA (odds ratio, 2.2 [CI, 0.9 to 4.5]) were more likely for transfer-in patients while that of mortality was lower (odds ratio, 0.9[CI, 0.7 to 1.4]), although none of these differences were significant. Transfer-in patients account for more patients than previously thought, and there are significant differences between them and direct-admit patients. Contrary to popular belief, outcomes for transfer-in patients are favorable compared to direct-admit patients, although confounder adjustment for these outcomes gives inconclusive results. This project was funded by the John A. Hartford Foundation/American Federation for Aging Research Scholars Program. (This paper won first place in the Clincial Medicine Category at the First Annual MS2 Research Symposium on October 5, 200; Winner of the Medical Student Division at the 2002 Biomedical Sciences Symposium on March 22, 2002).

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Otitis media caused by Mycobacterium chelonei (a case report)

Cindy Nguyen and Erlaine Bello, M.D.

A case of otitis media caused by Mycobacterium chelonei was detected in the right ear of a 15-year-old male. The patient was born with immature Eustachian tubes and had an extensive history of recurrent bilateral otitis media since childhood. As a result of his recurrent infections, the patient had lost about 50 percent of his hearing. A culture of the right ear grew out acid-fast bacilli, M. chelonei, which was sensitive to clarithromycin, amikacin, and cefoxitin, but resistant to ciprofloxacin, doxycycline, imipenem, and trimethoprim sulfate. The patient was treated with a six-month course of clarithromycin, and he reported that his hearing improved with treatment.

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BACK ON TRACK: A Quentin Burdick Project

Junedale Nishiyama, Ryanne Vierra, Julie Wiskind and Bev Cypriano, MSW

Back on Track is the name of a series of classes on nutrition and exercise held at the Hamakua Health Center in July 2001. It is also the name of a bound book of handouts and personal worksheets that accompanied these classes, and finally, Back on Track is an ongoing nutrition and exercise support group, run by Hamakua residents, to encourage one another to eat healthy and stay fit. The Back on Track program was developed by the Quentin N. Burdick Interdisciplinary Rural Health Team, Junedale Nishiyama, Ryanne Vierra and Julie Wiskind, graduate students at the University of Hawaii, studying, respectively, medicine, nurse practitioning, and social work. The team came to the Hamakua Health Center, located in Honoka'a on the Big Island of Hawaii for six weeks in the summer of 2001 to learn teamwork, experience life in the country, and to serve in a way that would increase the health capacity of the community. Rural communities like Honoka'a are often subject to interventions by well meaning outside groups. Residents are often left unchanged by these intermittent services. An outside group may sponsor a local smoking cessation class, for example, but once the teacher leaves town and the support is gone, there is a great tendency for the client to revert to former ways. Rural communities are isolated in the sense that they don't have the resources or the population to provide ongoing services like fitness classes, nutrition experts, or Alcoholics Anonymous meetings. Because of this lack of resources, it is critically important that rural residents receive services that they themselves are willing and able to sustain when the service provider leaves.

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Kidney Research Project

Kanani Texeira, Roxanne Reiny, Margaret Wise, Richard Servotoli, Marjorie Mau, MD

This project seeks to evaluate the association of renal risk factors with early renal disease (RD) in a "high risk" Asian-Pacific Islander population. The National Kidney Foundation -Hawaii partnered with community organizations to recruit "high risk" individuals for a renal screening program using KEEP (Kidney Early Evaluation Program), a nationally recognized standardized protocol. Eligible persons were invited to the KEEP screening if they met the following criteria for "high risk" for renal disease: 1) family history of ESRD, or 2) prior h/o hypertension (HTN) or 3) prior h/o of diabetes (DM). Presence of renal disease was defined by 1) a positive urine microalbumin or 2) creatine > 1.2 mg/dL or 3) prior h/o of kidney or bladder disease/infection. Two KEEP screenings were held (KEEP 1 and KEEP 2). Keep 1 screenings were held between May 1997 and December 1997. KEEP 2 screenings were held in January 2001. Association of renal risk factors with presence of RD was evaluated using chi-square, t-test, and multi-variable logistic regression. KEEP 1- Of the 316 participants screened, 65% were women with 48% self-identified as Pacific Islanders and 25% Asian, 52% of participants were found to have renal disease, 32% had DM, 63% had HTN, and 24.4% reported a h/o CVD. Renal disease was significantly associated with lower BMI, h/o CVD, HTN, and DM (all p-values<0.05). Presence of renal disease was only significantly associated with DM (p<0.0001) and marginally associated with female gender (p=.044) (adjusted for HTN, H/O CVD, FHx of renal disease, age, BMI, ethnicity, smoking) KEEP 2- Will have results on the week of September 10,2001. Combined KEEP 1 and KEEP 2- Will have results on the week of September 10,2001. KEEP 1- Initial results from the KEEP screening in a "high risk" Pacific Island and Asian population, confirms previous studies showing a significant association between DM and renal disease. Further studies are needed to examine the attributable risk of DM and other potentially important risk factors on the high rates of incident ESRD observed in this population.

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A Journey to Waimea, Kauai: A Quentin Brudick Project

Keahi Renaud, Deb Knight, Nghi Thai and Rebecca Smith

The Quentin Burdick Interdisciplinary Rural Health Program brings students of various health fields together to begin a process of "capacity building" in a rural setting. The student participants included a graduate psychology student, a third year nursing student, and a first year medical student. This report deals with the rural health program as implemented in the community of Waimea, on the Hawaiian island of Kaua'i. Community leaders and representatives were asked what issues did the community of Waimea, Kaua'i face and what might be some desirable approaches to addressing those issues. The program decided to focus on health issues such as nutrition, dental hygiene, smoking, and alcohol/drug abuse. The decision was made to work with students entering or leaving the 6,7, and 8th grade. There was a clear lack of summer programs geared to working with this at-risk age group. The pedagogical approach incorporated an understanding of Hawaiian epistemology with an emphasis on theories of Blooms Taxonomy. The use of multiple-intelligence ideas shaped a learn-by-doing, didactic lecture, and Socratic-method curriculum. Inquiry-based learning encouraged student participation and discourse. The common theme throughout was "ohana" (family) and was emphasized throughout the program. A major component on the class was cultural awareness. Hawaiian values of place, work, and learning was integrated within every facet and juncture of the daily curriculum. It was the belief of the team that a strong cultural foundation stimulates a healthy self-image, strong self-identity, and resilient self-confidence. The approach came through outdoor activities of canoe paddling, excursions to salt ponds, working in taro patches, and many hands experiences with Hawaiian crafts. This in conjunction with team and trust building activities resulted in students with a better awareness of themselves. These objectives, though difficult to measure, were indirectly corroborated by the continued enthusiastic participation on the part of the students, the positive feedback by the parents, and the observations of the support staff. There was remarkable retention on the cultural issues when questioned. Synthesis of the students personal ideas were encouraged and profound when prompted to give examples of how the values applied to their lives.

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Microsatellite Marker Based Map of the Williams Syndrome Deletion Region on Human Chromosome 7

Alok Sharma, Drs. Laurie Sadler, Dora Scheiber, Gyorgi Fekete, Arnold Munnich, Barbara Pober, Charles Boyd and Zsolt Urban

Williams Syndrome (WS) is a multisystem development disorder caused by unequal meiotic crossover resulting in haploinsufficiency for several contiguous genes at 7q11.23. These deletions show autosomal dominant inheritance in familial cases. WS presents a complex phenotype, which generally includes elfin facial features, cardiovascular abnormalities, increased incidence of metabolic and connective tissue abnormalities, and a characteristic neurobehavioral profile consisting of gregariousness, short attention span, hyperactivity, good verbal skills, and poor visuo-spatial integration. Although the relationship between deletion and phenotype is incompletely understood at present, several genes in the region could potentially be implicated with the symptoms of WS. To better understand the relationship between genotype and phenotype in WS, we used 16 microsatellite markers to assemble haplotypes of the deleted region in 5 patients and their families. These patients were selected because of their clinically apparent WS phenotype, but incomplete deletion at 7q11.23 as determined by fluorescent in situ hybridization (FISH). Our results currently show possible deletions in two patients, but these are still inconclusive. Further testing is necessary to evaluate the extent of the deletions they carry. It is our hope to use this data to correlate deletion size to severity of clinical phenotype.

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Differences in Preventive Health Counseling Performance Between Pediatric and Medicine-Pediatric Physicians-in-Training

Miki Shirakawa, MS and Meta Lee, MD

The number of practicing physicians who regularly counsel their patients to promote healthy behavior and prevent disease has been shown to be inadequate in numerous studies.1 The purpose of this study is to determine the current preventive health base knowledge among Medicine-Pediatric and Categorical Pediatric physicians-in-training (residents) at the University of Hawai'i School of Medicine's Integrated Pediatric Residency Program. A 50 item multiple-choice exam was administered to 11 Medicine-Pediatric and 18 Categorical Pediatric residents. Topic areas that were tested included: physician counseling, policies and guidelines, injury prevention, smoking cessation, obesity prevention, breastfeeding, and immunizations. Results from this exam revealed an overall low preventive health knowledge base of both Medicine-Pediatric and Categorical Pediatric residents. Residents scored an average of 54.91% and 46.33%, respectively. Medicine-Pediatric residents scored significantly higher (p<0.05) than Categorical Pediatric residents on the overall exam and in the topic of injury prevention. However, there was no significant difference in scores between groups in areas of physician counseling, policies and guidelines, smoking cessation, obesity prevention, breastfeeding, and immunizations. (This paper was presented in the Clinical Medicine Category at the First Annual MS2 Research Symposium on October 5, 2001).

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Adjuvants and a Plasmodium falciparum MSP-1 malaria vaccine: Is growth inhibitory antibody correlated with antibody affinity?

Yoichi Soma, Peter Chang, George Hui, PhD and Leslie Tam, PhD

Malaria is a leading cause of morbidity and mortality in tropical, developing countries and numerous efforts are underway to develop a malaria vaccine. The Plasmodium falciparum merozoite surface protein -1 (MSP-1) has been shown to completely protect Aotus monkeys against a leathal human malaria infection. The vaccine is believed to be dependent upon the use of Freund's complete adjuvant (FCA), a strong but clinically unacceptable immunologic adjuvant. Hui and coworkers (1991) reported that a combination of synthetic but clinically acceptable, low-toxicity synthetic adjuvants could produce parasite growth-inhibitory antibodies with MSP-1. In this study, inhibition of parasite growth was correlated with antibody titer. It is unknown, however, if growth inhibition is also correlated with antibody affinity. Kenney and co-workers (1989) reported that antibody affinity, in a study of various adjuvants, is not always correlated with antibody titer. The synthetic adjuvant Quil A produced lower antibody titers but higher affinity antibodies to bovine serum albumin when compared with FCA. KinExA is a newly available instrument (developed by Sapidyne, Inc.), which enables rapid measurement of antibody affinity. The instrument is based on a flow injection system and determines the unoccupied binding sites after an antibody and antigen are allowed to react in solution. This study was initiated to investigate the relationship between antibody affinity to MSP-1 (potentiated by FCA and other adjuvants), antibody titer, and the ability of antibodies to inhibit parasite growth in vitro. It is hypothesized that parasite growth inhibitory antibodies have high affinity, while non-inhibitory antibodies have low affinity. Serum samples from the 1991 study in which rabbits were immunized with MSP-1 with various adjuvants were analyzed. The results, discussion, and conclusion are still in progress. (This paper was presented in the Basic Science Category at the First Annual MS2 Research Symposium on October 5, 2001).

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Molokai: Linking the Past With the Future. A Quentin Burdick Project

Shawn Sumida, Shawna Hirata, Susana Helm, Cyrena Aguon and Judy Mikami, RN

The Quentin Burdick Rural Health Interdisciplinary Community Capacity Building Program was started for the purpose of teaching students about rural health and helping rural communities across the United States. Our original team consisted of a social work student, a medical student, a medical technology student, a community psychology student and a nursing student. Our faculty coordinator was a dental hygienist named Donna Fukuda, and our site coordinator was a nurse named Judy Mikami. We stayed in Molokai from June 18 to July 27 for a dual purpose: to learn about the community and participate in community activities and to develop a community capacity building project by the end of the 6 weeks. Our introduction to the island of Molokai was during our site-visit on the weekend of May 19. The timing was impeccable because our visit had fallen nicely into the weekend of Ka Hula Piko. Our visit began with a history of Ka Hula Piko given by John Kaimikaua. Filled with much excitement, we were brave enough make the drive to Pu 'u Nana for the early morning ceremony. As painful as it was to awake at 2 am, we strongly felt that this was apart of immersing ourselves into the community. Of course, our Hula Piko experience would not have been complete without attending the rest of the festivities at Popohaku Beach. Among a gamut of other things, our orientation was satiated with the cultural strengths of the island. Little did we know that this cultural glimpse would become a vehicle in understanding the cultural traditions and how this would mold our definition and experiences in rural health practice? However, Ka Hula Piko was only a snapshot of one of the many aspects or characteristics of the Molokai community. In order, to really learn about the community, we have to be involved with it and the way to understand a community is to participate in it. It is absolutely crucial to learn about the values, history, and customs of the people. Therefore, we spent considerable time immersing ourselves into the culture and milieu of the Molokai community. To facilitate our learning, many community activities and agency visits were scheduled for our group throughout the entire six weeks. All of the activities and agency visits were educational and significant in helping us to understand the community of Molokai. Some of the activities included: The Kekama Molokai Tour, the Relay for Life, the Halawa Valley hike, working in the Taro patches, and working at the fishponds. The paper will present all the activities and projects that we were involved with, using three categories or themes: (1) The Ahupua'a, a Native Hawaiian System of social governance; (2) Aha Kiole Council, made up of practitioners and priests to manage and preserve the land and the sea for the benefit of the generations to come; and (3) Hawaiian Values. We decided to present our activities and projects in this fashion in hopes of shedding light on our comprehension of "rural health in the Molokai community".

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Comparing the Methods of Measuring Compartment Pressures in Acute Compartment Syndrome

Annemarie Uliasz, Ishida, J., Fleming, J., Yamamoto, L., MD

Compartment syndrome is a potentially limb and life threatening condition in which pressure elevation of an enclosed space can irreversibly damage the contents of the space. Compartment syndrome may be caused by (1) constriction or decreasing the size of the compartment. This may be the result of closure of facial defects, compression dressings, a tight cast, or military anti-shock trousers (MAST). In these cases, the compartment's ability to expand to accommodate for increased volume is limited. Compartment syndrome may also be caused by (2) increasing the contents of the space. This may occur following hemorrhage after a fracture, surgery, or blunt injury. Increased volume in the compartment may also result from post-ischemic swelling due to arterial injury or restoration of blood flow after an arterial injury. Increase compartmental tissue pressure: Initial obstruction of venous blood, Occlusion of capillary beds, Blood shunted away from occluded areas, Muscle and nerve ischemia, Capillary basement membranes become leaky. Transudation of fluid into surrounding areas compounds the problem. If untreated, arterial flow to affected compartment becomes so impaired that muscle and nerve tissue with compartment die. If left untreated, compartment syndrome can lead to ischemia and necrosis, in turn, causing muscular and neurological damage. It is imperative to diagnose compartment syndrome and assess the intra-compartmental pressure in a timely and accurate fashion. The threshold for intracompartmental pressure has been detemined to be approximately 30 mmHg. At a measurement greater than 3OmmHg, fasciotomy is required to relieve the pressure. Speed of diagnosis and treatment determine the prognosis of this condition. The Stryker Stic instrument is a device specifically designed to measure intra-compartmental pressure. Because it is expensive, not all medical facilities may have access to this device. Alternatives to the Stryker device include the IV pump method and the Whitesides technique. The objectives of this study are to assess and compare the accuracy of several different methods of intra-compartmental pressure measurement. (This paper was presented in the Clinical Medicine Category at the First Annual MS2 Research Symposium on October 5, 2001).

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UA OLA LOKO I KE ALOHA, I OLA NO KE KINO I HANA: Love Gives Life Within. The Body Enjoys Health in Hana: A Quentin Burdick Project

Laura Williams, Brian Alejandro, Jenny Ragus, Joie Acosta and Valerie Ng, MSW

Our project title embodies both the physical and spiritual health of the people in Hana. We chose these special phrases to introduce our concept of the health of Hana's people, not simply as patients in the clinic but as whole people with mind, spirit, and physical nature. The health of a person requires attention of all aspects of their being. The health of Hana's people is not centered around and maintained solely through medical visits. A person's health includes maintaining spirit and mind through healthy relationships between friends and family. The focus on both the mind and body allowed us to incorporate the doctrines of our various disciplines and called for knowledge from each of our fields. Hana's deeply spiritual culture is rooted in it's long ancient Polynesian history beginning in 500 A.D, when the Polynesians first arrived in the islands. The largest heiau (Hawaiian temple) in the state, the fifteenth century Pi 'ilani Heiau, was built by the large Hawaiian community that resided in Hana in the 1500's. Only 200 years later, the famous Queen Ka'ahumanu was born in a cave along Hana shoreline in 1768. By the 1800's, Hana's land was utilized to cultivate sugar cane. By the 1900's, this industry transformed the small Hawaiian village into an industrious town. The Hana highway was constructed in 1926 allowing transportation to and from central Maui. By the mid 1900' s, sugar plantations were closing and ranchers began to buy the land to raise cattle and farm. Currently, the main source of employment in the community is Hana Hotel-Maui and Hana Ranch. Paul Fagan began this economic venture in 1944, and since then it has been bought and sold several times. However, Paul Fagan is memoralized in a large cross that resides atop a hill across from the current Hana Hotel-Maui. With the death of the sugar industry in Hana, the population decreased measurably in size. Today the population of East Maui, which includes the lands from Kaupo to Ke'anae, is approximately 3,000 people. According to the latest census data, 70% of the population base of East Maui consists of residents who are of Native Hawaiian ancestry. We were able to work with this population through our partnership with the Hana Community Health Center (HCHC). The HCHC is the only medical facility in East Maui and therefore provides a range of services, including prevention oriented family practice medicine, acute and chronic care, urgent care, family planning, dental care, opthamology, STD screening, well baby care and immunizations, health counseling and education, laboratory testing, x-ray services, home health care, behavioral health (smoking cessation, weight management) psychological individual and group counseling, and available medication in lieu of a full pharmacy. HCHC also works in conjunction with the American Medical Response personnel, and the Maui Memorial Medical Center emergency physicians to provide emergency service to those in East Maui. HCHC provided medical care to 1,553 individual patients, who made 4,234 visits to the center in the fiscal year 1999-2000. 20% of the clinics patient pool was uninsured and 23% received care through Medicaid or Medicare. Patients over the age of 65 or under the age of 13 comprised 1/3 of the clinic's patient pool. Dental care has been available in the clinic since October 1999. Dental services have been provided to 227 individual patients who visited the clinic 428 times between October 1999 and June 2000. Children and adolescents comprise 40% of the dental pool. One third of the dental patients were uninsured and 20% were insured through a Medicaid dental plan. Our project was centered around five main activities that were provided at the HCHC: (1) Fitness and nutrition program, (2) Kupuna Nutrition Program (Mai E ' Ai), (3) Hale Hulu Mamo (Hana Senior Center), (4) Clinic work, and (5) building interpersonal relationships with community members. These five activities provided an interdisciplinary approach to Hana's rural health care. In order to guide our actions and thoughts while we were in Hana, we designed an interdisciplinary mission statement. We felt that it was very important to have goals in order to make the most of our practicum experience and we wanted to make these goals interdisciplinary to address our individual interests.

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Project P.A.H.O.A.: A Quentin Burdick Project

Rodney Yamaki, Brandon Gima, Jennifer Graf, Jennifer Shibuya and Eileen Lovell, RN

In order to get a better understanding of the community's resources and people, we began our project by completing a 2-week informal needs assessment by talking with leaders in the community and representatives of Pahoa's many social service agencies. Some of the people who took the time out of their schedules to talk to us and whom we would like to thank include: Toddy Martin, a board member at the Bay Clinic, Kenn at the Pahoa Community Center, Une Rodero at the Center for Aging, Wendy Tamashiro of the Bay Clinic, Lynn Kaawaloa at the Bay Clinic, Dr. McAllister from the Bay Clinic, Dr. Hansen, psychologist at the Bay Clinic, Renee from Malama O' Puna, Dana Aguiar, nutrition coordinator for the Pahoa nutrition group, The Pahoa Senior Club; various shop owners around Pahoa town, Kay Laumberg and the staff of the mobile clinic and Maraiah Newte-Yamamoto, office manger at PFHC. We obtained numerous possibilities for our project from our "needs assessment." Coming to a consensus on what projects to pursue was very difficult. Our group's shared values and interests helped in determining what projects we accomplished. First, we wanted a project that addressed a need of the community but could be accomplished in the short six weeks of our stay. Second, it was important for us to decide on a project that did not require much additional maintenance after we left Pahoa. Given the workload of the staff of the Pahoa Family Health Center, we did not want to tax the staff with additional responsibilities. Finally, from our conversations with the community members, we understood it to be safer for us to plan a project in Pahoa town. With these constraints in mind, we decided on five projects, which we collectively called: Project P.A.H.O.A.

P - Providing Medical Insurance Applications Assistance
A - Assembling a Cookbook
H - Helping Update the Bay Clinic Website
O - Offering Fridays to the Senior Club
A - Assisting with the Asthma Camp

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