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Potions from Poison: Unusual Therapeutic Remedies in Homeopathic & Allopathic Medicine

Tomomi Billings, MS2 & Doreen Fukushima, MS2

Toxins and venoms from some of nature's most poisonous creatures are becoming increasingly popular targets to explore for potential therapeutic uses. Particularly of interest are studies that are being conducted to utilize the mechanisms of action of venomous components against diseases or conditions that currently have no effective treatment options. This paper will give a brief synopsis of some of the noxious chemicals that are currently being studied, including the induction of tumor suppression through the use of snake venom-derived disintegrins (Yeh et al., 2001) and modified toxins from bacteria such as Pseudomonas aeruginosa (Brooks et al., 2001), the use of conotoxins from snail venom to reduce brain damage (Bowersox et al., 1998), and the inhibition of graft rejection with cobra venom factor (Candinas et al., 1996). In addition to these studies, a brief review of how ACE inhibitors were derived using venom from a Brazilian snake (Bailey et al., 2001) will be covered, as well as the many conditions that can be treated using the botulinum toxin, including dystonia, tremors and several cosmetic procedures (Blitzer et al., 2001).

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A Teaching Model for Skin Suturing

David Boldt, MS2 & Keith Tokuhara, MS2
David Wong, MS4, JABSOM
Loren Yamamoto, MD, Department of Pediatrics, JABSOM

The comparison of different models to aid in teaching skin suturing is presented. Specifically pig's feet, pig's back, latex glove, and a hot dog were compared. All of the models, which have varying degrees of similarity to real skin, can be inexpensively obtained in almost any community.

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Trends in Stem Cells and Transplantation

Jason Brown, MS2

One of the goals of cloning technology is the application to human medicine in the form of organ transplantation. By manipulating embryonic stem cells to differentiate into cell of choice and using them to repair defective or damaged human parts, many lives can be improved and even saved. However, the technology itself and its use in human therapy is riddled with scores of unanswered problems from the mechanisms of genome reprogramming to the ability to integrate the cells into a fully functional organ. There are promising advances in all related fields of science that bring the possibility of therapeutic cloning, but making that possibility to reality is probably still far away.

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Surgical Treatment of Masked Contralateral Ptosis

Tiffany Chang, MS2

Muller's muscle-conjunctival resections were performed on 33 patients with unilateral or bilateral blepharoptosis. By taking measurements of digital photos from the electronic medical record, eyelid position estimates were obtained and analyzed. Bilateral surgery resulted in greater post-operative symmetry and better compensated for masked contralateral ptosis. No correlation was found between pre-operative elevation with phenylephrine and response to surgery.

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The JABSOM School Health Education Program at McKinley High School

Justin De Grado MS2 & Mary Chan, MS2
Bevan Ly, Premedical Student, UHM
Gwen Naguwa, MD, Office of Medical Education, JABSOM

Medicine is a profession of service. As medical students learn medicine, the concept of service is often lost while students spend countless hours studying biochemical pathways and microbiology. The John A. Burns School of Medicine (JABSOM) and the School Health Education Program (SHEP) have created a program of service learning where medical students serve the community, particularly high school sophomores, while continuing with their medical education. Medical students and premedical students presented four health science topics to two sophomore health science classes at McKinley High School in Honolulu, Hawaii. The goal of the presentations were to introduce new information to the high school students and teachers, and also expose the medical and premedical students to the health concerns of teenage high school students and to the education process. The presentations consisted of Healthy Living; Substance Abuse; Violence Prevention; and Sexual Health. The students were surveyed before and after the presentation to determine the knowledge they possessed before the presentation and the effectiveness of the presentation. The results demonstrate statistically significant improvement in post-presentation surveys versus pre-presentation surveys.

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The University of Hawaii John A. Burns School of Medicine School Health Education Program (SHEP), 2001-2002, Roosevelt and Waipahu High Schools Teaching Group

Edward Cheng, MS2, Myrna Kuo, MS2, Chad Iwashita, MS2, Raechel Torres, MS2, Mark Burger, MS2
Gwen Naguwa, Office of Medical Education, JABSOM

Background. The School Health Education Program (SHEP) places medical students and undergraduate premed students in public high school 10th grade health classes in the county of Oahu, Hawaii for the purpose of using non-traditional methods to teach sensitive health topics. The topics covered included 1)Violence, 2)Drug Use, 3)Healthy Living, and 4)Sexual Health. Objectives. To educate public high school students about the topics listed above using non-traditional teaching methods, and to assess the efficacy of the teaching methods employed in improving the students' knowledge of the topics covered. Methods. Five 1st-year medical students and an undergraduate pre-medical student taught the four listed topics to students at Waipahu and Roosevelt High Schools on Oahu, Hawaii during two semesters from September 2001- April 2002. Teaching methods included: breaking each class into small groups led by 1-2 teaching group members; use of PowerPoint presentations; use of static displays; skits; video clips; and student participation exercises. A pre-test was administered to each class before instruction commenced to assess baseline knowledge about the topic, and a post-test was administered after each class to assess improvement in knowledge. Results. 8 visits were made to Waipahu High School and 7 to Roosevelt High School for a total of 15 visits and 30 classes taught. 15 sets of data were collected, and the pre- and post-test scores were compared. 14 of the 15 classes demonstrated a significant improvement in knowledge after receiving instruction from the teaching group. Conclusions. The majority of students educated under the SHEP program showed a significant improvement in their knowledge about the topics covered. The SHEP program is therefore shown to be an effective means of educating public high school students about sensitive health topics.

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Effects of oleic acid on DGAT gene expression in HepG2 cells

Louis Chun, MS2
Andre Theriault, PhD, Division of Medical Technology, JABSOM

Triglyceride (TG) synthesis plays a role in important physiological processes such as intestinal fat absorption, energy storage in muscle and adipose tissue, and lactation. A number of recent studies have provided compelling evidence of the independent association of elevated TG and cardiovascular disease. Furthermore, increased levels of TG, an essential component of all lipoproteins, appear to be linked to elevated circulation of low density lipoproteins (LDLs), which have been implicated in increased risk for atherosclerosis and other diseases involving lipoproteins. Synthesis of TG from diacylglycerol (DG) is catalyzed by the enzyme acyl coA:diacylglycerol acyl transferase (DGAT). Two isoforms of DGAT have recently been cloned, namely DGAT-1 and DGAT-2 . Thus, the molecular triggers by which DGAT may be enhanced or suppressed in the regulation TG synthesis have not been fully explored. One trigger that has been extensively studied in TG modulation is oleic acid, an 18-carbon unsaturated fatty acid abundant in many sources of dietary lipids, including beef and olive oil. To gain insight into TG synthesis, we measured DGAT mRNA levels in HepG2 (liver-derived) cells treated with 0.4 mM and 0.8 mM oleic acid. Initial findings suggest similar levels of DGAT expression for both doses of oleic acid treatment relative to control. These results fail to support our proposal that DGAT expression should increase in the presence of oleic acid, due to previous work suggesting that oleic acid stimulates TG synthesis. Additional trials are underway to help clarify this uncertainty.

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The Correlation between Chronic Renal Insufficiency and Ethnic Background In a Community Screened Population in Hawaii

Jodi Hawk, MS2
Dr. Marjorie Mau, MD, Richard Severino, Department of Native Hawaiian Health, JABSOM

Objective: To examine the association between Chronic Renal Insufficiency (CRI) and ethnicity in a community-based sample by analyzing data collected by the National Kidney Foundation of Hawaii (NKFH). Methods: The NKFH conducted screenings for CRI at six community sites throughout Hawaii. Participants with risk factors for CRI were recruited and enrolled in the Kidney Early Evaluation Program 2 (KEEP 2). At community sites, the participants were evaluated for decreased kidney function using the nationally recognized KEEP 2 protocol. Data from the screening was entered into a database and analyzed to investigate whether CRI is associated with ethnic background. Results: Twenty-eight percent of the community-based sample met the criteria for CRI. CRI was correlated with hypertension, diabetes, age, and the location of the screening site. Ethnic background was also significantly associated with CRI (P < .001). CRI was not correlated with gender, weight, education level, smoking habits, doctor visits in the past six months, or family history of renal disease. Hypertension, diabetes, age, and screening site were independently associated with CRI. Ethnic background was also found to be independently associated with CRI once the renal risk factors of hypertension, diabetes, age, and screening site were taken into account. Conclusions: This study provides data from a community-based sample confirming the association between CRI and the known renal risk factors of hypertension, diabetes, and advancing age. The analysis demonstrates that participants with diabetes or hypertension have about twice the risk of developing CRI. CRI was significantly associated with a single screening site. Compared to the reference site, there was a 5 fold higher rate of CRI at this site. This study also suggests that ethnic background is independently associated with CRI. The data analysis suggests that in comparison to the reference Japanese group, Filipinos, Hawaiians, and Chinese may have a 2-3 fold higher risk for CRI. (This paper was presented at the 2nd Annual MS2 symposium).

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Bleeding Complications Following Talc Pleurodesis for Recurrent Pleural Effusion: A Case Report

Brandon Hirota, MS2
Jennifer Choi, MS2 & Michelle Nguyen, MS4, JABSOM
Jinichi Tokeshi, MD, Department of Family Practice and Community Health, JABSOM
Shigeo Irimajiri, MD, Family Practice Resident, Kuakini

Use of talc as a sclerosing agent is currently being debated due to recent reports of a number of serious complications associated with its use. Although there are significant data regarding the respiratory complications associated with talc, information concerning bleeding complications are extremely rare. We present the case of a 78 year-old male who was treated with video-assisted thoracoscopic surgery (VATS) with talc pleurodesis for recurrent pleural effusion and subsequently developed massive hemorrhage in the pleural cavity.

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Immunocytochemical Determination of Differential Expression of Alpha-9-Nicontinic Receptor Subunit inVestibular Organs of Rana Pipiens

Paul R. Holland, MS2
Paul Guth PhD, Maria Lioudyno, PhD, Samara Shipton, Tulane University Medical School

Over forty years ago acetylcholine esterase staining in the vestibular system prompted investigation to the role of acetylcholine in the inner ear. The organs of the inner ear detect linear movement and angular acceleration, thereby providing the brain with the orientation and movement of the head. The hair cells transduce the mechanical signals into biological signals that may be presented to the brain. In the past decade pharmacological, molecular biological, and immunocytochemical techniques have been developed which allow for a closer investigation of the hair cell. Isolated hair cell pharmacology along with molecular biological data suggest the presence of a nicotinic receptor involving the subunit a-9. Immunocytochemical data has confirmed the presence of a-9 receptor protein in isolated saccule (n=6) and semicircular canal hair cells (n=8). Quantification of these results has indicated that hair cells from the saccule are 238.9% brighter than those from the semicircular canal (n=8). Another interesting finding was the unusually high expression of a-9 from pear-shaped hair cells of the canal (259.8% brighter than average canal hair cell)(n=8). Surprisingly these cells exhibited an expression of a-9 that was slightly greater than expression seen in hair cells from the saccule. Further illumination of these results may be possible with the use molecular biological techniques. Analysis of mRNA levels between different cell types of the semicircular canal may confirm the immunocyto-chemical data presented in this report. The use of single cell immunocytochemical data has further elucidated the presence of the a-9 nicotinic receptor in saccule and semicircular canal hair cells. This information may provide a platform for defining its functional roles in the vestibular system. An enhanced understanding of the receptors nature within the vestibular organs may provide information for more selective pharmacological agents to treat vestibular pathologies and motion sickness.

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The JABSOM School Health Education Program at Castle High School

Taryne Imai, MS2, Ronson Sato, MS2 & Alan Wu, MS2
Gwen Naguwa, MD, Office of Medical Education, JABSOM

The main objective of the School Health Education Program (SHEP) was to educate high school students in various health issues by using medical students as teachers. Our school was Castle High School, located in Kaneohe with a mixed population of students from various ethnicities, cultures, and socio-economics. Castle High School was a first time participant in this program and the two classes that were taught were health occupation students that consisted of juniors and seniors. Various health issues included professionalism and medical ethics, vital signs (BMI, safety, blood pressure, height, weight, spinal curvature, hand washing, pulse rate and respiration rate), nutrition, and drugs and alcohol. Topics were taught by utilizing various methods, which included small group discussion/interaction, large group lecture using power point presentations, skits, games, interactive media, active participation following demonstration, and videos. To assess the efficacy of using medical students to teach health topics, a pre-evaluation and post-evaluation was administered in each session. These evaluations consisted of the same 4 multiple choice questions each with 4 answer options. The results of these evaluations were considered statistically insignificant using the paired t-test. Possible reasons for this result could be due to the few amount of sessions, the few amount questions per evaluation, and the difficulty of the questions. Although the results were insignificant, based on observation and the teacher evaluation of our performance, the students seem to agree that our sessions were still effective and worthwhile and made a positive impact on their health education. Also, the last question on every post-evaluation asked whether the students had improved their knowledge base and whether the presentations were effective. The usual answers all ranged from strongly agree to agree, therefore demonstrating that our presentations were actually effective and our time was worthwhile.

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Ethnicity and Psychiatric Admissions, Diagnoses, and Treatment Outcomes

Chia Granda, MS2

During recent years, Asians and Pacific Islanders were the fastest growing ethnic minority groups in the United States yet minimal research examining aspects of mental health care as experienced by these ethnic minorities has been conducted. Addressing the disparity of psychiatric or mental health care research pertinent to Native Hawaiians, Asians, and other Pacific Islanders is vital to the improvement of their mental health care. Although previous research has provided insight into the relationship between ethnicity and mental health care, there has merely been speculation of discrepancies occurring between Native Hawaiians and other Pacific Islanders being treated for mental illness. Thus, the proposed study will examine the effects of psychiatrist-patient ethnicities being similar versus different on the management and treatment of Native Hawaiian patients. The present study is primarily aimed at investigating the differences in psychiatric admission, diagnosis, treatment administered, and treatment outcomes related to ethnicity. There are two parts to the study which are proposed to take five years to complete: 1) A retrospective study that will provide a historical overview of patterns of admission, diagnosis, treatment, and treatment outcomes and 2) A prospective study, which will provide information regarding ethnic differences in psychiatric admission, diagnosis, and treatment by comparing the concordance or agreement between diagnoses derived from psychiatrists' clinical interviews and lay administrations of the Diagnostic Interview Schedule (DIS).

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HIV-Specific T-helper Cell Function and Acute HIV-1 Infection: Does in vitro Antiretroviral Therapy Improve the Ability of T cells to Profilerate?

Chia Granda, MS2
Eric Rosenberg, Harvard Medical School and Massachusetts General Hospital

In most HIV-infected patients, HIV-specific immune responses are seriously impaired, at least prior to initiating antiretroviral therapy (ART). Evidence of this is abundant and includes: a decrease in the number of CH4+ naive and memory T-cells; a decrease in DTH reactions to antigens; a decrease in Th1 cytokine production (e.g. IL-2 and IF-gamma); and an increase in the activity of CD38+ cells and HLR-DR+ cells. It appears that HIV-specific CD4+ cell responses are significantly impaired in the earliest stages of untreated acute infections. Acute HIV infection should elicit a strong HIV-specific proliferative response, which would be expected to orchestrate an effective cellular and humoral attack on the virus. Yet, because HIV selectively infects activated CD4+ cells, these cells become preferential targets for infection when the viral load is at its highest. Loss or dysfunction of these cells would impair immunologic activity needed to keep viral load replication at bay, including activation of cytotoxic lymphocytes. While ART appears to be capable of enhancing LPRs to such pathogens as CMV, Candida, tetanus toxoid, and M. tuberculosis, there is little evidence suggesting that ART stimulates proliferative responses to HIV. To determine whether or not in vitro therapy with ART will protect these responses from being lost, this study measured the ability of lymphocytes from HIV-infected patients to undergo polyclonal proliferation in vitro when stimulated by an antigen or mitogen. Results showed that there were no significance differences between ART treated and non-treated lymphocytes. This suggests that HIV-specific CD4+ T-cells could either be present in small numbers or dysfunctional. The long-term aim of this study is to provide insight into the immunopathogenesis of HIV, as well as strategies for vaccine development. (This paper was presented at the 2nd Annual MS2 symposium).

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The JABSOM School Health Education Program at Nanakuli High School: A Successful Service-Learning Partnership Between Medical Students and High School Students

Ravindu Gunatilake, MS2 & Makiko Sawada, MS2
Nina Teruya, Premedical Student, UHM
Jason Ninomiya, MS4, Department of Pediactrics, JABSOM
Gwen Naguwa, M.D., Office of Medical Education, JABSOM

The JABSOM School Health Education Program is a service-learning experience for first-year medical students to teach health issues to Hawaii public high school students. It serves as a conduit for cultivating social responsibility within JABSOM's problem-based curriculum, and a instrument for meeting the educational needs of the State of Hawaii. Addressing health care topics including nutrition, exercise, drug abuse, and sexuality, a team of JABSOM students employed ingenuity, student interaction, and highly visual learning aids to increase the health content knowledge of Nanakuli High School Students between grades 9-12. Utilizing a one-group pretest-posttest design for evaluating student, data analysis revealed that all three classes at Nanakuli increased their mean score of correct answers (t = 4.346, df = 31, significant at the p<0.05). Endnote: All members of the JABSOM educational team to Nanakuli voiced high praise for this program and would recommend that incoming MSI's participate in its continuation. Acknowledgements: The Queen Emma Clinics, HMSA Foundation, Mrs. Peggy Yoshida and Ms. Joye Hanabusa.

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At what age do Native Hawaiians begin to manifest hypercholesterolemia?

Lisa Kahikina, MS2
Shannon Hirose-Wong, PhD, Native Hawaiian Center of Excellence, JABSOM

Research has demonstrated that the health of Native Hawaiians is less than optimal. Native Hawaiians significantly display substandard health statistics. Among Native Hawaiians, the prevalence of diabetes mellitus type 2 (type 2 DM) and cardiovascular diseases is high. Diabetes and cardiovascular diseases, in particular, are diseases that are strongly associated with hypercholesterolemia. Elevated cholesterol serum levels as an etiologic factor in the pathogenesis of atherosclerosis in cardiovascular diseases has been substantiated through much research. Cardiovascular disease and diabetes are clinical events that result from a process that begins years in advance prior to onset of disease symptoms. Clinical evidence confirms that there is a strong correlation between cholesterol levels in young adults (as early as 20 years of age) and cardiovascular disease later in life (around 60 years of age). Furthermore these risks are predominantly affected by behavior, such as consuming a high-fat diet and/or living a low-exercise lifestyle. Hypercholesterolemia, a diabetic and cardiovascular constellation risk factor with obesity, is a complication of a way of life rather than of genetics, and therefore can be affected by behavior modification. This study aims to demonstrate the potential effectiveness of cholesterol screening to improve health behaviors in young adult Native Hawaiians and to establish the age-distribution of hypercholesterolemia in this population. Both of these factors are included in this study because the primary goal of this research project is to help dictate the direction of future health intervention solutions. It is important to understand whether hypercholesterolemia exists in this population, and whether the individual patient knowledge of cholesterol levels will have an impact on health behavior modification. The cholesterol screening survey portion of the study will recruit twenty young adult (20-35 years of age) individuals from the University of Hawaii at Manoa. The participation profile requirement is that the individual must be of Native Hawaiian decent. Native Hawaiian is defined as any individual having at least one biological parent of Native Hawaiian ancestry. The data for this portion of the study will consist of a brief survey designed to determine whether cholesterol screening in young adult Native Hawaiians would possibly be a successful intervention program for heart disease and health behavior modification. The cholesterol level portion of the study will recruit one hundred young adult (20-35 years of age) individuals from the community colleges on O'ahu (Leward, Kapi'olani, and Honolulu), University of Hawaii at Manoa, Waianae Coast Comprehensive Health Clinic, and Waimanalo Health Clinic. The participant profile requirements are that the individual must be Native Hawaiian, between 20-35 years of age, have a family history of type 2 DM or cardiovascular disease, and is asymptomatic for type 2 DM or cardiovascular disease. Native Hawaiian is defined as any individual that has at least one biological parent of Hawaiian ancestry. If the results of this study demonstrate hypercholesterolemia is present significantly in the young adult population and that young adults accept health behavior modification, it is hoped that attention to cholesterol screening in this age group can occur. Since young adults are typically asymptomatic of cardiovascular disease, knowledge of personal cholesterol levels may enable individuals to have concrete awareness of the effects of unhealthy living. Cholesterol levels may allow young adults to tangibly sense their health status and motivate these individuals to begin to make lifestyle changes that will improve their health, especially later in life.

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Prognosis of Hemorrhagic Complications During the Treatment of Acute Myocardial Infarction

Bryan O. King, MS2
Phillip Kuo, MD, PhD, UH Internal Medicine Resident

We retrospectively identified predictors of hemorrhagic complications among patients who were hospitalized for acute myocardial infarction. We were particularly interested in the predominantly Asian population of Hawaii, as various studies have suggested that this population may be more at risk for bleeding. We found that approximately 10% of admissions for acute myocardial infarction had clinically significant hemorrhagic complications, higher than the national average. We also found that, in agreement with previous studies, age and lower body weight were associated with a higher rate of bleeding complications.We also report the new finding that Asian-Pacific Islanders and patients with diabetes mellitus were at higher risk for hemorrhagic complications. No association was found between female sex and hemorrhage, as has been reported by others. We propose that maximal anti-platelet/anti-coagulation therapies may unmask previously occult genetic polymorphisms in coagulation pathways, including some that predominate in the Asian/Pacific Islander gene pool.

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"Moloka'i Miles Club:" A Community Based Intergenerational Physicial Fitness and Education in Rural Based Areas: A Quentin N. Burdick Rural Health Project

Kevin Kitagawa, MS2
Kathleen Grubbs, Clinical Psychology, Laura Hiyane, Social Work, Ty Uratani, Dental Hygiene, UHM
Lena Teves, High School Volunteer
Jan Scholtz, PhD, School of Nursing and Dental Hygiene, UHM

The "friendly isle" of Moloka 'i, boasting a population of nearly 7,000 people may very well be the "last Hawaiian island." With no stoplights or traffic, and a one-block city, Moloka'i is a tightly knit community bound together by many of the Hawaiian values that have been lost on the other islands. Those who live here, truly live the spirit of aloha, greeting you not with an impersonal handshake, but with a hug and a kiss. Our first glimpse into the island life of Moloka'i came during our site visit in April. While attending the Earth Day Celebration, the Taro Festival, and Kekama' s island tour, we were provided with several examples of the importance the local people place on their culture and their youth. Being introduced to these concepts would later come to play a crucial role in the formulation of our rural health project. Our Quentin Burdick Rural Health Team was made up of four students from the University of Hawai'i at Manoa, consisting of students from Clinical Psychology, Social Work, Dental Hygiene, and Medicine. The team also included a faculty member from the School of Nursing and Dental Hygiene (Donna Fukuda) and a site coordinator living on the island of Moloka'i (Judy Mikami). Working together with local organizations such as Lamalama Ka 'Ili, Na Pu'uwai, and Peter Pale from the Lamalama Ka 'Oiwi Fitness Center, our team set out with the goal of creating a project that would take an interdisciplinary approach to health in an underserved rural community, in an attempt at establishing a self-perpetuating project focusing on the needs of the people. The project that was spawned from our combined efforts attacked a common theme that seemed to run rampant throughout the Moloka'i community--obesity and it's associated chronic disease. To accomplish this end, we have devised a walking program incorporating both the youth and adults of the community. The youth would play the role of overseeing groups of interested walkers, thereby creating an intergenerational bond to provide the youth with an opportunity to learn from their elders about their culture. Through the Moloka'i Miles Club, it was felt that we would not only address a central issue of concern for the community, but we would also provide the basis for a program that could continue on even after we had left the island. With the help of our contacts in Lamalama Ka 'lli, Na Pu'uwai, and Lamalama Ka 'Oiwi Fitness Center, this program is designed to be carried out for years to come. To aid in this goal we have applied to the Healthy Hawai'i Initiative for program funding, which also cites obesity and lack of physical activity as a central issue facing the Moloka'i community.

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Continuers and Discontinuers of Raloxifene, Alendronate and Hormone Replacement Therapy for Treatment of Osteoporosis

Geoffrey Lam, MS2

Introduction: Osteoporosis currently affects approximately ten million Americans, leading to over one million osteoporosis-related fractures every year. Total costs for treatment of fractures is estimated at over thirteen billion dollars annually. This study examined reasons for users' compliance and noncompliance of osteoporosis medications, including various side effects experienced, severity of side effects, amount of educational counseling given and effects of ethnicity. The drugs investigated were Evista (raloxifene), Fosamax (alendronate) and hormone replacement therapy (HRT). Differences between pairs of medications were also analyzed. Previous studies have been completed comparing and contrasting two of the three medications, but no study examining usage of all three drugs within one patient population has previously been conducted. Historically, adverse drug effects and specific administration instructions have been major reasons for poor drug compliance, so the extent and severity of a variety of side effects were also examined for each drug, as well as between continuers and discontinuers. Methods: 1,915 female HMSA members aged fifty-five and older were surveyed on their use of osteoporosis medication between the years of 1999 and 2001. A total of 1,236 usable surveys were returned. Members were divided into groups based on whether or not they had persisted or discontinued use of their medication, and based on which drug they were prescribed. Comparison analyses were done using Stata software, and were made via Fisher's exact test and chi-square test. Results: Drug side effects proved to be the most common primary reason for discontinuers to stop taking their medication. 45.6% of discontinuers reported side effects as being the main reason for quitting. Continuers using all three medication types complained most about weight gain, leg cramps and aches and pains in the muscles, bones and joints. Leg cramps were more problematic among raloxifene continuers than the other two drug groups (p<0.050). Breast tenderness was more prevalent among the HRT group than the other two (p<0.001). Irregular menstrual bleeding was also a problem faced by HRT continuers more than alendronate continuers (p<0.050). Raloxifene discontinuers complained primarily of aches/pains in muscles/bones/joints, hot flashes and stomachache. Alendronate discontinuers also complained of aches and pains and stomachache, as well as heartburn. HRT discontinuers complained of breast tenderness, weight gain and aches/pains in muscles/bones/joints. Alendronate discontinuers suffered less from hot flashes than the raloxifene (p<0.001) and HRT (p<0.050) groups, but complained more of heartburn than the raloxifene group (p<0.050) and the HRT group (p<0.001). HRT discontinuers complained of breast tenderness more than the other two groups (p<0.001). HRT discontinuers also suffered more from irregular menstrual bleeding (p<0.001), regular menstrual bleeding (p<0.050) and weight gain (p<0.050) than the alendronate discontinuers, but the latter suffered more from stomachache (p<0.050). Incidences of hot flashes among raloxifene users and heartburn among alendronate users have been previously well-documented. In particular, alendronate users may potentially develop esophageal or gastric ulcers, esophagitis, gastritis or dyspepsia. Of the discontinuers, the raloxifene group complained more about their medication's side effects than the other two groups. Filipino and Native Hawaiian continuers felt most bothered by their medication. Conversely, Caucasian and Chinese discontinuers felt most bothered by their medication. As expected, discontinuers as a whole felt more bothered by their drug's side effects than continuers. Raloxifene discontinuers complained most about poor treatment (45.4%), followed by the HRT and alendronate groups. The Korean and Japanese continuers reported having the worst treatment experiences. For the discontinuers, the Japanese and Chinese groups had the highest proportion of members with bad experiences. As expected, discontinuers as a whole had a poorer treatment experience than continuers. Raloxifene discontinuers tended to stop taking their medication earliest, followed by alendronate discontinuers, then the HRT group. 53.4% of discontinuers had stopped taking their medication within the first six months. Most continuers had taken their medication for at least six months. 48.6% had taken their medication for over three years. Alendronate continuers reported having the best rate of instruction on how to take their medication properly (98.1%). The majority of continuers felt that they had been educated adequately (94.0%). A smaller proportion of discontinuers felt they had been properly instructed (85.6%). Most continuers were instructed by a doctor (81.2%) and/or pharmacist (14.3%). Alendronate continuers were most likely to have been instructed by a pharmacist (24.9%), followed by the raloxifene group (12.0%), then HRT group (6.1%). A much lower proportion of discontinuers had been instructed by a doctor (68.8%) or pharmacist (6.6%). As a group, the continuers had a higher proportion of members (76.4%) who had been instructed by at least one professional than the discontinuers (68.0%). (This paper was presented at the 2nd Annual MS2 symposium).

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Effects of Xanthohumol, a Flavonoid from Hops (Humulus lupulus), on Triglyceride Synthesis and Secretion in HepG2 Cells

Summer R. Lam, MS2
Andre Theriault, PhD, Division of Medical Technology, JABSOM

Xanthohumol is a plant flavonoid from hops with a prenylated chalcone structure. The focus of this study was to determine the effects of xanthohumol on triglyceride synthesis and secretion in HepG2 cells. Following a 24-hour treatment with xanthohumol, the cells showed a dose-dependent reduction in triglyceride secretion with a 65 + 9% reduction at 25 uM of xanthohumol. The response in triglyceride synthesis was variable, and did not correlate with xanthohumol dosage. A preliminary cell viability assay showed that changes in triglyceride synthesis and secretion were in response to xanthohumol, and not the result of cell death. In summary, the data imply that xanthohumol is capable of reducing triglyceride-rich VLDL secretion in human liver cells, but is ineffective in reducing total hepatic triglyceride synthesis.

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Men's Preferences Regarding the Use of Chaperone During Genital and Rectal Examinations

Lorraine Manlolo, MS2
Diane Jerng, M.D., Curtis Lin, DrPh, Family Health Center, Pomona Valley Hospital Medical Center

Although many studies in the literature have addressed the preferences of women, children, and adolescents regarding the use of chaperones during breast, genital, and pelvic examinations, a literature search on men's preferences regarding chaperone use revealed conflicting results, as well as an overall paucity of investigation in this area. A large discrepancy in the results of the only two studies found in the literature may be due to different settings, different patient populations, or other unknown factors that need further investigation. This study will focus on adult men's preferences for or against the use of chaperones during genital and rectal examinations with different age groups, with male vs. female physicians, and with different degrees of familiarity with the examining physician. This project will also examine who are men's preferred chaperones and how that choice differs by marital status. This study will be conducted at our hospital-based family medicine residency program at Pomona Valley Hospital Family Medicine. These objectives will be achieved through a three page questionnaire survey of all male patients age 18 and older visiting our office practice. The sample size will be determined by the number of subjects surveyed in a 4 month time interval, estimated to be about 720 men. A comparison of proportions using chi square analysis will be used to analyze the data to determine men's preferences for or against chaperones according to age groups as well as gender and familiarity of the physician. The marital status will be analyzed to determine any influence on the type of chaperone preferred. This study will help develop a better understanding of the needs of male patients in regards to chaperone use during genital and rectal examinations. These results will help guide physicians to demonstrate increased sensitivity to male patients and offer an appropriate chaperone for patients when desired. This study will help determine if there is a need for the hiring practices of physicians' offices to accommodate an appropriate chaperone for male patients. This service will increase patient satisfaction in men's health care.

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Simple bone cyst: A case report with bilateral involvement of the distal femoral metaphyses

Jonathan Mau, MS2
Suzanne Yandow, MD & Ramona Fillman, Shriner's Hospital, Hawaii

An extremely rare case of bilateral involvement of distal femoral metaphyses by simple bone cysts in a boy 15 years is described. Simple bone cysts are usually metaphyseal lesions of long bones in skeletally immature persons, most commonly located in the proximal humerous and proximal femur. Reported cases of bilateral simple bone cysts are extremely rare.

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Kawasaki Syndrome: The Diagnosis Project

Jonathan Mau, MS2
Marian Melish, MD, Department of Pediatrics, JABSOM

At present the diagnosis of Kawasaki Syndrome (KS) is entirely subjective, the 6 point diagnostic criteria are cumbersome and generally require past experience for their application. An improved diagnostic approach is urgently needed to ensure that all KS patients, including those with incomplete or atypical clinical signs, receive the current standard of treatment. In an attempt to simplify the clinical criteria for KS, we will develop a database recording the pertinent clinical history of patients in the study. We will evaluate and characterize patients with classical KS, incomplete KS, atypical KS, febrile conditions which mimic KS (febrile controls) and afebrile children (well controls) of the same ages. The patient database will be correlated with positive results from the echocardiographic and the genetic array based laboratory testing to determine how well each element performed in diagnosis of classical, incomplete and atypical KS. A diagnostic algorithm for KS will be constructed based upon this analysis.

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Cultural Variations in Cancer Pain Expression

Trissy Mineshima, MS2
Christopher Wood, MD, MPH, Department of Psychiatry, JABSOM

Context: The treatment of cancer pain is a major challenge in health care today. A person's cultural identity often impacts how pain is perceived, which shows that there are differences of cancer pain expression among cultures, yet this is not recognized. Therefore, there is concern that a person may be given the wrong pain medication due to inadequate pain assessment. In Hawaii where multiculturalism is the norm, there may exist differences in cancer pain expression among the variety of ethnic groups. Objective: The main purpose of this study is to determine whether there are indeed cultural variations in cancer pain expression. Design: A retrospective chart review of approximately 250 random cancer patients of five ethnic groups (Hawaiian, Filipino, Japanese, Chinese, and Caucasian) who were diagnosed with stage IV bone metastases from 1999 through 2001. A basic data form was used to abstract information from the charts, which included demographic variables, ethnicity, medical diagnoses, medications, and pain ratings. The pain ratings were taken from patients by using the Queen's Medical Center FACES pain scale. The data will be analyzed by using a statistical package for social sciences (SPSS). Cross-ethnic comparisons of pain expression will be made by using analysis of variance (ANOVA) and chi square. Results: There were no statistically significant results between ethnic groups on the first day of admission (P= .653) or on the day of discharge (P=.237). Conclusions: We found no evidence to support that there are variations of cancer pain expression between different cultures. Further work is needed to describe the cultural variations of cancer pain expression.

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The Use of Bone Marrow Aspirate to Supplement Spinal Fusion

Kyle Mitsunaga, MS2
Morris M. Mitsunaga, MD

Objectives: To assess the clinical and radiographic success of spinal fusions supplemented with bone marrow aspirate in comparison to literature reported fusion using autogenous and allograft bone grafts. To evaluate patient outcome of spinal fusion surgery using bone marrow aspirate in terms of function, work disability, satisfaction, medication use, and post-operative pain levels. Methods: 47 patients were followed for a minimum of 2 years post spinal fusion. Fusions were classified as "definitely fused", "probably fused" or "pseudarthrosis" based on review of plain radiographs. Cervial spine fusions were assessed using flexion-extension radiographs and CT scans. The Bridwell classification was used to assess thoracolumbar fusions with hardware. The Heggeness and Essess classification was used to evaluate posterolateral lumbar fusions. Post-operative economic and functional outcomes were assessed using the Prolo Scale. Results: No complications occurred at the bone marrow aspirate site. The overall radiographic fusion rate was 79%. Atrophic pseudoarthrosis occurred in 8 patients. Lumbar fusion was achieved in 71% of patients. Cervical fusion was successful in 86% of patients. Thoracic and thoracolumbar fusion was achieved in 87% of patients. In terms of functional outcomes, the Prolo rating was determined to be good (E4, F4) overall as well as for each specific group. Conclusions: We believe that the use of bone marrow aspirate enhances spinal fusions and circumvents the complications associated with the use of iliac bone grafts. (This paper was presented at the 2nd Annual MS2 symposium).

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Improving Morbidity and Mortality in Extremely Obese Native Hawaiians Through A Culturally-Based Exercise, Diet, and Behavioral Modification Program

Kaipo T Pau, MS2 & Greg K Sakamoto, MS2
Blane Chong, M.D., Queen's Healthcare System

Previous studies have attempted to address the high prevalence rates of cardiovascular diseases in Native Hawaiians. However, there has not been an intense, comprehensive wellness program targeting extremely obese Native Hawaiians. This study will examine the combined accepted components of diet, exercise, and behavioral modification in a wellness program. It seeks to answer the question of whether the implementation of such a program will decrease the obesity-associated risk factors in a group of extremely obese Native Hawaiians. Eleven extremely obese Native Hawaiians from Moloka`i at high risk for cardiovascular diseases participated in this study. The group's average initial weight was 418 lbs. (an average BMI of 58.4), the total cholesterol was 183.5, Total Cholesterol:HDL Ratio was 4.2, and the average fasting plasma glucose (FPG) was 125.36 mg/dL, and exercise tolerance was 10.2 minutes. Upon completion of the 3-week program, there was a dramatic improvement in their cardiovascular risk factors. There was an average weight loss of 14 lbs. In addition, the average total cholesterol decreased by 8.7% and the Total Cholesterol:HDL Ratio increased by 8.7%. The average FPG dropped by 16.7%. Exercise tolerance markedly improved by 42.2%. (This paper was presented at the 2nd Annual MS2 symposium).

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The JABSOM School Health Education Program at Farrington High School

Shayla Penarosa, MS2 & Gareth Nakasone, MS2
Julie Andrada, & Cindy Melo, Premedical Students, UHM
Gwen Naguwa, MD, Office of Medical Education, JABSOM

The School Health Education Program (SHEP) at the University of Hawaii John A. Burns School of Medicine (JABSOM) was started with the goal of educating high school students on health-related topics. Through the SHEP program, a group consisting of two JABSOM first-year medical students and three UH premedical students was formed to educate high school students at Farrington High School. Our group gave interactive presentations to students in grades 10-12 on topics including nutrition, vital signs, and complementary and alternative medicine. The high school students' knowledge of each presentation topic was tested before and after each presentation via a short quiz consisting of multiple-choice questions. There were four presentations on four different dates for which we collected data. Upon analysis, we show a significant difference between the pre- and post-test data for one of the four presentations. The class at Farrington High School demonstrated an increase in their mean score of correct answers on the written test after the presentation on vital signs. This indicates that the students increased their knowledge of this health topic after our presentation.

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Reliability of Internet Resources in a PBL Curriculum: Analysis of Website Advice on Management of Acute Gastroenteritis in Children

Anthony Phung, MS2

Objectives: To assess the reliability of healthcare information on the World Wide Web and its effectiveness when used as a resource by medical students in a problem-based learning curriculum. Design: Survey of internet resources. Data Sources: 49 websites providing information about the management of gastroenteritis in children. Outcome Measures: Quality scores based on predefined characteristics in each website. Accountability and conformity with core standards defined by the American Academy of Pediatrics for each site in question. Correlation between accountability and quality scores were measured. Results: Of the 49 sites analyzed for accountability and quality, only 36% conformed for quality standards defined by the AAP guidelines for the management of gastroenteritis in children. However, the source of information did increase the prediction on the website's likelihood of compliance or noncompliance. Conclusions: After careful assessment of all the websites, recommendations on the treatment of acute diarrhea in children proved to be incorrect or incomplete. The information in each website passed onto perspective readers (i.e. students) can mislead them into treatment options that do not completely correlate with the AAP guidelines. Despites the inaccuracies, many sites still contained important and useful information. If the reader were able to siphon useful information from all websites, he/she would be able to maximize the potential provided by the Internet.

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Effects of a Novel Curriculum to Educate Residents in Smoking Cessation Counseling

Timur Roytman, MS2
Jennifer Holzman, MS4, JABSOM
Susan Steinemann, M.D., Department of Surgery, JABSOM

The purpose of this project is to develop a novel and innovative smoking cessation counseling curriculum for residents in the University of Hawaii John A. Burns School of Medicine's Department of General Surgery. It is the principal investigator's hypothesis that a targeted educational program will improve residents' attitude, knowledge, confidence and skills in providing smoking cessation counseling. The study involves 25 surgery residents. A baseline survey evaluating residents' attitude, knowledge and confidence in providing smoking cessation counseling was administered. The skills in proving smoking cessation counseling were evaluated by standardized patients. The baseline information obtained was evaluated and used to design a targeted educational program. The study employs a crossover design. Residents' attitude, knowledge, confidence and skills in providing smoking cessation counseling will be reevaluated following the administration of the targeted educational program.

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Development and Evaluation of an Acute Graft-Versus-Host Disease Activity Index in Patients Undergoing Allogeneic Hematopoietic Cell Transplantation

Raymond C. Salazar, MS2
George B. McDonald, M.D., University of Washington School of Medicine

Background: The current scoring system for graft-versus-host disease (GVHD) following allogeneic hematopoietic cell transplantation is problematic due to the retrospective assignment of scores, no consideration for the efficacy of treatment, and inter-observer error in the grading system. A system for scoring GVHD that measures disease activity over time is desirable.Methods: We performed a chart review of 80 randomly selected patients from among a cohort of 411 patients with chronic myeloid leukemia who underwent allogeneic hematopoietic cell transplantation. A unique letter score was assigned for each degree of abnormality in the following seven categories: skin, liver, upper gastrointestinal tract, lower gastrointestinal tract, immunosuppressive drug therapy, fever, and performance status. Weightings were assigned for each letter, values were summed over a 10-day period, and an average GVHDAI score was calculated for each patient. Numerical values from GVHDAI were compared to independently determined GVHD grading. Results: 20 patients in each of the four GVHD grade populations (N = 80) had determination of GVHDAI at 10-day intervals. Average GVHDAI scores were arrayed in a step-wise fashion according to GVHD grade . There was considerable overlap of average GVHDAI scores among traditional GVHD grades. 15/20 grade III GVHD, 5/20 grade II GVHD, and 6/20 grade I GVHD overlapped with grade IV GVHD. Despite the overlaps of GVHDAI values between GVHD grades, mean GVHDAI values within each GVHD grade are statistically significantly different from one another, with the exception of grade I versus grade II GVHD cohorts. Conclusions: GVHDAI calculation was relatively simple. Though average grade IV GVHDAI scores were significantly higher than lower grades, much overlap exists, suggesting that the standard GVHD grading underestimates grade I/II GVHD severity and overestimates GVHD severity in some grade III and IV patients. The results justify proceeding with a refinement of the GVHDAI system in the entire study cohort. (This paper was presented at the 2nd Annual MS2 symposium).

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Attitudes and Knowledge about Osteoporosis in Young and Old Populations

Jocelyn M. Sonson, MS
Kamal Masaki, MD, Department of Geriatrics, JABSOM

Objectives: To determine the knowledge of and attitudes toward osteoporosis, its risk factors, prevention, and treatment among young and old populations, and to compare differences between age groups and gender groups. Methods: Cross-sectional descriptive survey was used to assess the knowledge of and attitudes towards osteoporosis of 116 women and 22 men attending community senior center or the UH Manoa. Eighty-four participants were 65 years or older (senior group, 76 female and 8 males) and fifty four participants were between 18 and 29 years old (younger group, 40 females and 14 males). Results: 98% of the participants had heard about osteoporosis. TV, newspapers and health care clinics were identified as the source of information. More women (81%) were concerned about developing the disease than men (27%, p<0.001) and more seniors (38%) than younger participants were concerned belief they would develop osteoporosis in the future (p<0.001). In both groups, 74% consumed calcium rich diets, although more seniors reported taking calcium supplements, multivitamins, and vitamin D (ps<0.05). 74% reported exercising regularly, although only 54% were meeting the current public health recommendations, and more younger participants (57%) than seniors (27%) reported in engaging in regular, active exercise (p<0.001). Conclusions: The results revealed a high degree of background knowledge and awareness of risk factors and preventions, however belief or concern about developing osteoporosis was low, particularly in certain cohorts (ie., younger participants and males). This study highlights the gap between knowledge and participation in prevention of osteoporosis. Specific recommendation are made to close this gap.(This paper was presented at the 2nd Annual MS2 symposium).

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Utility of the IQ CODE in a Japanese American Population of Hawaii

Keith Tokuhara, MS2
Kamal Masaki, MD, Patricia Blanchette, MD and V Valcour, Department of Geriatrics, JABSOM

Objectives: To assess the specificity and sensitivity of the IQCODE for dementia in a Japanese American Population in Hawaii. Design: Cross-sectional study. Setting: A multiphysician private practice clinic in a predominantly Asian American community of Honolulu. Participants: 262 ambulatory patients aged 65 and older who were self-identified as Japanese/Okinawan. Methods: Cognitive function of the participant was assessed by physician interview using the Mini-Mental State Exam (MMSE) Cognitive Abilities Screening Instrument (CASI), Clock-Drawing Task, and Clinical Dementia Rating. The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) was given to a close relative, friend or caregiver of the participant. Results: Of the 262 self-reported Japanese/Okinawan participants selected for the study, 20 (7.6%) had dementia. Correlation of the IQCODE to the CASI was -0.2976 (p<0.0001) and -0.2535 (p<0.0001) to the Clock-Drawing Task. The sensitivity and specificity of the IQCODE for both Impairment and Dementia was optimized using a cut-point of 3.4. Conclusions: In this convenience sample of Japanese Americans in Hawaii, the IQCODE was highly specific (95%) and sensitive (83%) as a screen for dementia using a 3.4 cut-point score. This is a lower cut-point than has been reported in non-Asian populations. Cultural factors including the understatement of the degree of cognitive decline should be considered when using informant tests in a Japanese American population. (This paper was presented at the 2nd Annual MS2 symposium).

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Serum Albumin Level as a Predictor of Incident Coronary Heart Disease and Mortality in Elderly Japanese-American Men: The Honolulu Heart Program

Brett Yamane, MS2
Kamal Masaki, MD, Patricia Blanchette, MD, Helen Petrovitch, MD, Randi Chen, MS, Dept of Geriatrics, JABSOM
N. V. Bhagavan, PhD, Department of Biochemistry, JABSOM
J. David Curb, MD, Honolulu Heart Program, Kuakini Medical Center

Background: Longitudinal studies have observed an inverse association between serum albumin levels and both incident coronary heart disease and mortality. This relationship has yet to be observed in elderly Japanese-American men. Methods and Results: The Honolulu Heart Program is a prospective epidemiologic study of cardiovascular disease in Japanese-American men. Using the data from the fourth examination (1991-1993), albumin levels were measured in a random sub-sample of 998 men between the ages of 71-93 years. Subjects were divided into tertiles and cutpoints by serum albumin levels after excluding those with prevalent CHD (N=729). Outcome variables were incident CHD and total mortality, and incident CHD was defined as new cases of angina, acute myocardial infarctions, or having had PTCA or CABG. Six-year age-adjusted rates for incident CHD were 25 and 18.7 per 1000 person years. Using Cox proportional hazards models, after adjusting for age and CHD risk factors, every unit increase in serum albumin was associated with a 13% decreased risk of CHD events (RR=0.87; 95%CI=0.52,1.44), while low albumin levels (£ 4g/dL) were associated with a 31% increased risk of incident disease when compared to normal albumin levels (RR=1.31; 95%CI=0.58,2.95). Nine-year age-adjusted mortality rates in those with low and normal albumin levels were 160.6 and 77.5 per 1000 person years, respectively. After adjusting for age, risk factors, and chronic disease, for every unit increase in serum albumin the decrease in relative risk for total mortality was 26% (RR=0.74; 95%CI=0.60,0.92). However, when using cutpoints, there was a 30% increased risk of mortality for those with low levels compared to subjects with normal albumin levels of albumin (RR=1.30; 5%CI=0.94,1.81). Expectedly, there was a statistically significant negative association between serum albumin level and total mortality. However there was only a U-shaped trend between SAL and incident CHD, with the lowest rates of CHD in the middle tertile of albumin level.

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A Retrospective Chart Review Measuring the Impact of the Hawaii Residency Program's Tobacco Reduction Project on Resident Physicians' Smoking Cessation Counseling Practices

Kelly Yamasato, MS2
Meta Lee, MD, Department of Internal Medicine, JABSOM

Tobacco is the leading cause of preventable death in the United States. Though studies show that physicians can effectively promote smoking cessation, many physicians do not adequately address smoking with their patients. This deficiency has been largely attributed to lack of physician confidence and training. Faculty at the John A.Burns School of Medicine have been working to improve the skills of their residents in smoking counseling by designing and implementing a new curriculum. This study will involve a retrospective chart review of patients seen by medicine-pediatric residents who participated in the new curriculum during August to September of 2001. Patient charts will be reviewed for demographic data as well as for the frequency of smoking assessment, counseling, and success in obtaining quit dates and cessation. The purpose of this project is to evaluate the impact of the new smoking cessation curricula on physician-patient interactions in the outpatient clinic setting.

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Normal Oxygen Saturation Values in Pediatric Patients

Kelly Yamasato, MS2
Loren Yamamoto, MD, Department of Pediatrics, JABSOM
Monica Mau, MS2, JABSOM

Pulse oximetry is widely used as an inexpensive, noninvasive, and generally reliable means to assess oxygenation. However, to our knowledge, normal pulse oximetry readings in children have not yet been clearly defined. This study surveyed oxygen saturation values of pediatric patients undergoing elective or outpatient surgery as recorded on preoperative assessment forms. Because elective and outpatient procedures are generally performed on children of stable health status, these values should be indicative of normal oxygen saturation values. Data has been collected and categorized, and further analysis is currently in progress. The purpose of this study is to more clearly define "normal" oxygen saturation values in pediatric patients.

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Potentially Hepatoprotective Dietary Supplements for Hepatitis

Cindy Yang, MS2
Amy Brown, PhD, Department of Human Nutrition, Food and Animal Sciences, UHM

Purpose: The purpose of this study was to conduct a literature review of MEDLINE to determine possible beneficial nutrients or herbs for patients recovering from hepatitis. Methods: A comprehensive literature review using MEDLINE, spanning from 1967 to August 2002, was conducted to determine what nutrients or herbs were reported to benefit the recovery of patients with hepatitis. The keywords used in combination with hepatitis: diet, nutrition, milk thistle, herbs, herbal medicine, nutrient(s), nutritional deficiency, nutritional support, nutritional therapy, nutrition therapy, diet recommendation, dietary recommendation, zinc, and vitamin, vitamin E. Randomized placebo-controlled trials were reviewed to evaluate the efficacy of Silymarin (milk thistle extract) usage (6 studies), Vitamin E (3 studies), zinc supplementation (1study), and combination nutritional therapy involving an amino acid-enriched, high carbohydrate, and low fat diet (6 studies). Measurable outcomes of primary interest were survival rates, mortality rates, and liver function test results which included: serum transaminases [alanine aminotransferase (ALT) and aspartate aminotransferase (AST)], gamma-glutamyl transferase (GGT), alkaline phosphatase (AKP), bilirubin level, albumin level, as well as prothrombin time (PT). Results: In all of the Silymarin clinical trials, positive results were observed in the herb-treated groups, which showed significantly reduced serum liver enzymes: AST, ALT, GGT, AKP, and total bilirubin levels. The considerable improvements in patient liver function tests clearly demonstrate the hepatoprotective properties of milk thistle, as well as its beneficial effects on hepatitis recovery. Vitamin E induced a significant normalization in the aminotransferase status of patients suffering from viral hepatitis B or C. Zinc supplementation enhanced patient responses to IFN therapy. Finally, the combination nutritional therapy trials support total enteral nutrition (an amino
acid-enriched, high carbohydrate, low fat diet) for hepatic recovery. Conclusion: Milk thistle, vitamin E, zinc, and enteral nutrition significantly improve the clinical parameters and measurable outcomes of liver function, such as serum liver enzymes, among patients with chronic liver disease. The evidence from randomized placebo-controlled clinical trials collectively verify that these dietary supplements have both hepatoprotective properties as well as positive effects on hepatitis recovery. It is suggested that future research determine the beneficial effect of these substances in "combination" on the hepatic recovery of patients in a randomized, double-blind, placebo-controlled trial.

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Olfaction Predicts Cognitive Decline in Elderly Japanese-American Men

Sallis Yip, MS2
Kamal Masaki, MD, Department of Geriatrics, JABSOM

The prevalence of dementia has been on the rise as our population continues to age. It has been found that structural and biochemical changes associated with Alzheimer's patients may also affect olfaction. This study investigates whether impairment in olfaction predicts cognitive decline in patients with normal cognitive function at baseline. Subjects from the Honolulu Heart Program were tested for dementia since Exam 4 in from 1991-1993 using the CASI. At Exam 5 from 1994-1996, they received another CASI as well as a 12-item Cross Cultural Smell Identification Test (CC-SIT). For analysis, subjects will be divided into 3 groups based on olfaction testing at baseline.

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