.HAWAII MEDICAL

JOURNAL December 1995 Volume 54, No. 12 ISSN: 0017-8594

The 1996 E-Class: Spacious interior. Dual-zone climate control. Burl walnut. Double-wishbone

front suspension. Side air bagst mounted in front doors. No wonder you don't want to be

reached. (!} Mercedes-Benz

'MSRP for an £300 Deisel Sedan includes $595 transporation charge. Excludes all taxes, tiUeldocumentary fees, registration tags, dealer prep charges, insurance, optional equipment, certificate of compliance or noncompliance fees, and finance charges. Prices may vary by dealer. fAir bags are a supplemental restraint. Always wear your seat belts. ©1995 Authorized Mercedes-Benz Dealers

,_ __ .., TtEOD~VIES iii EUROMOTORS

704 Ala Moana Blvd., Honolulu, HI 96813 Phone (808) 531-5971 • Fax (808) 538-7252

HAWAII MEDICAL

JOURNAL (USPS 237-&10)

Published monthly by the Hawaii Medical Association

Incorporated in 1856 under the Monarchy 1360 South Beretania, Second Aoor

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

Editors Editor: Norman Goldstein MD

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

Editorial Board Vincent S. Aoki MD, Benjamin W. Berg MD,

John Breinich, Theresa Danao MD, Satoru lzutsu PhD, James Lumeng MD,

Douglas G. Massey MD, Irwin J. Schatz MD, Myron E. Shirasu MD, Frank L. Tabrah MD,

Kim M. Thorburn MD

Journal Staff Business Manager: Beeky Kendro

Copy Editor: Jan Estioko Editorial Assistant: Carol Uyeda

Classified: Noreen Kamiya

Officers President Carl W. Lehman MD

President-elect JohnS . Spangler MD Secretary: Roger T. Kimura MD

Treasurer: Leonard R. Howard MD Past President: Frederick C. Holschuh MD

County Presidents Hawaii: Ernest Bade MD

Honolulu: Patricia Lanoie Blanchette MD Maui: Madhup Joshi MD

West Hawaii: Theresa Smith MD Kauai: Timothy Crane MD

Advertising Representatives Hawaii Professional Media Group

3036-A Kahaloa Drive Honolulu, Hawaii 96822

Phone (808) 988-6478 Fax (808) 988-2785

The Journal cannot be held responsible for opinions expressed in papers, discussion, communications or advertisements. The ad­vertising policy of the Hawaii M edicaiJ ournal is governed by the rules of the CoW1Cil on Drugs oflhe American Medical Associa­tion. The right is reserved to reject material submitted for editorial or advertising columns. The Hawaii Medical Journal (USPS 237640) is published monthly by the Hawaii Medical Association (ISSN 0017-8594), 1360 South Beretania Street, Second Aoor, Honolulu, Hawaii 96814.

Postmaster: Send address changes to the Hawaii Medical Journal, 1360 South Beretania Street. Second Aoor, Honolulu, Hawaii 96814. Second-dass postage paid at Honolulu, Hawaii.

Nonmember subscriptions are $25. Copyright 1995 by the Hawaii Medical Association. Printed in the U.S.

Contents

Editorial Norman Goldstein MD .. .. ... ...................... ..... ............................................... .... ..... ....... 807

HMA President's Message Carl W. Lehman MD ...... ... .......... .. ........ .... .. ..... .. ... ............ ........ ... ... ..... ..... ........ ... ..... ... . 807

Alliance Cherlita Gutteling ......................................................................................................... 808

Military Medicine Benjamin W. Berg MD ........... .... ... ........ ..... ... .. ........ ... ..... .. ........ .... .... .... ...... ................. 808

Medical School Hotline Al Castle, Director of Development .......... ........................ .. .............................. .. ......... 810

Hepatic Cryosurgery: Early Experience in Hawaii Linda Wong MD, Whitney M.L. Limm MD, Alan HS Cheung MD, F ong-Liang Fan MD, Livingston M.F. Wong MD ........ ...................... .. .... .... .......... ..... 811

Kidney Stone Center of the Pacific Summary of Operations 1986 to 1993 Thomas Y.lto, Rosemae Chibana RN, Lois Simpson RN, Marlaine Fern RT, Kathy Puetz ....... ..... ....... ..................... ... .... ............. .... ........... ................ ............ ..... ...... . 814

Recurrent Chylothorax Associated with Sarcoidosis Robert J. Lengyel MD, Dean J. Shanley DO .... .................... .... .................... ...... .... ...... 817

News and Notes HenryN. Yokoyama MD .... .. ...... .. .... ...................... .. ........................ ...... .. ........ .... ........ 819

Classified Notices ........ ........ ................... ........ .. ............................. .................... ...... .. .. 819

The W eathervane Russell T. Stodd MD ............................ ......... .. ................ .... .................... .............. ........ 820

Index to the Hawaii Medical Journal, Volume 53, 1994 .. ...... .............................. .. . 82 1

Index to the Hawaii Medical Journal, Volume 54, 1995 ...... .................... ............... 824

Council Highlights Roger T. Kimura MD ..... .... ..... ... ............ .... ..... .. ............ ........ ........ ...... .... .. ...... .. ... ..... ... 828

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

Pele at Haleakala

Pele, goddess of Hawaii ' s volcanos, also spent so1lle time on the island of Maui. Up in Haleakala crater she dug with her special digging stick in search of a home. Eventually, after a fight with her sister, she left for Kilauea where she has been ever since.

-HAWAII MEDICAL JOURNAL, VOL 54, DECEMBER1995 805

Hawaii Emergency Physicians Associated, Inc. HEPA Established: 1971

Serving:

Hila Medical Center Castle Medical Center Lucy Henriques Medical Center Wahiawa General Hospital

Mahalo nui loa to Mr. Jon Won, Executive Director of the Hawaii Medical Association, for your 30 years

of service to the Hawaii medical community.

HEPA is a participating provider with:

HMSA---continuous since 1971 Kaiser-continuous since 1971 PGMA CHAMP US Medicare HDS

>NC

Aloha Care HMSA

OUEST- Kaiser Queen's Straub

PO. Box 1266 • Kailua, HI 96734 • (808) 261-3326 • Fax (808) 262-0514

~ Editorial

Norman Goldstein MD

Yes, it has been two years. This issue of the Journal is our 24th in the New Journal. In

addition to some very scholarly manuscripts, we have receeived the practical as well as the esoteric. We have tried to publish a variety of subjects-to appeal to the broad base of our membership. Our special issues have been especially well received. The Hawaiian Medicine and Health; Medicine Law and Bioethics; 75 years of Military Medicine in Hawaii; and last month's issue on the History of Medicine in Hawaii-as well as our Fred Reppun Memorial issue and the Fred Gilbert Festshrift have all been superb Journals.

Many thanks to the authors, guest editors, and a special thank you to our Journal staff: Jan Estioko, Carol Uyeda, Becky Kendro, and Noreen Kamiya.

Our covers by Big Island artist Dietrich V arez with quality printing by Pacific Printers are classic.

The advertisers deserve a special mahalo, too. We need you! Thank you to our association of officers, our office staff, our peer

reviewers and our editorial board for their support. We look forward to another great year in 1996.

HMA President's Message

Carl W. Lehman MD

The HMA Leadership Planning Conference on Sunday morning October 29 from 8:30 to 11:30 was extremely well attended with our HMA Conference room filled to the max with about 65 physicians. Not only was the attendance great, the enthusiasm and participation were superb. With the interchange of ideas and discussion, many new ideas surfaced. The committee chairs are urged to incorporate these ideas into their plans and activities for the upcoming year. Committee chairs are not restricted by the goals suggested at this meeting-they are intended to be helpful catalysts in energizing the activities of the committees. During the discussions it was apparent there are functions of several committees that overlap. The chairs are encouraged to plan combined committee meetings when appro­priate.

In addition to meeting with and working with legislators and their staff, acting as a liaison with the community, and serving as a resource for the HMA on legislative issues, Dr Au has submitted a proposal from the Legislative Committee that will enable it to be representative of the entire organization. The core committee will be composed of specific committee members and HMA officers. The work on specific legislative bills and activities will be done within each of many working committees. If a member wants to participate and be active on a given political issue, he or she will be assigned to the committee working on that particular issue.

The following is an outline of the Legislative Committee structure to aid in your understanding of how that committee will function.

Purpose: to coordinate and facilitate the representation of legislative opinions and policies on behalf of the Hawaii Medical Association. The -

committee in itself does not necessarily formulate policy on any particu­lar issue but may advise Council of recommendations. Where possible, the Legislative Committee should promote involvement of the entire organization in legislative matters. Although not a member of the Legislative Committee, every member of the HMA should feel a commit­ment to all of the issues reviewed by this committee. The committee, as well as the organization, should foster the ideal of the entire HMA as a legislative body, rather than just being represented by the Legislative Committee.

Each member of the Legislative Committee will be assigned oversight duties for a particular issue. The Legislative Committee will serve as a clearinghouse and coordinator, and not the official policy-making body of the HMA.

Specific recommendations of the planning conference are: • Create a Communications Commission with Public Relations,

Publications, Computers, Membership Benefits and Membership Recruitment under that commissioner.

• Improve communications via electronics with Hawaii Online, a home page, and AMA Net.

• Provide a one or two-hour meeting on Davis Rules of Order prior to the House of Delegates.

• Consider restructuring the HMA with input from the Long­Range Planning Committtee, all past presidents, and revise the bylaws.

• Committees in the Public Health Commission saw the need to work together: Educating the community about domestic violence, tobacco prevention, and alcohol and other drug use remain top priorities. It was noted that a facility for drug-addicted youths should be studied, the crack versus cocaine sentencing should be reviewed, and the tolerance level for alcohol and driving should be examined. Another concern was the safety of patients who use alternative methods of healing.

• Physicians Health Committee needs to raise funds to hire a substance abuse counselor.

• Medical Legal needs to update the code. • Continue to look at medical savings accounts. • Managed Care Committee will work on education and dialogue

with existing managed care groups. • Monitor QUEST and other County/State programs. • The format of the annual meeting will be evaluated for possible

changes. • Review legislation for a 24-hour care option. • Overview of No Fault Law. • Chairs of committees are encouraged to schedule their meet­

ings more than one month in advance when possible. We will publish the known schedule of committee meetings in theN ewslet­ter. These dates and times are subject to change, so please call first to confirm and let the committee secretary know you are coming. Members who wish to attend a specific committee meeting are invited to contact the chair and attend the meetings or present specific issues of concern.

After the planning committee, the Council met. One of our members, Bernard Portner MD, called to our attention the inequities of the Hawaii No Fault Law; his case was referred to the No Fault Committee for further study. He and I also attended a House of Representatives Committee meeting on October 30 and presented our objections to the present law and how it interferes with good patient care.

This week has been exciting for me as your new president to see the enthusiasm and activity of organized medicine accomplishing things that individual physicians cannot accomplish on their own. Let's keep up the good work!

HAWAII MEDICAL JOURNAL, VOL 54, DECEMBER1995 807

DAlliance

Cherlita Gutteling Alliance President

Our new AMAA president, Sharon Scott, is calling for our medical Alliances this year to strive for unity and to put a personal face to our community work. That should be an easy task for those of us from the state known for its aloha spirit. This coming year, we reach out in that aloha spirit to all potential Alliance members and to the communities our spouses serve.

We wish to rebuild a medical Alliance that is strong and visible as a caring group in every county of the state of Hawaii. There is more need than ever for Alliance members to help keep the caring face of medicine prominent among ourselves and our communities. As physician's spouses, we cannot help but be affected by the chal­lenges in the medical profession today. Sometimes those challenges are so overwhelming it is difficult to simply survive let alone remind ourselves, as our national president says, that we are protectors of certain rights of medicine, both for ourselves and our patients.

And we do care. The medical spouses I know are active, intelli­gent, professional, and caring. Individually, so many of you give your time to so many worthy causes. Wouldn't it be a source of strength and satisfaction to have meaningful affiliations with others who share your concerns? Acting together, we can make an even larger community impact. As a group, we can support the national project of the year: SAVE-Stop America's Violence Everywhere. Who more than physicians and their spouses are aware of the personal pain and psychological damage perpetrated by the vio­lence our doctors are asked to repair? This project and others need all of the aloha we can bring them.

The benefits of cooperation and caring are personal, too. This year on the island of Hawaii, we have experienced firsthand the impor­tance of a cohesive, caring group. More than one physician has faced an unexpected, difficult challenge in his or her profession that deeply affected the spouse and family. Whenever something ad­verse affects one physician, it often reverberates throughout the medical community. Because our Alliance is strong and caring and personally involved with our members, we were able to offer immediate support. All of us gained new appreciation for the spirit of aloha. We can extend that statewide.

One thing that keeps some potential members from joining the Alliance is that they are already so busy. But everyone needs to

CHU LAN SHUBERT President,

& Eve. loon Spedalilt

1st IN LOANS & SERVICE! NO HASSLE LOANSU

We offer special clscounts to cloctorsf • 1 0% Down on Jumbo to $500K • COFi Neg. ARM 4.75% max: 11.950% • 30 YR-7.25% /15YR-6.875% /1 YR ARM 5.75% • 1st TIITI9 Buyer only 3% down "0" points! Excellent Customer Service - Fast & Knowledgeable.

Apply by Phone - Free loan analysis. Great Time to Refinance or Consolidate debts!

PAY LESS AND GU MOREl

recognize that one benefit of Alliance membership is that there is room for all kinds of commitment, from long-term heavy commit­ment to very short-term light commitment. There are officer and board openings that require heavier responsibility and time, com­mittee chairs with limited time commitments, and committee mem­bers and event volunteers who support one day or one weekend as they wish. The important thing is that as paid members we have options, both to give and to receive from the HMA Alliance.

One last word: Stereotypes are strange. When there is little know ledge of what a group is or does, when little knowledge of them as individuals and of the work they do is known, negative stereotyp­ing seeps in. When that same group becomes known and more visible for its good work, it takes on a completely different face. We have the opportunity to put whatever personal face we want on our Hawaii Medical Association Alliance. My dream is that whenever our name is heard, it will bring a warm smile and a feeling of the spirit of aloha!

Note: If you wish to form a medical Alliance in your area to reactivate your group, or if you are not now a member of the Hawaii Medical Association Alliance and wish to join, please call me at (808) 935-2526.

D Military Medicine

Benjamin W. Berg MD Department of Medicine

Tripier Army Medical Center

Ulaanbaatar, Mongolia. A team of 16 military medical personnel from Tripier Army

Medical Center traveled to Ulaanbaatar, Mongolia in September 1995. This team was comprised of five surgeons (general, thoracic, ENT, OB/Gyn, and orthopedic), two pediatricians, two family practitioners (one staff and one resident), two internists, one preven­tive medicine specialist, one anesthesiologist, one laboratory pa­thologist, one dentist, and one preventive medicine officer (nonphysician).

This team was deployed to participate in an ongoing program of annual medical support and exchange between the U.S. and Mongolia. Exchange of ideas, the delivery of health care, and the assessment of an evolving modem health care delivery system were the primary

JOHN SHUBERT V~ee President,

General Manager

goals for the team. Health care was provided primarily to civilians; both civilian and military medical facilities were visited. The team expe­rienced a warm and receptive people who treated them like family.

ABCMORTGAGE 545-2442

My last visit to Mongolia had been in February, and the most striking difference in September was the weather! I was not able to see my breath in the fall, and the hospitals were much less populated than in the cold dark winter months. During the summer months much of the urban population of Ulaanbaatar retires to the countryside, where over 40% of the nation's 2.2 million people reside. The rural population maintains a nomadic lifestyle, rais­ing sheep and cattle on expansive prairie-like terrain. Health care in the rural regions is deliv-

918 H Smith Street • Honolulu, Hawaii 96817 "We Do Loans Right!" -HAWAII MEDICAL JOURNAL, VOL 54, DECEMBER 1995 808

Acupuncture therapy for Bell's palsy.

ered by feldshers who are trained in three-year practical apprenticeships. The feldsher' s scope of practice is similar to that of a physician assistant in the U.S., and they frequently travel by camel or horseback to care for patients.

Medical training in Mongolia has undergone a revolution in the past five years. Since Soviet Russia withdrew support and personnel from Mongolia in 1991, economic realities have been harsh. A technologic infrastructure with little sustaining expertise or cash for maintenance exists.

Much medical equipment is nonoperational and the dire need for supplies is evident. The medical school in Ulaanbaatar has de­creased the size of the class from 400 to 35. In earlier years many students were sent to the USSR, other Soviet block nations, or to European countries for advanced training. Few opportunities for foreign training exist now. Virtually all physicians now are trained exclusively in Mongolia. The medical curriculum begins after secondary school and lasts for six years; thereafter, all physicians train for one year as intern equivalents. Advanced training in surgical, medical, or other specialties consists of one year clinical training. An examination is administered after one year, to certify competency in the chosen field, be it neurosurgery or pediatrics. A junior physician in Ulaanbaatarearns the equivalentof$40 a month. An average apartment rents for $6 a month. Many people live in traditional skin-and-felt dwellings called yurts. These dwellings have been integrated into the urban sprawl of Ulaanbaatar.

Medical practice in Mongolia is a melange of traditional Mongo­lian techniques, Soviet block medicine, and evidence-based modem Western medical practices. Cultural practices influence expecta­tions of both patients and caregivers. We found our concepts of continuity of care, chronic care, and differential diagnosis genera­tion to be relatively alien, but not unheard of by our colleagues in Mongolia. These concepts were impractical to implement because there are scant resources for diagnosis, long-term therapy, or for transport to regular medical follow-up. Patients reported organ­based symptoms, such as, "I have a pain in my heart." Complaints were frequently accepted and treated by physicians without inquiry as to the specific nature, timing, or precipitating factors. In short, complaints were commonly accepted without

Traditional nomadic dwelling or yurt.

lack of equipment for even simple spinal anesthesia. Our Mongolian hosts were capable, caring and compassionate

physicians. They enjoyed academic interactions and eagerly sought information and discourse. Our surgical team operated with Mon­golian physicians and learned valuable techniques from skilled surgeons. Cholecystectomy, craniotomy, and septoplasty were some of the procedures performed. A vaginal footling birth was attended by our obstetrician and colposcopy was introduced. Internists saw advanced illness in young patients, and helped with diagnosis in many. A ventricular septal defect in a 14-year-old boy, and deform­ing rheumatoid arthritis in a 24-year-old woman were but two previously undiagnosed conditions we encountered.

Mongolian health authorities identified the development of pri­mary care, control of infectious diseases, child health, and immuni­zation programs as the nation's premier health care priorities. Tuberculosis, meningitis, hepatitis B, STDs, and scabies are in­creasing in frequency. AIDS remains a reportedly negligible prob­lem with only one reported case to date. Bubonic plague is endemic during marmot-hunting season.

We met a group of capable physicians, and found a tradition of hospitality that made the journey a priceless experience for all. The striking poverty and severity of illness encountered reminded us of all we have to share, and of our responsibilities as physicians to do so. We will return to Mongolia in the years to come with a better understanding of how to learn from Mongolia, and how best to give of ourselves.

question and therapy administered without much investigation. The complete interaction between physician and patient was in many ways for­eign to us as Western observers; we have lots to learn about observing.

ATTENTION DOCTORS Traditional methods such as acupuncture and

moxibustion are practiced with skill and effect. Others, such as drinking mare's milk for the treatment of tuberculosis seemed quaint and of unclear benefit to our naive eyes. Practices learned in Soviet block medical institutes were likewise eye-openers. Ultraviolet irradiation of blood for allergic disorders, and ultrasound therapy for ear infections were unfamiliar to us. Anesthetic technique was severely limited by ref. 1008

Learn how to increase your cash flow without increasing your patient load.

1-800-650-8068 24 hour for your free report

-HAWAII MEDICAL JOURNAL, VOL 54. DECEMBER1995 809

M Medical School Hotline

Private Sector to Finance a Greater Share of Hawaii's Medical Education

AI Castle, Director of Development

The John A. Bums School of Medicine, preparing to celebrate its 30th anniversary in 1997, is a small, nationally respected medical school. Its national prominence comes from a combination of excellent leadership, a strong faculty, the growing reputation of its graduates, its high admission standards, and a strong record of private sector financial support.

JABSOM receives about 30% of its total budget from the State of Hawaii. The rest of the annual operating budget comes from service contr~cts: gifts, gr~ts: and federal research and training dollars. Considenng the maJor Impact the school has in the state-virtually every resident is served in some way by the school-JABSOM is a bargain for Hawaii.

With ~owing demands on the resources of JABSOM, however, changes m the way health care is managed and the uncertainties surrounding public financing of education, the medical school will need .to flll:d add~tional sources of funding from the private sector.

!n hne with natiOnal trends for funding medical schools, JABSOM will seek mutually beneficial, collaborative relationships with cor­

porations, additional funding from charitable

Suzanne Watkins ASID, IIDA

Interior designer, art consultant & artist

Fine art enhances the spaces in which people live and work.

For a personalized art consultation call

595 ... 0003 ~ portion of the sales to physiciim

members will help support the HMA.

1360 S. Beretania St.. Suite 305 Honolulu, HI 96314

(808) 523-3041 • FAX (808) 523-3315

foundations, and cash and planned gifts from patrons, almnni, faculty and staff, and physi­cians in Hawaii. Cur­rently, such gifts are used to support student scholarships, library acquisitions, computers and other instructional equipment purchases, student professional ac­tivities, faculty profes­sional development, medical and basic sci­ence research, and pro­gram development.

Of particular interest is JABSOM' s ability to offer tax-advantaged life-income planned gifts through the UH Foundation.

Gifts to JABSOM may be arranged as part of an estate plan in many advantageous ways in­cluding the following:

Giving through a will can be a convenient way to leave a philanthropic

l~gacy. Aft~r providing for loved ones, a benefactor might decide to give a specifi~ amount, a percentage of an estate, or all or a portion of what remams after individuals have been remembered. Often a gift by will can be arranged simply with the addition of a codicil to an existing will. . ~iving through ~evocable living trusts.-More people now use a

hvmg trust to provide for management and final distribution of their assets. A simple amendment to a living trust can be all that is required to arrange a gift.

Gifts ~hat give back.-A donor can make a gift today and retain an annual mcome for the remainder of his or her life (and perhaps that of a loved one) through the use of charitable remainder trusts and similar gift plans; these plans also yield an income tax deduction in the y~ar the gif~ is completed. They may be used effectively in plannmg for retirement, caring for older relatives, and covering educational expenses for children or grandchildren.

Such gifts can convert appreciated, low-yielding assets to a source of additional income without incurring capital gains taxes at the time of the gift.

Donations that provide a lifetime income can be made for as little as $5,000 to the University of Hawaii pooled income fund. Pooled ~nds allow donors to transfer cash and appreciated securities to an ~nvestment fund held by a corporate trustee, and to receive regular mterest payments, proportionate to their share in the fund, for the rest of their lives. Donors also get tax breaks for making a charitable contribution.

Arranging a temporary gift. -Charitable gifts that result in imme­diate funding for a charitable interest can be made for a period of time, with assets eventually returned to the donor or to other non­charitable beneficiaries.

Assets can be set aside in a charitable lead trust. Payments from the trust go for charitable use for a chosen length of time. The assets in the trust are then returned to the donor, his or her family, or others.

Giving through life insurance can allow a gift of assets no longer nee~~d for o~e's family's security. A donor can give existing policies or assign proceeds to be paid in part or in full to charitable beneficiaries.

If the policies have served their original purpose, for instance, to educ~te children or protect a spouse who no longerneeds protection, conside.r letting these policies do double duty by naming a charitable benefiCiary. Income and estate tax benefits may result from such gifts.

A. donor might also consider using tax savings to purchase a policy designed to replace the assets that have been earmarked for chari­table use.

Through gifts of cash, appreciated real estate, stocks and bonds, and planned gifts, there are opportunities to shape Hawaii's medical education and delivery system's future. A development officer can be contacted at the University of Hawaii Foundation by telephoning (808) 956-5105.

-HAWAII MEDICAL JOURNAL, VOL 54, DECEMBER 1995 810

Hepatic Cryosurgery: Early Experience in Hawaii

Linda L. Wong MD, Whitney M.L .. ~imm MD, Alan H.S. Cheung MD, Fong-Liang Fan MD, L1v1ngston M.F. Wong MD

Liver cancer, both primary and metastatic, is often deemed hope­less and patients with advanced disease cannot be offered a treatment that is completely effective. Surgical resection is the treatment of choice, but less than 20% of patients are candidates for this treatment.

Hepatic cryosurgery is a relatively new procedure in which the tumor is localized intraoperatively with ultrasound guidance and exposed to liquid nitrogen at -196·c. Nine cases have been per­formed in Hawaii, and we present the first four cases here. Of these cases, there were no mortalities and only one patient required blood transfusion. All patients currently are alive with up to 11-month follow-up. Longer-term studies will be necessary to assess the effectiveness of this modality.

Primary hepatic neoplasms account for more than one million deaths a year worldwide. There is considerable geographic varia­tion-as low as one death per 100,000 in the U.S. and as high as 100/ 100,000 deaths in parts of Asia and southern Africa. Risk factors for hepatoma include the presence of viral hepatitis B and C, exposure to certain toxins ( aflatoxins or thorotrast), primary biliary cirrhosis, hemochromatosis, and alcoholic liver disease. Any chronic liver disease can predispose a patient to liver cancer and 70% of all hepatocellular cancers occur in those with cirrhosis.' Typically, symptoms occur late and most patients present with advanced disease.

Metastatic liver cancer frequently originates in the gastrointesti­nal (GI) tract, but can come from any primary tumor in the body. Colorectal cancer is the most common GI malignancy that metasta­sizes to the liver. More than 138,000patients in the U.S. will develop colorectal cancer, and 55,000 will die of it yearly. Nearly 70% of patients who die of colorectal cancer will have metastatic lesions to the liver.2

The only potentially curative therapy for both primary and sec­ondary liver cancer is surgical resection and liver transplantation in certain circumstances. The magnitude of this problem lies in the fact that less than 20% of all patients will be candidates for surgery and other therapies, such as chemotherapy, chemo-embolization, intrahepatic artery chemotherapy, and percutaneous ethanol injec­tion, used only for palliative or adjunctive therapies. Hepatic cryosurgery is a new surgical treatment used to eradicate disease and possibly improve long-term survival. It can be used for unresectable lesions because of the presence of multiple lesions, hi­lobar disease, poor liver reserve, or proximity to major vessels. Morbidity and mortality are low and early studies are promising. In essence, it increases the number of patients who are surgical candidates and provides them with a potential cure. Early studies are promising; however, the long-term benefit of this treatment needs to be studied.

-

Methods and Materials The four cases of hepatic cryosurgery performed at St Francis

Medical Center all underwent general anesthesia with placement of central venous and arterial catheters for monitoring. Body tempera­ture was carefully monitored and a Bair Hugger® was used for warming. All lesions were biopsied prior to treatment. All proce­dures were performed using a Cryotech LCS 2000 cryosurgical system with intraoperative ultrasound guidance. Various probes were used to freeze the tumor with liquid nitrogen to -1so·c to -190T: 5 mm, 10 mm, and flat. Each lesion was frozen until a halo of normal tissue measuring about 1 em could be seen around the tumor on the ultrasound, about 7 to 10 minutes, after which the lesion was thawed completely. Each lesion underwent two freeze­thaw cycles. Areas were carefully inspected for liver cracking and hemorrhage; bleeding was controlled with Gelfoam and suture ligation. All patients remained in the intensive care unit for the first 24 hours and were maintained with mannitol and low-dose dopam­ine to prevent rhabdomyolysis and acute renal insufficiency. Bleed­ing parameters were monitored closely and liver enzymes were obtained daily. An ultrasound of the abdomen was done before the patient was discharged. CT scans were used for follow-up at one month, three months, and every three months thereafter and tumor markers were followed.

Case One A 71-year-old man with Duke's B rectal carcinoma underwent

abdominoperineal resection in 1991. No evidence ofliver metastases was noted and his medical history was notable for non-insulin diabetes. He remained completely asymptomatic; a follow-up CT scan in September 1994 demonstrated a 2.5 em lesion in the left medial segment of the liver, and a 1.0 em lesion in the right lobe. Carcinoembryonic antigen or CEA: 2.0 ng/ml; alpha fetoprotein was normal. Percutaneous biopsies of these lesions were consistent with adenocarcinoma. Chest x-ray and bone scan were negative for metastatic disease. Exploration of the abdomen was notable for micronodular cirrhosis and two liver lesions: a 3.3 em lesion in the left medial segment just adjacent to the falciform ligament and a 1.8 em lesion in the right lobe of the liver. Frozen section liver biopsies were not diagnostic for carcinoma and the abdomen was closed. Permanent stains were consistent with hepatocellular carcinoma. The patient returned to the operating room 72 hours later and underwent hepatic cryosurgery on both lesions. He had no intraoperative problems, received no blood transfusions, and was discharged six days following the operation. His highest SGOT was 771. He had mild thrombocytopenia, 75,000/cc, which resolved by the time of discharge. At 11 months post-cryosurgery, he is doing well and the liver lesions have decreased on serial CT scans.

HAWAII MEDICAL JOURNAL, VOL 54, DECEMBER1995 811

Case Two A 52-year-old woman with invasive ductal breast carcinoma

underwent left modified radical mastectomy and adjuvant chemo­therapy in 1986. She did well until 1992 when she developed superior vena cava syndrome as a result of neck node metastases. She also had bony metastases and both areas were radiated. In 1994, she underwent autologous bone marrow transplantation with good response. She had several metastatic skin nodules that were excised. In September 1994, she underwent a routine CT scan of the liver and a 3 em mass was noted in the left medial segment. The CT scan of the chest/head and bones were all negative. Because the liver mass appeared to be an isolated lesion, and she was in good health otherwise-working and gaining weight-she was considered for hepatic cryosurgery. On December 1, 1994, she underwent explor­atory laparotomy and had an isolated lesion in the left medial segment that measured 3.9 em in the greatest dimension. The biopsy was consistent with a breast primary and she underwent cryosurgery of the lesion. Although no problems were encountered during surgery, 3 U of packed red blood cells was administered postopera­tively for a subcapsular hematoma. She also had thrombocytopenia to 60,000/mm3

• She was discharged six days following the proce­dure but was readmitted a week later with a large right pleural effusion and mild dyspnea that were managed with a tube thoracostomy and pleurodesis. Transient hyperbilirubinemia was detected, probably related to reabsorption of the subcapsular hematoma. Eleven months after surgery she is alive and the liver lesion is smaller; however, she recently developed brain metastases.

Case Three A 51-year-old woman underwent low anterior resection for mod­

erately well-differentiated adenocarcinoma of the rectum in No­vember 1993. At the time of surgery, she had four metastatic lesions involving both right and left lobes of the liver and ranging from 1.0 em to 4.0 em. Postoperatively she received multiple courses of chemotherapy that included 5-FU and leucovorin. Serial CT scans were variable with the lesions sometimes appearing unchanged, and at other times much smaller. Cryosurgery was considered, but CT scans in November 1994 showed an increase in the largest lesion to about 6.0 em. She underwent exploratory laparotomy and an intrahepatic arterial catheter was inserted. There was no evidence for extrahepatic metastases. She received intrahepatic arterial floxuridine and leucovorin and a decrease in lesion size was seen by CT scan. On February 28, 1995, she underwent exploratory laparotomy which revealed five liver lesions. A 6 em mass in the left lateral segment was completely excised with segunentectomy. A 1.5 em lesion at the edge of the right lobe anteriorly was wedge resected. The other three lesions (5.5 em, 1 em, and 1 em) were all in the right lobe and each underwent cryoablation. She had no perioperative problems, received no transfusions, and was dis­charged seven days later. She is currently alive and the lesions have decreased in size on subsequent CT scans, but she recently has developed several small lesions elsewhere in the liver.

Case Four A 65-year-old woman was found to have gall bladder carcinoma

on elective laparoscopic cholecystectomy for symptomatic cholelithiasis. Her past history is otherwise unremarkable. A CT scan demonstrated a 1.5 em lesion on the left medial segment of the liver. She underwent five courses of systemic chemotherapy with 5-FU, Adriamycin, and mitomycin-C. After chemotherapy, CT scan with arteriograrn/portagram showed no change in the previous lesion and a small mass in the area of the cystic duct. On April 6, 1995, exploratory CT scan with arteriograrn/portagram showed no

change in the previous lesion and laparotomy showed four sites of metastatic disease. A 1.9 em mass in the left medial segment was resected. Two small lesions, each less than 1 em (left lateral segment and right lobe), were treated with cryosurgery. A 2 em mass near the cystic duct stump was also positive for carcinoma and this was surgically debulked.

Cryosurgery could not be performed on this lesion due to the proximity of the bile ducts. She had no perioperative problems, received no blood transfusions, and was discharged five days following the procedure. Her highest SGOT was 7251U/L. She also underwent adjuvant radiation therapy to the lesion near the bile duct, as well as brachytherapy through a common duct T -tube placed at the time of surgery. Her lesions have decreased on subsequent CT scans and she is doing well six months after surgery.

Discussion Cryosurgery is an operative procedure whereby a tumor is local­

ized with intraoperative ultrasound guidance and exposed to liquid nitrogen at -196·c. Use of ultrasound is especially important as it allows detection oflesions less than 2 em which might otherwise be missed.3 Cryosurgery has been used to treat both primary and metastatic liver cancers which are not resectable by conventional means due to multiple lesions, bi-lobar disease, poor liver reserve, or proximity to major vessels.

The biology of cryoablation is such that damage occurs primarily due to ice crystal formation. Ice forms in the extracellular fluid and with slow cooling, intracellular fluid migrates across an osmotic gradient to the extracellular space. This leads to cell shrinkage and death. The ice mass is then allowed to thaw and this increases the damage to the cells.4 Repeating the freeze-thaw cycle has been shown to be more effective than a single cycle. 4-? Other effects of freezing include denaturing of lipid-protein complexes which dis­rupts cell membranes and causes leakage of organelles. Freezing also damages the walls of the small vessels, leading to deposition of platelets and thrombus formation. After several days, the frozen lesion becomes necrotic and separates from the normal liver. It is essentially a sterile infarct that eventually becomes encapsulated by fibrous tissue.4

•8

The advantages of cryosurgery are related to its low morbidity and mortality. Multiple studies have been done with no mortalities.4-5•9-10 A review of the literature revealed three known deaths-two from hepatic failure and one from cardiac arrest. 7

Complications include liver cracking and hemorrhage which are easily controlled with sutures and packing. Blood loss is consider­ably less than with a standard liver resection. One unitofblood is the average requirement. 5 Cryosurgery can also injure the bile ducts, as freezing of the ducts can lead to edema and eventually stenosis.4

•11

Mild myoglobinuria occurs in most patients, and alkalization of the urine, low-dose dopamine, adequate hydration, and mannitol have been recommended.7 Intraoperatively, patients may have mild hypothermia, but this is easily controlled with the use of warming devices such as the Bair Hugger®. 12

To date, results of cryosurgery to the liver have been comparable to liver resection. Onik et al reported 57 patients with unresectable hepatic metastases and demonstrated a 27% disease-free survival with 21-month follow-up. 7 Zhou et al, in a study of 107 patients with hepatomas, yielded a 22% survival at five years. In smaller tumors (<5 em) survival was 93.3% at one year and 48.8% at five years. 11

Ravikumar performed cryoablation for either metastatic or primary liver cancer in 24 patients, and 24% had a complete response at 14 monthsY

Preliminary data also suggest that cryosurgery may be helpful in non-colorectal metastases. Rammings et al treated 16 patients with -HAWAII MEDICAL JOURNAL, VOL 54, DECEMBER 1995 812

disease including development of meta­static lesions in the brain and elsewhere in the liver. (Since the four cases presented here, we have performed an additional five cases for hepatoma, metastatic breast can­cer, and metastatic colon cancer. All pa­tients are alive and without evidence of recurrence at two to five months.) Our results are consistent with those reported in the literature in that cryosurgery is ex­cellent for controlling liver lesions, but lesions can occur elsewhere in the liver.9

Longer follow-up will be necessary to as­sess the true benefit of cryosurgery.

Conclusion

Fig 1.-Hepatic cryosurgery of a tumor in the right lobe. A larger (1 0 mm) probe (single arrow) is used to create an iceball (double arrow) including the tumor and a 1 em rim of normal tissue. Ultrasound guidance is used to both locate the tumor and observe c?mpleteness of the freezing process (triple arrow).

Hepatic cryotherapy with ultrasound guidance allows us to treat a greater num­ber of lesions and lesions not surgically resectable with clear margins. Morbidity and mortality are minimal. Although the prognosis with cryosurgery is not signifi­cantly better than with liver resection, we must consider that we are treating a group of patients that has a five-year survival of zero. Perhaps the addition of cryotherapy will allow us to improve on the dismal

metastases from ovary, breast, thyroid, and neuroendocrine tumors. They demonstrated a decrease in the appropriate tumor markers and an improvement in neuroendocrine symptoms. Mean overall sur­vival was 9.1 months (range 1 to 21 months). 14 Cryoablationcan be used to assist in hepatic resection in order to allow clearance of tumor margins. 15 At the moment, the results are not much worse than liver resection and the morbidity is considerably less. Long-term follow-up and controlled studies will be necessary to understand the true benefit of this modality.

Cryotherapy alone can be helpful in liver tumors, but when used in combination with other modalities may prove to be more benefi­cial. Tang et al, in evaluating unresectable primary liver cancers in 137 patients between 1966 and 1977, noted that the five-year survival was zero. In the period between 1978 and 1989, 345 unresectable liver tumors had a 16.9% five-year survival with the use of cytoreduction (hepatic artery ligation, hepatic artery infusion, cryotherapy, and/or radiation) and sequential resection. 16

In our early experience, the four patients have undergone cryosurgery for varying tumors including hepatocellular carci­noma, and metastatic lesions from the rectum, breast, and gall bladder. There were no mortalities and only one patient had compli­cations of a subcapsular hematoma of the liver requiring transfu­sion. Transfusions were not needed in the other patients. Three of the four patients have undergone multi-modality therapy with combinations of liver resection, cryosurgery, chemotherapy, intraarterial chemotherapy, and radiation. All patients are alive and functioning well; however, two patients have had progression of

-

outlook of metastatic and primary liver cancer, using a technique that has minimal morbidity and mortality.

References 1. Blumgart LH. Surgery of the Liver and Biliary Tract London, England; Churchii~Livingstone. 1993. 2. Wingo PA, Tong T, Bolden S. Cancer statistics 1995. CA Cancer J CHn. 1995;45:6-30. 3. Masters A, Steger AC, Brovin SG. Role of interstitial therapy in treatment of liver cancer. 8r J Surg.

1991;78:516-23. 4. Bayjoo P, Jacob G. Hepatic cryosurgery: biological and clinical considerations. J R Coli Surg Ecinb.

1991;36:424-7. 5. Steele G. Cryoablation in hepatic surgery. Semin Liver Dis. 1994;14:12(}.5. 6. Morris 01, Horton MD, Diney AV. Treatment of hepatic metastases by cryotherapy and regional cytotoxic

perfusion. Gut. 1993;34:115&-7.91 7. Onik GM, Atkinson D, Zemel R, et al. Cryosurgery of liver cancer. Semin SurgOncol. 1993;9:309·317. 8. Brown NJ, Bayjoo P, Reed MWR. Effect of cryosurgery on liver blood flow. 8r J Cancer. 1993;68:1(}.

12. 9. Ravikumar TS, Steel GO. Hepatic cryosurgery. Surg C/in North Am. 1989-69:433-9. 10. Ravikumar TS, Kane R, Cady B, et al. Hepatic cryosurgery with intraoperative ultrasound monijoring

for metastatic colon carcinoma Arch Surg. 1987;122:403-409. 11. Zhou XD, Tang l:Y, Uy YQ, et al. The role of cryosurgery in the treatment of hepatic cancer: A report

of 113 cases. J Cancer Res C/in Oncol. 1993;120:1()().102. 12. Onik GM, Chambers NC, Chernus SA. Hepatic cryosurgery with and without the Bair Hugger. J Surg

Oneal. 1993;52: 185-7. 13. Ravikumar TS, Buenaventura S, Salem RR, et al.lntraoperative ultrasonography of liver: Detection of

occuh liver tumors and treatment by cryosurgery. Cancer Detect Prev. 1994;18:131-138. 14. Ramming KP, Wardlaw JC, Guenther JM, Kirgan OM. Cryosurgical ablation ol non-colorectal iver

metastases and primary hepatic cancers. Presented at the PacifiC Coast Surgical Society. Seattle, Wash: February 1995.

15. Polk W, Fang Y, Kalp8h M, Blumgart LH. A technique for the use ol cryosurgery to assist hepatic resection. JAmCoi/Surg. 1995;180:171·176.

16. Tang l:Y, Yu YQ, Zhou XD. Cytoreduction and sequential resection: A hope lor unresectable primary liver cancer. J Surg Oncol. 1991;47:27·31.

HAWAII MEDICAL JOURNAL. VOL 54, DECEMBER1995 813

Kidney Stone Center of the Pacific Summary of Operations 1986 to 1993 Thomas Y. Ito MD, Rosemae Chibana RN, Lois Simpson RN, Marlaine Fern RT, Kathy Puetz

In Memory of Doris Oshiro RN First Supervisor, Kidney Stone Center of the Pacific

The history and operational results in the six years since the Kidney Stone Center of the Pacific opened in 1986 are summarized and compared to the published literature, with particular attention to Hawaii's unique racial composition. We hope that the results will enable us to improve our management of stones in the future.

Background The Kidney Stone Center of the Pacific began operations in

December 1986; by the end of 1993, a total of 2,945 patients had been treated. The Kidney Stone Center of the Pacific is a coopera­tive venture of three entities: Kuakini Development Corporation, Queen's Health Technologies and Straub Imaging Services, all located in Honolulu.

In the mid 1980s the Domier company of Germany developed the extracorporeal shock wave lithotriptor (ESWL).1 This machine used shock waves generated by a large spark-plug-like device transmitted through water to fragment kidney stones, which could then be passed as sand-like particles through the ureter. The shock waves are aimed by using fluoroscopy to visualize the stone and are controlled by the patient's electrocardiogram (Fig 1).

Before this time, stones usually had to be removed by incising the patient, which required hospitalization and a long period of conva­lescence. Complications of surgery included bleeding, infection, and urinary leakage.

Lithotripsy represented a revolution in the treatment of stones; now patients could be treated as outpatients and the risk of compli­cations was greatly reduced. Urologists in Hawaii saw the benefits of the machine and discussed how to obtain one to serve the Pacific. However, several obstacles had to be overcome.

The cost of the machine was $1.5 million, not including the space and support equipment, which brought the total cost to about $3 million. At one point a partnership of urologists was considered that would purchase, set up, and operate the machine, but that was rejected as being impracticable. Instead, interested hospitals were invited to participate. All of the hospitals on Oahu were asked to participate; finally, three hospitals contributed equal amounts of capital and combined their expertise to form the Kidney Stone Center of the Pacific. Each partner contributed support; for ex­ample, Kuakini was responsible for marketing, Queen's for sched­uling and operations, and Straub for the business plan.

The location of the lithotriptor was the subject of much discussion. At first, a neutral site was considered; however, this was impracti­cable because ancillary services such as cystoscopy, x-ray, and post-anesthetic recovery were required. This meant a hospital site was needed, and Queen's was selected.

Meanwhile, a state review process by the State Health & Phar­macy Development Agency (SHPDA) was required. At first, there was skepticism by the board that there was a need for a machine.

However, thanks to testimony by the urologists and hospitals, approval was granted and construction began.

On December 10, 1986, the first patient was treated on the Domier HM-3. The originallithotriptor, now seven years old, continues to serve Hawaii and the Pacific today. It represents an example of the benefits of a cooperative, rather than competitive and more costly, approach to health care in Hawaii.

Review of Operations 1986 to 1993

Data Analysis Patient records have been maintained on a personal computer

using the Q & A data base since the Kidney Stone Center began operations. Standardized reporting forms permitted the collection of data in a systematic manner. The data was extracted on the computer using different criteria. Of course, the data retrieved is only as good as the data input, which is why it was important to complete the forms as thoroughly as possible.

Total Patients Treated The total number of patients treated from December 10, 1986 to

December 31, 1993 was 2,945 or about 500 patients a year (Fig 2). The total number of patients treated has remained fairly constant over the years. There was not a great monthly variation in patients treated. This information has been useful in planning for staffing and equipment allocation. Compared to national statistics, in a study of more than one million patients, Hawaii had a stone rate of 8.2 which was about average for the nation.2

Age of Patients The oldest patient treated was 92 years old; the youngest, 4 years

and 9 months. The average age of the patients was 43, with a mean of 40 years. Very young patients, because of their small stature, required a special arrangement of the lithotriptor gantry. Other than that, no special techniques were required for patients because of their age.

Gender Sixty percent of the patients were male and 40% were female,

which is in keeping with published statistics for stones. The litera­ture reports that up to 70% of patients were male.3

Race Hawaii has a unique mixture of races. In fact, in analyzing the

data, many times determining the race of the patient was a problem because of the number of ethnic backgrounds. Of the patients treated at the Kidney Stone Center, the majority were Caucasian. It is -HAWAII MEDICAL JOURNAL, VOL 54, DECEMBER 1995 814

Fig 1.-Schematic of lithotriptor

interesting to compare the observed incidence of stones with the population makeup of the state (Fig 3). For example, Caucasians accounted for 34.16% of the general population in the 1990 census and represented 34.35% of the stones. Filipinos were overrepre­sented, comprising 15.59% of the state population, they accounted for 20.41% of the stones. The Japanese, Chinese, and Hawaiians were underrepresented.

Source of Patients The lithotriptor serves the Pacific region including islands in the

South Pacific. Non-Hawaii residents accounted for 10.6% of the treatments, including patients from the continental United States, Pacific Islands, Japan, Australia, American Samoa, Guam, and Canada.

Location of Calculi Renal calculi accounted for 84% of the stones, with ureteral

calculi representing 15.6% of the stones. Single stones were found in 69% of the patients, with multiple stones in one kidney in 21%. Single stones in both kidneys were 5% of the group, with multiple stones in both kidneys found in another 5%. Again, this is in accordance with ranges found in the published literature.2·6

Size of Calculi The calculi ranged in size from <I em to >9 em, and as expected,

there were more smaller stones. The size of the stone is significant because the larger stone requires more shocks than the smaller one, thereby increasing the patient's exposure to shock wave energy and greater complications. In fact, some larger staghom calculi can be treated best with percutaneous nephrostolithotomy, in which the calculi are removed through a small opening in the patient's back. As expected, the smaller stones were more prevalent.

Number of Shocks The amount of energy varied. The mean was 21 kV with a range

of 14 k V to 28 k V. The number of shocks ranged from 300 to >5000 per treatment, and the median number of shocks was 1,500 to 2,000. Generally, the larger the stone, the more shocks required. Some stones, such as uric acid stones, are harder and require more shocks. The number of shocks was less for smaller stones and increased as the stone size increased, but seemed to stabilize at about 2,500 to 2, 700 shocks in the range from 4 em to 9 em. -

Annual Patient Load

Year #orRx -++-t-+--H---4-j----i6l-----++--l.j---w- 500

Dec.'86 28

1987 463

1988 411

1989 427

1990 . 494

1991 463

1992 498

1993 501

'86 '87 '88 '89 '90 '91 '92 '93

Fig 2.-Annual treatment load

Types of Stones Stone analysis was incomplete because many of the patients had

no data that could be gleaned from the records. This is expected because the data is pretreatment and, of course, stone analysis has not yet been performed. Of the 656 cases that could be evaluated, 77% had calcium oxalate, 16% uric acid, and 7% struvite. A large study indicates that the Mainland incidence of the different types of calculi are 80% calcium oxalate, 7% struvite, and only 3% each of uric acid, cystine, and calcium phosphate.2 It is interesting to note the racial differences in relation to the type of stone (Fig 4). The only other study from Hawaii addressing this issue was published in 1970.7 In this study, it was noted that Tripier Army Medical Center patients, who were 82% Caucasian, had only 2% uric acid calculi, while patients at St Francis Medical Center, who were 29% Cauca­sian, had a 29% rate of uric acid stones. When broken down, uric acid stones accounted for 30% of the stones among the Chinese, Japanese, and Filipino population. This compared to the 14% rate of uric acid stones in Caucasian patients at St Francis Medical Center. The authors noted this and suggested diet could have played a role.

Our experience more than 20 years later seems to indicate that we are seeing fewer uric acid calculi since the overall rate among the general population was 16%. However, that is still high by national standards. It is interesting to note that the Filipino and Chinese rates of uric acid stones were low, while the rate among Japanese and Hawaiian patients was significantly higher. We can only speculate about the reason for this, but diet might still be a factor.

Retreatments and Complications Retreatments accounted for 10.7% of the cases. This is in line with

the reported literature, which reports a retreatment rate of 9% to 17%.3-6

The rate of retreatment is particularly important because it illus­trates the degree of effectiveness of treatment. We believe our figures are accurate because there is only one site for treatment with ESWL in the state.

Complications have been low,less than I%. They have included occasional pain and nausea; however, there have been no deaths directly attributable to ESWL.

Radiation Exposure of Personnel One of the concerns of treatment was the exposure of the staff and

physicians to radiation with the use of fluoroscopy and snapshots. 8

HAWAII MEDICAL JOURNAL, VOL 54, DECEMBEA1995 8111

Radiation exposure using fluoroscopy was measured by the amount of time and number of snapshots. This ranged from <1 minute to > 16 minutes, the mean was about 3 minutes. The number of snapshots taken ranged from 0 to 55 and more, which compares well with published reports from other facilities.

The radiation exposure delivered to the patient can be calculated from the fluoroscopy time and number of snapshots using measured radiation output. From the above data, the patient exposures ranged from 0.04 Gy to .21 Gy with an average of .12 Gy. This is similar to the dose delivered during other fluoroscopic procedures, such as an upper gastrointestinal barium study.

The walls and water of the stainless steel tub attenuate the scatter radiation quite effectively. This means that the radiation exposure in the vicinity of the ESWL tub is negligible, and the staff is not required to wear lead aprons during the procedure.

We have used the radiation usage and exposure for individual physicians in order to increase awareness and enable more efficient use of x-rays.

Future Studies Our data collection has given us insight into how the Kidney Stone

Center has been performing, and the retreatment rate of 10.7% falls within generally accepted standards. In the future, we will be focusing more on post-treatment outcomes. We have instituted a program offollow-up phone calls to the patients to assess their state after the treatment, focusing not only on the effects of lithotripsy, but on anesthetic effects. In this way we hope to improve patient care at the Center.

Summary The Kidney Stone Center, now more than seven years old, has

served Hawaii well. It has fulfilled its mission of serving the people in Hawaii and the Pacific Basin. During its tenure, it has provided state-of-the-art treatment and improved patient care; it has resulted in a significant net savings in patient discomfort, complications, lost work time, and hospitalization. It serves as a model for other cooperative ventures, especially in light of our limited geography and population.

Technological progress has resulted in the production of newer lithotriptors that use different means of shock-wave generation and require less anesthesia or no anesthesia at alU The Kidney Stone Center is evaluating the feasibility of upgrading its lithotriptor.

References 1. Chaussy C, Schmied! E, Jocham D, Brendel W, Forsmann B, Walther V. First clinical experience with

extracorporeally induced destruction of kidney stones by shock waves. J Urol. 1982;127:417. 2. Soucie JM,Thun MJ, Coates RJ, McClellan W, Austin H. Demographic and [eoqraphic variability ol

kidiley stones ih the lfnifecfSlafes. Ki?firey ltJt. 1W4;46':em:899: 3. Drach GW, Dretler S, Fair W, et al. Report ol the United States cooperative study of extracorporeal shock

wave lithotripsy. J Urol. 1986: 135:1127. 4. Graff J, Didlus W, Schulze H. Long-term followup in 1003 ESWL patients. J Urol. 1986;140:479. 5. Fuchs G, Miller K, Rassweiler J, Eisenberger F. Extracorporeal shock wave l~hotripsy: one yeat

experience with the Domier lithotriptor. Eur Uro/. 1985;11:145. 6. Riehle RA, Fair WR, Vaughan ED, Jr. Extracorporeal shock wave lithotripsy for upper urinary tract

calculi: One year's experience at a single center. JAMA. 1988; 255:204. 7. Wurster JC, Ceccarelli FE, Jr, Chinn HYH. A comparative study of relative incidence of stone types

between a transient mil~ population and the indigenous population o1 the Hawaiian Islands. J Urol. 1970; 104:581.

8. Lingeman JE, Newman D, Mertz JNO, et al. Extracorporeal shock wave ~thotripsy, the Methodist Hospital of Indiana experience. J Urol. 1984; 135:1134.

9. Griffrth DP, Gleeson MJ, Politis G, GlazeS. Effectiveness of radiation control program for Domier HM3 lithotriptor. Urology. 1989; 33:20.25.

10. Rassweiler J, Aiken P. ESWL 90-state of the art Lim~tions and future trends of shock wave l~otripsy. Urol Res. 1990;18(suppi):S13-23.

R etirement Pl ans How to live with someone who's living with cancer.

mel r. hertz MBA, CFP

• Investment M anagement

Consulting

• Life and Di sa bili ty

Insurance

• Charitable Remainder

Trusts

Certified Financial Planner

Pacific Tower, Suite 2800 100 1 Bishop Street Honolulu, Hawaii 96813 (808) 599-4504 (d:)detand Socuriliooo Cllloor.d n-<po lfG ,...._.to s-.n.-. Inc. FQ, Motmbero NASO ...:1 SIPC. Flnanclol Pl..,."'s s..r.b. "'""""'" -.1 ~ Pt. ........ , Inc. WPJ, Lai-.1 '"-- ol.dvi- mol r.....,. • • nJi-.d princp.l ol FG """ ...... -.:1 Npn-u .. n. ol d.J • n ... " fP, .............. dl .. ""'-wn. un..tfiW.-d w~ d.wd.

-HAWAII MEDICAL JOURNAL, VOL 54, DECEMBER 1995 818

When one person gets cancer, everyone in the family suffers.

Nobody knows better than we do how much help and understanding is needed. That's why our service and rehabili­tation programs emphasize the whole family, not just the cancer patient.

Among our regular services we provide information and guidance to patients and families, transport patients to and from treatment, supply home care items and assist patients in their return to everyday life.

Life is what concerns us. The life of cancer patients. The lives of their families. So you can see we are even more than the research organization we are so well known to be.

j· No one faces cancer alone.

f AMERICAN CANCER SOCETY•

Recurrent Chylothorax Associated with Sarcoidosis

Robert J. Lengyel MD, Dean J. Shanley DO

Spontaneous chylothorax, an uncommon manifestation of pulmo­nary disease, has been described in association with infectious and inflammatory conditions involving the chest, thoracic trauma, and thoracic neoplasms. Isolated chylothorax is a rare manifestation of sarcoidosis and is usually associated with the presence of medias­tinal and hilar adenopathy causing obstruction of the thoracic duct. We report a case of recurrent spontaneous chylothorax in a patient with parenchymal sarcoidosis without hilar or mediastinal adenopathy.

Chylothorax is usually the result of compromise oflymphatic flow through the thoracic duct. Neoplastic processes and trauma account for the majority of cases of chylothorax described in the literature.'· 2 Other etiologies incluqe infectious and inflammatory diseases, congenital malformations of the lymphatics, and idiopathic causes. Sarcoidosis has rarely been reported as a cause of isolated chylothorax; three case reports in the literature describe patients with extensive intrathoracic adenopathy associated with sarcoidosis and complicated by chylothorax.3·5 The following report describes a patient with parenchymal sarcoidosis only, complicated by recur­rent right chylous effusions.

Case Report A 42-year-old black man complained of increasing shortness of

breath and right pleuritic chest pain during the past six months. The patient denied any history of recent or remote thoracic trauma. He was diagnosed with sarcoidosis six years prior and had experienced recurrent right-sided chylous effusions for more than two years despite corticosteroid therapy. Thoracentesis was performed monthly during the past year to relieve recurrent symptoms of shortness of breath and pleuritic pain.

Address reprint requests to: Robert J_ Lengyel MD Department of the Army Medical Department Activity Kenner Army Community Hospital Dept of Radiology Ft Lee, Virginia 23801 -

Fig 1. --42-year-old man with stage Ill sarcoidosis complicated by recurrent right chylothorax.

The admission chest radiograph (Fig I) showed a large right pleural effusion and diffuse reticular nodular infiltrates involving both lungs. No evidence of hilar or mediastinal adenopathy was present. Findings were consistent with stage III (parenchymal) sarcoidosis. CT scan of the chest (Fig 2, 3) was obtained and confirmed the presence of a large right pleural effusion and bilateral reticular nodular infiltrates. The nodular opacities were small, innumerable, less than I mm in diameter and distributed diffusely throughout the parenchyma. Small densely calcified lymph nodes were identified in the mediastinum; no enlarged lymph nodes were present.

The patient opted for surgical intervention because of the chronic nature of the effusion and lack of efficacy of conservative therapy. The patient subsequently underwent right thoracotomy which re­vealed a large chylous effusion, a dilated thoracic duct, and peri ductal adhesions. Approximately 1.5 L of chylous fluid was removed from the right hemithorax. The thoracic duct was ligated and divided, followed by physical and chemical pleurodesis. The patient did well postoperatively and follow-up chest radiographs over a six-month period showed no recurrence of the chylous effusion.

Discussion The thoracic duct normally ascends into the thorax through the

aortic hiatus and maintains a position to the right of midline. The

HAWAII MEDICAL JOURNAL, VOL 54, DECEMBER1995 817

Fig 2.--CT Scan of the chest shows a large right pleural effusion which proved to be chylous . Bilateral reticular nodular infiltrates are present throughout the lungs.

duct crosses obliquely to the left at approximately the level of the fourth or fifth thoracic vertebral body and continues to ascend into the left neck region for several centimeters. The duct then courses downward to join the venous system near the junction of the left internal jugular vein and subclavian vein. Obstruction or disruption of the thoracic duct anywhere along its course can lead to the development of chylothorax. Injury or obstruction to the lower portion of the duct typically results in a right chylous effusion, whereas involvement of the most cephalad portion of the duct usually results in a left chylothorax.•

Spontaneous chylothorax, although an uncommon manifestation of intrathoracic disease, has been reported in association with neoplastic processes, benign conditions, and trauma involving the chest.1•2·6-7 Nix et al reviewed 302 cases of chylothorax and chylous ascites, of which 123 cases were of isolated chylothorax.• Of those cases of isolated chylothorax, approximately 55% of cases were traumatic in origin and almost 45% were spontaneous in nature. Thoracic surgery accounted for the majority of cases of chylothorax complicatingpenetrating trauma, and thoracic trauma without bony fracture resulted in the majority of cases associated with nonpenetrating trauma. Malignant neoplasms, especially lymphoma, resulting in extrinsic or intrinsic lymphatic obstruction account for the vast majority of spontaneous chylothoraces.2 Benign lymphadenopathy is a less common cause of spontaneous chylothorax, contributing to less than 10% of the chylothoraces reviewed by Nix et al. 1

Three previous cases of sarcoidosis with an associated chylothorax have been reported. Aberg et al reported extensive mediastinal and thoracic adenopathy causing obstruction of the thoracic duct, seen at postmortem examination? Haigli and Keller reported mediastinal and hilar adenopathy, although the thoracic duct appeared unaf­fected at thoracoscopy.4 The pathogenesis of the chylothorax was unclear and it gradually cleared after long-term corticosteroid treatment and pleural drainage. In a more recent case reported by Parker et al, a young woman with sarcoidosis developed a right chylous effusion and worsening mediastinal and hilar adenopathy

Fig 3.--CT scan of the chest using mediastinal (B) and lung (C) windows shows large right chylous effusion. Reticular nodular infil­trates are better demonstrated using lung windows. Small calcified lymph nodes are presen~ anterior to the right main-stem bronchus.

within three months of fiberoptic bronchoscopy and trans bronchial biopsy.5 Thoracentesis and oral corticosteroid therapy resulted in resolution of the chylothorax.

Although spontaneous in nature, our patient's recurrent chylothorax was likely caused by the presence of peri ductal adhesions visualized during surgery, resulting in obstruction to the flow of lymph within the thoracic duct. Our patient had undergone transbronchial biopsy six years prior to the development of a persistent chylothorax, so there is no immediate temporal relationship between the effusion and the biopsy. Mediastinal and hilar adenopathy were present in our patient when the diagnosis of sarcoid was established six years prior; however, the adenopathy had regressed within two years. Imaging studies during the past four years showed no evidence of abnormally enlarged lymph nodes in the hilar regions or mediasti­num, and the patient remained asymptomatic except for complaints of shortness ofbreath and pleuritic chest pain related to the recurrent chylothorax. During the progression of our patient's sarcoidosis fibrotic changes in the pleural space and perinodal regions probably contributed to the formation of periductal adhesions, gradual ob­struction of the thoracic duct, and the development of recurrent chylous effusions. Unlike previous reports, this case is of interest because the recurrent chylothorax associated with sarcoidosis de­veloped in the absence oflymphadenopathy, presumably caused by fibrotic changes in the pleural space and perinodal regions contrib­uting to the formation of periductal adhesions and gradual obstruc­tion of the thoracic duct.

References 1. Nix JT. AlbertM, DugasJE, Wendt DL. Chylothorax and chylous ascites: A study of 302 selected cases.

Am J Gastroenterol. 1957; 28:40-55. 2. Bower GC. Chylothorax: observations in 20 cases. Dis Chest. 1964; 46: 464468. 3. Aberg H. Bah M, Waters AW. Sarcoidosis complicated by chylothorax. Minn Med. 1966; 49:100S:70. 4. Haegli A. Keller R. Chylothorax associated with sarcoidosis. Schweiz Med Wochenschr. 1981;111:

12~. 5. Parlier JM, Torrington KG, Phillips YY. Sarcoidosiscomplicatedbychylothorax. SoMedJ. 1994;87:860-

62. 6. Caweil MS, Friedman D. Mikhail N. Chyloperitoneum associated with chronic severe sarcoidosis. Am

J Gastrolentero/. 1993; 88:99-101 . 7. Rockoff SO. Rohatgi PS. Unusual manijestations of thoracic sarcoidosis. Am J Roentginol. 1985;

144:513-528. -HAWAII MEDICAL JOURNAL, VOL 54, DECEMBER 1995 818

a News and Notes Henry N. Yokoyama MD

Life in These Parts Conference Notes: "Preventive Cardiology" Lecture by Straub cardiologist Roger White at Hilton Hawaiian Village on April 1, 1995. Introduction

• Inscription on Egyptian scroll: A heart light as a feather means a good life ... Twenty correct commandments gets one to heaven.

• Framingham studies on arteriosclerosis: 1/3 angina; 1/3 sudden death; 113 infarction, viz, 2/3 of the patients have catastrophic events as a presenting symptom.

Cardiac Risk Factors • Age • Male sex • Family history • Cholesterol • Hypertension • Diabetes • Sedentary lifestyle • Stress • Smoking

(all are correctable factors) Cholesterol

LDL: less than 150; HDL: greater than 50; triglyceride: less than 200 (triglyceride level varies with diet; elevated in diabetes) LDL below 80 can reverse atherosclerosis HDL: Hereditary; women have high HDL values until menopause; ERT raises HDL. LDL: Hereditary; ale diets high fats, eg, dairy

products, saturated fats, ale obesity, low fiber diets, sedentary lifestyle. HDL: related to heredity and sex; increases with regular exercise; increases slightly with cold-water fish; rises with alcohol intake (1 glass wine); decreases with smoking.

• Cholesterol control: ale optimal weight; limit fat content; high fiber; exercise; monitor blood levels; treat metabolic hyperlipidemia

• Reversal of atherosclerosis is next frontier: "Statins" are easy to take and have low inci­dence of side effects.

Hypertension • May be hereditary. • Increased risk with high-salt diet. • Alcohol can raise BP. • Sedentary lifestyle. • Obesity. • Evalutate for secondary causes (eg, renal,

endocrine, vascular problems). • Stress • Interrelate with diet, exercise, lifestyle; self­

monitoring important for adequate control; medical treatment; exercise.

Diabetes • Weight reduction. • Self-monitoring. • Medical treatment. • Reduce risk of complications. • Exercise helps control.

Smoking

• 50% greater risk for sudden death in smokers.

• Short-term effect on vasoconstriction. • Long-term cumulative effect. • Lowers HDL.

Exercise • Aerobic (walking, swimming, jogging). • Sustained (ie, 30 to 60 min). • Regular (3 to 4 times a week). • Warm up and cool down. • Should be enjoyable.

How to reduce heart attacks? Aspirin; fish oils? garlic? vitamins? walnuts; ginseng; alcohol; caffeine?

To avoid heart attacks? Stay young; nonsmoking woman; choose par­ents with no heart disease; eat a modified Italian-Chinese diet and take 1 aspirin/d; exer­cise; drink 1 glass of wine/d. (Roger White waxed philosophical as he enu­merated the following doctrines)

To reduce Ml: • A void hurry • A void worry • A void curry (has coconut oil) • Do not be obsessed with longevity • Enjoy the quality and miracle of everyday

The joy is in the journey!

Classified Notices To place a classified notice: HMA members.-Piease send a signed and typewritten ad to the HMA office. As a benefit of membership, HMA members may place a complimentary one-time classified ad in HMJ as space is available. Nonmembers.-Piease call536-7702 for a nonmember form. Rates are $1.50 a word with a minimum of 20 words or $30. Not commissionable. Payment must accompany written order.

Offices For Sale

Practice for sale.-Established medical practice on Oahu. Retiring. Annual net income 90K. Has federal income tax return to show. Selling for 1 OK. Call (808) 625-1410.

Locum Tenens

Radiologist-Available on short notice for locum tenens. Full or part time, any island. (808) 875-9794.

Locum tenensavailable.-Board-certifiedfamily prac­tice, 12 years' clinical experience in Hawaii. Deborah C. Love MD; Home phone on Oahu: (808) 637-8611; cellular phone Maui: (808) 281-4713.

Office Space

Aiea Medical Bldg.-1400 sq ft fully equipped medi­cal office for part-time rental or to share [Wednesdays/ Fridays]. Close to Pali Momi Hospital. Excellent for medical/surgical specialty use. Call Marie at 487-7938.

Physician practice has space to share with flexible arrangements for individual practice needs. Ground floor, free parking. Call Deborah at 532-0517 for more information.

Pearl City Business Plaza.-Long leases; 680+ sq ft; 24 hr security; free tenanVcustomer pkg; available now; call531-3526 Gifford.

-HAWAII MEDICAL JOURNAL. VOL 54. DECEMBER1995 819

Services

A Tisket A Tasket ... a very special basket! Custom gift basket arrangements artistically designed and filled with a variety of items. Corporate party centerpieces and favors made to order. JoAnn, 377-5436/57 4-924 7 (pager).

Waikiki Gallery represents Hawaii's artists with integ­rity. Call 523-3041 and visit our showroom at 1360 S Beretania Street, Suite 305. For an appointment, con­tact Suzanne Watkins, artist, art consultant, interior designer at 595-G003. A portion of sales benefit HMA.

Time for a new Look.-Logos, stationery, forms de­signed. Informational material, brochures, written and designed. Call House of Hastings. (808) 595-3653.

~ The Weathervane

If he had rubber pockets, he could steal soup. A jury found ophthalmologist Jeffrey Rutgard ofLaJolla, Califor­

nia, guilty of running an insurance mill that cheated Medicare, CHAMPUS, and private insurers of$I6 million for unnecessary eye surgery. The judge threw the book at this buccaneer and ordered him to pay $I50,000 in fines, $I5.9 million in restitution, and to serve II years and three months in jail. Doctor bashing is a favorite media space filler, and criminals like Jeffrey Rutgard provide fodder that critics will repeatedly cite. Unfortunately, organized medicine has no way to penalize such villainous outlaws beyond an appeal to the state medical board.

A patriot must always be ready to defend his country against his govemment.

It should be funny, but who's laughing? On average, Medicaid paid doctors $I23.04 for each beneficiary cared for last year in Kentucky. A taxicab company, by comparison, collected $I25.65 from Medicaid for each beneficiary they trucked to the doctor's office in the same time period. Result-Medicaid reduced doctors' reimbursement by 20%. This is true! Question-Does this mean that Medicaid equates I2 years of higher education with two weeks of driving school?

Why buy a politician? It's cheaper to rent them. In Illinois, the legislature and Republican Governor Edgar are

badly in need of education. The Governor recently signed a bill that will permit optometrists to treat glaucoma, infection, and inflamma­tion of the eyes. A related story in the state of Oregon is that optometrists are now legally described as "optometric physicians," despite the protests of numerous medical groups. The title of doctor has been cheapened by many organizations and diluted to include virtually any occupation, even including doctor of sanitation (gar­bage collector). Physician, however, has historically been reserved to indicate "doctor of medicine." The busy pretenders accomplish with legislation that which they are unwilling or unable to obtain through education.

Nothing is so firmly believed as that which we least know.

The ozone hole sky watchers claimed inN ewsweek four years ago that the rise in UV exposure in southern Chile in October I992, when atmospheric ozone reached record lows, was causing sheep

Russell T. Stodd MD

claiming that improper positioning and monitoring had caused the injury. A trial court returned a verdict for the defendants, and the patient appealed on the basis that the doctor had failed the anesthesia board exams. The court found no merit in that argument, and stated that evidence of test failure is not sufficient to impeach the anesthesiologist's credibility as an expert.

Money, to be worth striving for, must have blood and sweat on it-preferably that of someone else.

As tourists flock to our captivating island state, one might think that our individual buying power is falling below that of foreigners. Visitors often give the impression of great wealth, because they can take advantage of the favorable exchange rate. Not true! No foreign country even approaches the U.S. for annual individual spending. Switzerland is the closest at 83.4% per capita spending compared with Americans.

They couldn't decide to have a child or buy a dog­whether to ruin their carpet or their lives.

As if organized medicine was not troubled aplenty for failure to monitor itself, the fertility reproductive researchers at University of California at Irvine are under fire for allegedly conducting unautho­rized research by transferring eggs and embryos from unconsenting donors to other women. Some of the women bore children as a result. The university closed the clinic and has accused the doctors of as many as 40 instances of egg and embryo "misappropriation" (Is that the right word?). Cecil Jacobsen MD, a research shining star for his work in amniocentesis, was found guilty in I992 of using his own sperm to inseminate infertility patients. The medical field is regulated only by standards set by the American Society for Repro­ductive Medicine, but adherence to the standards is voluntary.

"She hate's California-it's cold and its damp." California has been the land of promise and opportunity, and

during the booming I980s, the state enjoyed an annual increase in domestic arrivals of 90,000 per year. Now, because of weakened economic conditions, an out-of-control litigation system, prohibi­tively rigorous environmental regulations and oppressive taxes, business has been hurt, and people are leaving in droves. In the I990s, 687,000 have departed for other pastures, and 300,000 in I993 alone.

Addenda and bunnies to go blind with cataracts, and that people were suffering from UV-related skin and eye diseases. But a study by a Johns Hopkins research group reporting in the American Journal of Public Health, found no significant rise in acute UV-related skin •:• and eye problems. Veterinarians examined 224 local sheep and found no blindness, and of I7 rabbits they found only one had cataracts. The report stated that southern Chileans experienced a mere I% increase in UV exposure. Maybe the sky isn't falling after

•:• More that 90% oflawsuits filed against doctors in the U.S. each year are without merit, and thus go nowhere. America's most expensive public health problem is automobile trauma: $137 billion is lost annually in medical bills and lost productivity.

•> Only 4% of Americans didn't eat at McDonald's last year. •:• If you can find something everyone agrees on, it's wrong.

all.

A little inaccuracy sometimes saves tons of explanation.

A patient underwent back surgery and was anesthetized for 7-112 hours. Upon awakening he had almost total loss of sight in his left eye. Later he sued the anesthesiologist and nurse anesthetist,

Aloha and keep the faith-rts •

-HAWAII MEDICAL JOURNAL, VOL 54, DECEMBER 1995 820

INDEX to the Hawaii Medical Journal, Volume 53, 1994

Compiled by Suzanne M. Carnes and Eileen Herring of the Hawaii Medical Library

Keyword Index

ACQUIRED IMMUNODEFICIENCY VIRUS. Military medicine, 53(!0):274 ADENOMA TO US POLYPS. Ethnic differences in the recurrence of adenomatous polyps after colonoscopic polypectomy, 53( I): 16 ADOLESCENCE. Non-traditional and traditional treatment ofHawaiian and non-Hawaiian adolescents, 53(12):344 AGED. The Rise of cancer among the elderly in Hawaii, 53(7): 188 ALTERNATIVE MEDICINE. Non-traditional and traditionallreatment of Hawaiian and non-Hawaiian adolescents. 53(12):344 ANESTHESIA, SPINAL. Historical notes, 53(9):234 ARTERIOVENOUS MALFORMATIONS. Diffuse venous malforma­tion with intraosseous involvement, 53(8):218 ASTHMA. Mamane: scientific therapy for asthma?, 53(12):350 AUTISM. New hope in the lreatment of autism in Hawaii, 53(7): 194 AUW AE, HENRY A. Native Hawaiian traditional healing, 53(12):348 BAROTRAUMA. Baromedicine today-rational uses of hyperbaric oxygen therapy, 53(4):112 BILE DUCTS. The Accessory bile duct of Luschka and bile leakage in laparoscopic cholecystectomy, 53(6):164 BIOCHEMISTRY. Medical school hotline, 53(7):184 BIOGRAPHY. Historical notes, 53(11):298 BIOPHYSICS. Medical school hotline, 53(7): 184 BLOOD TRANSFUSION. Blood transfusion: the risks and benefits, 53(1):20 BLOOD-BORNE PATHOGENS. Blood transfusion: the risks and ben­efits, 53(1):20 BOARD OF HEALTH. Historical notes, 53(10):272 -Historical notes, 53(12):329 BONE MARROW TRANSPLANTATION. Allogenic and autologous bone marrow transplant experiences in Hawaii. 53(3):72 BOOK REVIEWS. Ethical health care reform, 53(1 ):5 -Hurricane Iniki, 53(7):182 - Laau Hawaii: traditional Hawaiian uses of plants. 53(12):332 -Plants in Hawaiian culture, 53( 12):332 -Polynesian herbal medicine. 53(12):332 BREAST NEOPLASMS. Controversies in breast cancer diagnosis and management, 53(9):246 CALORIC !NT AKE. Health care aboard the Hokulea-energy require­ment study, 53(12):352 CARDIOVASCULAR DISEASES. Diabetic mellitus and heart disease risk factors in Hawaiians. 53(12):340 CATHETER ABLATION. Radiofrequency catheter cure of idiopathic ventricular tachycardia-first experience in Hawaii, 53(11):310 CENTRALIDENTIFICATIONLABORATORY-HICKAMAFB.Mili­tary medicine, 53(3):60 CEREBROVASCULAR DISORDERS. Stroke in women, 53(9):258 CHILD ABUSE. Parents' reporting of symptoms in their children: physicians' perceptions, 53(8):216 - Home-based family support services: part of the comprehensive national plan to improve overall health and safety of children, 53(9):252 CHINESE. Historical notes, 53(5):129 CHOLECYSTECTOMY, LAPAROSCOPIC. The Accessory bile duct ofLuschka and bile leakage in laparoscopic cholecystectomy, 53(6): 164 CLINICAL TRIALS. Medical school hotline, 53(9):235 COLON. Colonic sphincters revisited: simulators of organic disease, 53(10):278 COLONIC NEOPLASMS. Ethnic differences in the recurrence of adenomatous polyps after colonoscopic polypectomy, 53( I): 16 COMBAT DISORDERS. Characteristics of veterans in Hawaii with and without diagnoses of posHraumatic stress disorder, 53(11 ):314 CONTRACEPTIVE AGENTS. Contraception, 53(9):250 CONTRACEPTIVE DEVICES. Contraception, 53(9):250 COVER ILLUSTRATIONS. Birth ofMoloka'i, 53(2):33 - Hina-the goddess. 53(1):2 -Birth of Maui, 53(4): 103 -Birth ofMoloka'i [Kamapua'a], 53(3):57 -Birth of Palila, 53(5): 128 -Many forms ofHina. 53(6):157 -Fleeing of Hina, 53(7): 181 - Hina and the Hana fishermen, 53(8):209 - Hina-the goddess of food plants, 53(9):234 -Conflict of Kamapua'a, 53(10):269 -Slowing of the sun, 53(11):297 - Hina-the goddess of fishermen, 53(12):325 DELIVERY OF HEALTH CARE. Non-traditional and traditional treat­ment of Hawaiian and non~Hawaiian adolescents, 53(12):344 DENGUE. Historical notes, 53( 12):329 DIABETES MELLITUS. Pancreas transplantation for diabetic patients in Hawaii. 53(3):90 -Diabetic mellitus and heart disease risk factors in Hawaiians, 53( 12):340 DIET. The Waianae diet program: a culturally sensitive, community· based obesity and clinical intervention program for the native Hawaiian population. 53(5): 136 -Health care aboard the Hokulea-energy requirement study, 53( 12):352 -Hawaiian diet at the Maui Memorial Hospital, 53( 12):354 DISEASE OUTBREAKS. Hawaiians and medicine [orig. pub. October !981], 53(12):336 DIVING. Baromedicine today-rational uses of hyperbaric oxygen therapy, 53(4):112 DOMESTIC VIOLENCE. Domestic violence-a medical perspective, 53(9):242 -Domestic violence-identifying abuse, 53(9):246

DRUG UTILIZATION REVIEW. Military medicine, 53(9):235 E OLA MAU. Native Hawaiian traditional healing, 53(12):348 EDITORIALS. We are off and running!, 53(2):32 -Secret life of Jobn Alfred Burden MD, 53(2):32 -New Hawaii Medical Journal, 53( I ):4 -Letter to our legislators, 53(4):104 - Helicobacter pylori infection-gastritis, ulcers and gastric cancer, 53(4):104 ' -Mahalonui loa, 53(4):123 -Doctor, we need your organs! And your help!, 53(3):56 -Organ transplantation overview, 53(3):56 -[Medicine in Hawaii], 53(5):128 -Mice are not men!, 53(6):158 -Autism in Hawaii, 53(6): 158 -Horticultural activities at the Hawaii Medical Library. 53(6):158 - Cancers in gray Hawaiians. 53(7): 182 -Hurricanes in Hawaii, 53(7): 182 -Health reform and special issues, 53(8):210 -Aloha to Samuel D. Allison MD, 53(10):270 -Common sense prescription for health care, 53(1 0):270 -Hawaii Medical Association annual meeting, 53(11):298 -Native Hawaiian health special issue, dedicated to George Mills, MD (1921-1992), 53(12):326 - Memories of a great husband, physician and native Hawaiian, 53(12):326 EDUCATION, MEDICAL. On the quest for the humane physician, 53(7):196 -Medical school hotline, 53(12):329 ELECTROMAGNETIC FIELDS. Prolonged static magnetic field expo­sure and myeloma, 53( I 0):287 ENCHONDROMATOSIS. Diffuse venous malformation with intraosseous involvement, 53(8):218 ENERGY METABOLISM. Health care aboard the Hokulea-energy requirement study, 53(12):352 ESTROGEN REPLACEMENT THERAPY. Menopause, 53(9):244 -Treatment options for postmenopausal osteoporosis, 53(9):256 ETHICS. On the quest for the humane physician, 53(7): 196 ETHNIC GROUPS. Ethnic differences in the recurrence of adenomatous polyps after colonoscopic polypectomy, 53(1):16 - Helicobacter pylori infection and chronic active gastritis, 53(4): 116 -Rise of cancer among the elderly in Hawaii, 53(7):188 -Non-traditional and traditional treatment ofHawaiian and non-Hawai-ian adolescents, 53(12):344 FAMILY HEALTH. Home-based family support services: part of the comprehensive national plan to improve overall health and safety of children, 53(9):252 FAMILY PRACTICE. Medical school hotline, 53(10):272 FATTY ACIDS, OMEGA-3. Omega-3 fatty acids in Hawaii seafood, 53(5):142 FINANCIAL MANAGEMENT. He says/she says: women not well prepared financially. 53(9):240 GASTRITIS. Helicobacter pylori infection and chronic active gastritis, 53(4):116 GENE THERAPY. The Robert T. Wong lectureship, February 1994, 53(10):287 GLOVES, SURGICAL. Historical notes, 53(9):234 GOUT. A Review of the radiographic manifestations of gout, 53(2):40 HAW All. The Immunologic staging of chronic active hepatitis B patients in Hawaii, 53(2):44 -Retinopathy of prematurity: incidence and severity in Hawaii, 53( I): 12 -25 years of kidney transplantation in Hawaii, 53(3):64

Allogenic and autologous bone marrow transplant experiences in Hawaii, 53(3):72 -Cardiac transplantation in Hawaii, 53(3):80 -Liver transplantation in Hawaii, 53(3):86 -Pancreas transplantation for diabetic patients in Hawaii, 53(3):90 -Need for organ donation in Hawaii, 53(3):94 -Historical notes, 53(5): 129 -Omega-3 fatty acids in Hawaii seafood, 53(5):142 -Historical notes, 53(6): 161 -Psychological response to disaster: implications in Hawaii, 53(6): 166 -Rise of cancer among the elderly in Hawaii, 53(7): 188 -New hope in the treatment of autism in Hawaii, 53(7): 194 -Medical school hotline, 53(9):235 -Medical school hotline, 53( I 0):272 -Historical notes, 53(10):272 -Historical notes, 53(11):298 - Radiofrequency catheter cure of idiopathic ventricular tachycardia-first experience in Hawaii, 53(11):310 -Characteristics of veterans in Hawaii with and without diagnoses of post-traumatic stress disorder, 53( II ):314 -Hawaiians and medicine [orig. pub. October 1981], 53(12):336 - Mamane: scientific therapy for asthma?, 53(12):350 -Health care aboard the Hokulea-energy requirement study. 53( 12):352 -Hawaiian medicine, 53(12):358 HAWAII MEDICAL ASSOCIATION. HMA president's message, 53(2):35 -Highlights of the 1993 HMA house of delegates, 53( I ):9 - HMA president's message, 53(4): 106 - HMA council highlights, February 4, 1994, 53(4): 107 - HMA president"s message, 53(3):59 -Highlights of the HMA council meeting of January 7, 1994. 53(3):61 - HMA President"s Message, 53(1):8 - HMA president's message, 53(5):130 -HAWAII MEDICAL JOURNAL, VOL 54, DECEMBER1995

821

- HMA council highlights, March 4, 1994, 53(5):131 - HMA president's message, 53(6):163 - HMA council highlights of AprilS, 1994, 53(6):170 - HMA council highlights, May 6, 1994, 53(7): 185 - HMA president's message, 53(7): 186 - HMA council highlights, June 3, 1994, 53(8):213 - HMA council highlights, July 8, 1994, 53(9):236 - HMA president's message, 53(9):239 - HMA president's message, 53(10):276 - HMA council highlights, September 2, 1994, 53(11 ):300 - HMA president's message, 53(11 ):30 I -Highlights of the proceedings of the HMA house of delegates, October 7to9,1994,53(11):305 -HighJightsofthe I 38th annual scientific sessions, October? to9, 1994. 53(11):307 - HMA president's message, 53(12):328 HAWAII MEDICAL ASSOCIATION ALLIANCE. HMA alliance, 53(2):37 -HMA alliance, 53(4):111 - HMA alliance, 53(3):62 - HMA alliance, 53( I );6 - HMA alliance, 53(5): 135 - HMA alliance, 53(6): 161 - HMA alliance, 53(8):212 - HMA alliance, 53(9):239 - HMA alliance, 53(10):274 - HMA alliance, 53(11 ):304 - HMA alliance, 53( 12):330 HAW All MEDICAL JOURNAL. Historical notes, 53(2):46 -Historical notes, 53(1 ):7 -Index to the Hawaii Medical Journal, volume 52, 1993, 53(12):360 HAW All TUMOR REGISTRY. The Rise of cancer among the elderly in Hawaii, 53(7):188 HEALTH CARE COSTS. Historical notes, 53( 4): 108 HEALTH CARE REFORM. Medical savings account, 53(8):214 HEALTH SERVICES ACCESSIBILITY. Medical school hotline, 53(12):329 HEART TRANSPLANTATION. Cardiac transplantation in Hawaii, 53(3):80 HELICOBACTER INFECTIONS. Helicobacter pylori infection and chronic active gastritis, 53(4): 116 HEMANGIOMA. Diffuse venous malformation with intraosseous in­volvement, 53(8):218 HEMORRHAGE. Low predictive value of an elevated prothrombin time for bleeding on oral anticoagulation, 53(1 0):284 HEPATITIS B. The Immunologic staging of chronic active hepatitis B patients in Hawaii, 53(2):44 HISTORY OF MEDICINE. Historical notes, 53(2):46 -Historical notes, 53( 4): 108 -Historical notes, 53(3):60 -Historical notes, 53(5): 129 -Historical notes, 53(6):161 -Historical notes. 53(8):2I1 -Historical notes, 53(9):234 -Historical notes, 53(10):272 -Historical notes, 53(11 ):298 -Historical notes, 53(12):329 -Hawaiians and medicine [orig. pub. October 1981], 53(12):336 -Hawaiian medicine, 53(12):358 HIV. Military medicine, 53(10):274 HOKULEA. Health care aboard the Hokulea--energy requirement study, 53(12):352 HYPERBARIC OXYGENATION. Baromedicine today-rational uses of hyperbaric oxygen therapy, 53(4): 112 IMI HO'OLA. Medical school hot!ine, 53(6): 160 IN MEMORIUM. Historical notes, 53( II ):298 INDEX. Index to the Hawaii Medical Journal, volume52,1993.53(12):360 INSURANCE. HEALTH. Medical savings account, 53(8):214 INTERFERON ALFA-28. The Immunologic staging of chronic active hepatitis B patients in Hawaii, 53(2):44 INTERNATIONAL TRAVELERS HEALTH CLINIC-TAMC. Mili­tary medicine, 53(2):38 JOHN A BURNS SCHOOL OF MEDICINE. Medical school hotline, 53(2):38 -Medical school hotline, 53( 4): 105 -Medical school hotline, 53(3):62 -Medical school hotline, 53(1 ):7 -Medical school hotline, 53(5): 129 -Medical school hotline. 53(6): 160 -Medical school hotline, 53(7): 184 -Medical school hot!ine, 53(8):212 -Medical school hotline. 53(9):235 -Medical school hotline, 53(1 0):272 -Medical school hotline, 53( II ):298 -Medical school hotline, 53(12):329 JOURNAL REVIEWS. Pacific Health Dialog, 53(12):332 KAHUNA LAAU LAPAAU. Native Hawaiian traditional healing, 53(12):348 KE OLA 0 HAW All. Medical school hotline. 53(5): 129 KIDNEY TRANSPLANTATION. Historical notes, 53(3):60 - 25 years of kidney transplantation in Hawaii, 53(3):64 KONG, TAl HEONG. Historical notes. 53(5): 129 LAPAROSCOPY. Pelvic pain, 53(9):247 LEISHMANIASIS, VISCERAL. Military medicine, 53(7): 184

LETI'ERS TO THE EDITOR. re: Letter to Hilary Rodham Clinton, 53(2):33 - re: Smoking cessation programs, 53(2):34 - re: Hawaii legislature, 53(6): 158 - re: Physician attestation responsibilities, 53(8):210 -re: Medical schools, 53(10):271 LI, KHAI FAI. Historical notes, 53(5):129 LNER TRANSPLANTATION. Liver transplantation in Hawaii, 53(3 ):86 MAGNETIC RESONANCE IMAGING. Diffuse venous malformation with intraosseous involvement, 53(8):218 MARSHAlL ISLANDS. Military medicine, 53(6):160 MAUl MEMORIAL HOSPITAL. The Hawaiian diet at the Maui Memo­rial Hospital, 53(12):354 MEDICINE, HAW AllAN TRADITIONAL. Non-traditional and tradi­tional treatment of Hawaiian and non-Hawaiian adolescents, 53(1 2):344 -Native Hawaiian traditional healing, 53(12):348 - Mamane: scientific therapy for asthma?, 53( 12):350 -Hawaiian medicine, 53(12):358 MEDICINE, HERBAL. Mamane: scientific therapy for asthma?, 53(12):350 MELANOMA. The Rise of cancer among the elderly in Hawaii, 53(7): 188 MENOPAUSE. Menopause, 53(9):244 MENTAL DISORDERS. Psychological response to disaster. implica­tions in Hawaii, 53(6): 166 MENTAL HEALTH. Medical school hotline, 53(3):62 MICROBIOLOGY. Medical school hotline, 53( 4): I 05 MILITARY MEDICINE. Military medicine, 53(1):6 MILITARY PERSONNEL. Military medicine, 53(10):274 MULTIPLE MYELOMA. Prolonged static magnetic field exposure and myeloma, 53(10):287 MUNCHAUSEN SYNDROME BY PROXY. Parents' reporting of symptoms in their children: physicians' perceptions, 53(8):216 NATIVE HAWAIIANS. Medical school hotline, 53(3):62 -Waianae diet program: a culturally sensitive, community-based obe­sity and clinical intervention program for the native Hawaiian population, 53(5):136 - Medical school hotline, 53( 6): 160 -Medical school hotline, 53(12):329 -Hawaiians and medicine [orig. pub. October 1981], 53(12):336 -Diabetic mellitus and heart disease risk factors in Hawaiians, 53( 12):340 -Non-traditional and traditional treatment of Hawaiian and non-Hawai-ian adolescents, 53(12):344 -Hawaiian diet at the Maui Memorial Hospital, 53(12):354 NATURAL DISASlERS. Psychological response to disaster: implica­tions in Hawaii, 53(6):166 NEOPLASMS. The Rise of cancer among the elderly in Hawaii, 53(7): 188 NEOPLASMS,RADIA TION-INDUCED. Military medicine, 53(6): 160 OBESITY. The Waianae diet program: a culturally sensitive, commu­nity-based obesity and clinical intervention program for the native Hawaiian population, 53(5): 136 ORGAN PROCUREMENT. The Need for organ donation in Hawaii, 53(3):94 OSTEOPOROSIS, POSTMENOPAUSAL. Treatment options for post­menopausal osteoporosis, 53(9):256 PANCREAS TRANSPLANTATION. Pancreas transplantation for dia­betic patients in Hawaii, 53(3):90 PEL VIS. Pelvic pain, 53(9):247 PEPTIC ULCER. Helicobacter pylori infection and chronic active gastritis, 53(4): 116 PERSIAN GULF. Military medicine, 53(7):184 PHYSICIAN-PATIENT RELATIONS. Parents' reporting of symptoms in their children: physicians' perceptions, 53(8):216 PHYSICIANS. On the quest for the humane physician, 53(7): 196 -Historical notes, 53(11 ):298 PHYSICIANS, FAMILY. Medical school hotline, 53(5): 129 PLAGUE. Historical notes, 53(12):329 POLYNESIA. Pacific Health Dialog, 53(12):332 -Health care aboard the Hokulea-energy requirement study, 53( 12): 352 POLYNESIAN VOYAGING SOCIETY. Health care aboard the Hokulea--energy requirement study, 53( 12):352 POSTOPERATIVE COMPLICATIONS. Persistent postoperative ven­tricular tachycardia treatment by using external cardiopulmonary sup­port, 53(1 ): I 0 PRE-ECLAMPSIA. Postpartum preeclampsia complicated by acute pul­monary edema, 53(9):248 PREMENSTRUAL SYNDROME. Premenstrual syndrome: a guide for the clinician, 53(9):254 PROBLEM-BASED LEARNING. Medical school hotline, 53( 4): 105 PRO'TIIROMBIN TIME. Low predictive value of an elevated prothrom­bin time for bleeding on oral anticoagulation, 53( I 0):284 PSYCHIATRY. Medical school hotline, 53(3):62 PUBLIC HEAL Til. Pacific Health Dialog, 53( 12):332 PULMONARY EDEMA. Postpartum preeclampsia complicated by acute pulmonary edema, 53(9):248 QUEEN'S MEDICAL CENTER. Historical notes, 53(4):108 RADIATION INJURIES. Military medicine, 53(6): 160 RADIOGRAPHY. A Review of the radiographic manifestations of gout, 53(2):40 -Colonic sphincters revisited: simulators of organic disea~. 53( I 0):278 REIMBURSEMENT MECHANISMS. Historical notes, 53(8):211 RESEARCH. Medical school hotline, 53( 11 ):298 RETINOPATHY OF PREMATURITY. Retinopathy of prematurity: incidence and severity in Hawaii, 53(1):12 RISK FACfORS. Diabetic mellitus and heart disease risk factors in Hawaiians, 53(12):340 SEAFOOD. Omega-3 fatty acids in Hawaii seafood, 53(5): 142 SHIPS. Health care aboard the Hokulea--energy requirement study, 53(12):352 SOCIAL SUPPORT. Home-based family suppott services: part of the comprehensive national plan to improve overall health and safety of children, 53(9):252 ST FRANCIS MEDICAL CENTER. 25 years of kidney transplantation in Hawaii, 53(3):64

Allogenic and autologous bone marrow transplant experiences in Hawaii, 53(3):72 -Cardiac transplantation in Hawaii, 53(3):80 STRESS DISORDERS, POST-TRAUMA TIC. Characteristics of veter­ans in Hawaii with and without diagnoses of post-traumatic stress disorder, 53(11):314 SURGERY. Medical school hotline, 53(8):212 SURGERY, LAPAROSCOPIC. Military medicine, 53(11):302 TACHYCARDIA, VENTRICULAR. Persistent postoperative ventricu­lar tachycardia treatment by using external cardiopulmonary support,

53(1):10 - Radiofrequency catheter cure of idiopathic ventricular tachycardia­first experience in Hawaii, 53(11):310 TELEMEDICINE. Military medicine, 53( 11 ):302 TRANSPLANTATION. Historical notes, 53(3):60 - 25 years of kidney transplantation in Hawaii, 53(3):64 - Allogenic and autologous bone marrow transplant experiences in Hawaii, 53(3):72 -Cardiac transplantation in Hawaii, 53(3):80 -Liver transplantation in Hawaii, 53(3):86 -Pancreas transplantation for diabetic patients in Hawaii, 53(3):90 -Need for organ donation in Hawaii, 53(3):94 TRAVEL. Military medicine, 53(2):38 TRIPLER ARMY MEDICAL CENTER. Military medicine, 53(2):38 -Military medicine, 53(5): 135 -Military medicine, 53(9):235 -Military medicine, 53( 12):330 VETERANS. Characteristics of veterans in Hawaii with and without diagnoses of post-traumatic stress disorder, 53(11 ):314 WAIANAE DIET PROGRAM. The Waianae diet program: a culturally sensitive, community-based obesity and clinical intervention program for the native Hawaiian population, 53(5): 136 WOMEN'S HEAL Til. Medical school hotline, 53(9):235 -Domestic violence-a medical perspective, 53(9):242 -Stroke in women, 53(9):258 -Highlightsofthe I 38th annual scientific sessions,October7to9, 1994, 53(11):307 -Military medicine, 53(12):330

Author Index

ADAMS EM. Highlights of the I 38th annual scientific sessions, October 7 to 9, 1994, 53(1 I ):307 AIU PK. Health care aboard the Hokulea--energy requirement study, 53(12):352 AKO H. Omega-3 fatty acids in Hawaii seafood, 53(5): 142 ANDRADE NN. Medical school hotline, 53(3):62 -Non-traditional and traditional treatment ofHawaiian and non-Hawai­ian adolescents, 53(1 2):344 ARAKAKI R. Diabetic mellitus and heart disease risk factors in Hawai­ians, 53(12):340 ASHMORE RC. Postpartum preeclampsia complicated by acute pulmo­nary edema, 53(9):248 AZUMA SS. Persistent postoperative ventricular tachycardia treatment by using external cardiopulmonary support, 53(1 ): 10 BATKIN S. Baromedicine today-rational uses of hyperbaric oxygen therapy, 53(4): 112 BECKMAN S. Waianae diet program: a culturally sensitive, community­based obesity and clinical intervention program for the native Hawaiian population, 53(5): 136 BERG BW. Military medicine, 53(2):38 -Military medicine, 53(3):60 -Military medicine, 53(1):6 -Military medicine, 53(5): 135 -Military medicine, 53(6):160 -Military medicine, 53(7): 184 -Military medicine, 53(9):235 -Military medicine, 53(12):330 BETWEEJ. re: Medical schools, 53(10):271 BHAGA VAN NV. Medical school hotline, 53(7):184 BINTLIFF S. Domestic violence-identifying abuse, 53(9):246 SOLMAN W. New hope in the treatment of autism in Hawaii, 53(7): 194 BREINICH JA. Historical notes, 53(2):46 -Historical notes, 53(3):60 -Historical notes, 53(1 ):7 -Historical notes, 53(5): 129 -Historical notes, 53(8):211 -Historical notes, 53(9):234 -Historical notes, 53(10):272 -Historical notes, 53(11):298 -Historical notes, 53( 12):329 BRUNO P. Military medicine, 53(2):38 CAMARA EG. Premenstrual syndrome: a guide for the clinician, 53(9):254 CARLSON JG. Characteristics of veterans in Hawaii with and without diagnoses of post-traumatic stress disorder, 53(1 I ):314 CARNES SM. Index to the Hawaii Medical Journal, volume 52, 1993, 53(12):360 CHANG H. Diabetic mellitus and heart disease risk factors in Hawaiians, 53(12):340 CHEMTOB CM. Characteristics of veterans in Hawaii with and without diagnoses of post-traumatic stress disorder, 53( II ):314 CHEUNG AH. Organ transplantation overview, 53(3):56 - 25 years of kidney transplantation in Hawaii, 53(3):64 -Liver transplantation in Hawaii, 53(3):86 -Pancreas transplantation for diabetic patients in Hawaii, 53(3):90 -Need for organ donation in Hawaii, 53(3):94 CHIEN YK. Mamane: scientific therapy for asthma?, 53(12):350 CHING CY. Immunologic staging of chronic active hepatitis B patients in Hawaii, 53(2):44 CHING N. Immunologic staging of chronic active hepatitis B patients in Hawaii, 53(2):44 CHINN HY. 25 years of kidney transplantation in Hawaii, 53(3):64 CHONG CD. Allogenic and autologous bone marrow transplant experi­ences in Hawaii, 53(3):72 COAKLEY D. Diabetes mellitus and heart disease risk factors in Hawai­ians, 53(12):340 CURB JD. Medical school hotline, 53(9):235 DANKO GP. Non-traditional and traditional treatment of Hawaiian and non~Hawaiian adolescent~. 53(12):344 DE LEON PH. re: Physician attestation responsibilities, 53(8):21 0 DENNY NR. Characteristics of veterans in Hawaii with and without diagnoses ofpost~traumatic stress disorder, 53(11):314 DI PRETA JE. Psychological response to disaster: implications in Ha~ waii, 53(6):166 DON A. HMA president's message, 53(2):35 - HMA president's message, 53(4): 106 - HMA president's message, 53(3):59 - HMA President's Message, 53(1):8 - HMA president's message, 53(5): 130 - HMA president's message, 53(6): 163 - HMA president's message, 53(7): 186 - HMA president's message, 53(9):239 -- HMA president's message, 53( I 0):276 -HAWAII MEDICAL JOURNAL, VOL 54, DECEMBER 1995

822

DROUU..HET JH. Retinopathy of prematurity: incidence and severity in Hawaii, 53( 1): 12 EASA D. Retinopathy of prematurity: incidence and severity in Hawaii. 53(1):12 EDMAN J. Non-traditional and traditional treatment of Hawaiian and non-Hawaiian adolescents, 53(12):344 FAN FL. 25 years of kidney transplantation in Hawaii, 53(3):64 FELETTI G. Pacific Health Dialog, 53(12):332 FOLEY HA. Medical school hotline, 53(5): 129 FOG SL. HMA alliance, 53(2):37 - HMA alliance, 53( 4): Ill - HMA alliance, 53(3):62 - HMA alliance, 53(1 );6 - HMA alliance, 53(5): 135 - HMA alliance, 53(6):161 - HMA alliance, 53(8):212 - HMA alliance, 53(9):239 - HMA alliance, 53(10):274 FOURNIER-MASSEY G. Mamane: scientific therapy for asthma?, 53(12):350 FROHLICH JA. Blood transfusion: the risks and benefits, 53(1):20 FU T. Rise of cancer among the elderly in Hawaii, 53(7): 188 GAGLIARDI JA. Review of the radiographic manifestations of gout, 53(2):40 -Diffuse venous malformation with intraosseous involvement, 53(8):218 -Colonic sphincters revisited: simulators of organic disease, 53( I 0):278 GILBERT FI JR. re: Physician attestation responsibilities, 53(8):210 GODLESKI LS. Psychological response to disaster: implications in Hawaii, 53(6):166 GOLDSTEIN N. We are off and running!, 53(2):32 -New Hawaii Medical Journal, 53(1 ):4 -Letter to our legislators, 53(4): 104 - Helicobacter pylori infection-gastritis, ulcers and gastric cancer, 53(4):104 - Mahalo nui loa, 53(4): 123 -Doctor, we need your organs! And your help!, 53(3):56 -[Medicine in Hawaii], 53(5):128 -Mice are not men!, 53(6):158 -Autism in Hawaii, 53(6): 158 -Horticultural activities at the Hawaii Medical Library, 53(6): 158 - Cancers in gray Hawaiians, 53(7): 182 -Hurricanes in Hawaii, 53(7): 182 -Health reform and special issues, 53(8):21 0 -Aloha to Samuel D. Allison MD, 53(1 0):270 -Hawaii Medical Association annual meeting, 53(11):298 -Native Hawaiian health special issue, dedicated to George Mills, MD (1921-1992), 53(12):326 GOODMAN MT. Rise of cancer among the elderly in Hawaii, 53(7): 188 GRANDINETI1 A. Diabetes mellitus and heart disease risk factors in Hawaiians, 53(12):340 GUTTELING C. HMA alliance, 53( 4): Ill HAMID BA. Persistent postoperative ventricular tachycardia treatment by using external cardiopulmonary support, 53(1):10 HANSEN J. Postpartum preeclampsia complicated by acute pulmonary edema, 53(9):248 HASTERT M. Historical notes, 53( 4): I 08 -Historical notes, 53(6):161 HEDLUND NL. Characteristics of veterans in Hawaii with and without diagnoses of post-traumatic stress disorder, 53( II ):314 HERRING E. Laau Hawaii: traditional Hawaiian uses of plants, 53( 12):332 -Plants in Hawaiian culture, 53(12):332 -Polynesian herbal medicine, 53(12):332 -Index to the Hawaii Medical Journal, volume 52, 1993, 53(12):360 HITCHCOCK MA. Medical school hotline, 53(12):329 HOLSCHUH FC. HMA president's message, 53(11):301 - HMA president's message, 53(12):328 HONG RA. Persistent postoperative ventricular tachycardia treatment by using external cardiopulmonary support, 53(1 ): I 0 HOOVERJ. Hurricane lniki, 53(7):182 HOWARD L. Highlights of the proceedings of the HMA house of delegates, October 7 to 9, 1994, 53(11):305 HUGHES C. Waianae diet program: a culturally sensitive, community­based obesity and clinical intervention program for the native Hawaiian population, 53(5): 136 lNG M. Retinopathy of prematurity: incidence and severity in Hawaii, 53(1):12 ISHIMOTO S. Need for organ donation in Hawaii, 53(3):94 IZUTSU S. Medical school hotline, 53(2):38 JIM RT. Allogenic and autologous bone marrow transplant experiences in Hawaii, 53(3):72 -Prolonged static magnetic field exposure and myeloma, 53( I 0):287 JOHNSON AC Ill. Military medicine, 53(10):274 JOHNSON RC. Non-traditional and traditional treatment of Hawaiian and non-Hawaiian adolescents, 53( 12):344 JOSHI M. re: Smoking cessation programs, 53(2):34 JUDD NL. Medical school hotline, 53(6):160 -Native Hawaiian traditional healing, 53( 12):348 KELLEY RR. Common sense prescription for health care, 53(10):270 KILKENNY lE. Colonic sphincters revisited: simulators of organic disease, 53( 10):278 KOKAME G. Retinopathy of prematurity: incidence and severity in Hawaii, 53(1):12 KOLONEL LN. Rise of cancer among the elderly in Hawaii, 53(7): 188 KOSASA TS. Pelvic pain, 53(9):247 LAU JM. Persistent postoperative ventricular tachycardia treatment by using external cardiopulmonary support, 53(1): 10 LENGYEL RJ. Review of the radiographic manifestations of gout, 53(2):40 LIMM WM. 25 years of kidney transplantation in Hawaii, 53(3):64 -Liver transplantation in Hawaii, 53(3):86 -Pancreas transplantation for diabetic patients in Hawaii, 53(3):90 -Need for organ donation in Hawaii. 53(3):94 LISEHORA GB. Military medicine, 53(11):302 LOH KK. Allogenic and autologous bone marrow transplant experiences in Hawaii, 53(3):72 LOVE BB. Stroke in women, 53(9):258 LUKE KN. Psychological response to disaster. implications in Hawaii, 53(6): 166 LUMENG J. Immunologic staging of chronic active hepatitis B patients in Hawaii, 53(2):44 MACNAMARA JJ. Medical school hotline, 53(8):212 MAKINI GK JR. Non-traditional and traditional treatment of Hawaiian and non~Hawaiian adolescents, 53( 12):344

MASAKI K. Medical school hotline, 53(9):235 MASSEY DG. Mamane: scientific therapy for asthma?, 53(12):350 MASTROFRANCESCO L. Controversies in breast cancer diagnosis and management, 53(9):246 MAU M. Diabetic mellitus and heart disease risk factors in Hawaiians, 53(12):340 MCDERMOTI IF JR. Non-traditional and traditional treatment of Hawaiian and non· Hawaiian adolescents, 53(1 2):344 MCNAMEE C. HMA alliance, 53(11):304 MILLS B. Memories of a great husband, physician and native Hawaiian, 53(12):326 MILLS GH. Hawaiians and medicine [orig. pub. October 1981], 53(12):336 MlSHELL DR JR. Menopause, 53(9):244 - ContiaCeption, 53(9):250 MIZUGUCHI N. ''"Hawaii legislature, 53(6):158 MORENO-CABRAL CE. Cardiac transplantation in Hawaii, 53(3):80 MOSER SM. Hawaiian diet at the Maui Memorial Hospital, 53(12):354 NAGAMINE J. Postpartum preeclampsia complicated by acute pulmo­nary edema, 53(9):248 NAHULU LB. Non-traditional and traditional treatmentofHawaiian and non-Hawaiian adolescents, 53(12):344 NAKAAHIKl JH. Cardiac transplantation in Hawaii, 53(3):80 NISHI L. HMA alliance, 53(12):330 NOMURA AM. Rise of cancer among the elderly in Hawaii, 53(7): 188 O'CONNOR HK. Waianae diet program: a culturally sensitive, commu­nity-based obesity and clinical intervention program for the native Hawaiian population, 53(5): 136 O'FRIEL M. Need for organ donation in Hawaii, 53(3):94 OGASAWARA A. Omega-3 fatty acids in Hawaii seafood, 53(5):142 OKAMURA D. Ethnic differences in the recurrence of adenomatous polyps after colonoscopic polypectomy, 53(1 ): 16 OT A E. Omega-3 fatty acids in Hawaii seafood, 53(5): 142 OWENS J. Dotnestic violence-a medical perspective, 53(9):242 PANG GM. Helicobacter pylori infection and chronic active gastritis. 53(4):116 PANG RJ. Helicobacter pylori infection and chronic active gastritis. 53(4):116 PANG RK. 25 years of kidney transplantation in Hawaii, 53(3):64 P ARTIKA N. New hope in the treatment of autism in Hawaii, 53(7): 194 PELKE S. Retinopathy of prematurity: incidence and severity in Hawaii, 53(1):12 PETROVITCH H. Medical school hotline, 53(9):235 PHILLIPS DL. Ethnic differences in the recurrence of adenomatous polyps after colonoscopic polypectomy, 53(1):16 PIGNONE PR. He says/she says: women not well prepared financially, 53(9):240 PON E. Immunologic staging of chronic active hepatitis B patients in Hawaii, 53(2):44 POON L. New hope in the treatment of autism in Hawaii, 53(7): 194 RADV ANY MG. Colonic sphincters revisited: simulators of organic disease, 53(10):278 RAYNER MD. Medical school hotline, 53(11 ):298 REPPUN JI. re: Letter to Hilary Rodham Clinton, 53(2):33 -Ethical health care reform, 53(1):5 -Robert T. Wong lectureship, February 1994, 53(10):287 RO MS. Helicobacter pylori infection and chronic active gastritis, 53(4):116 RODRIGUEZ B. Medical school hotline, 53(9):235 RUSNAK K. Characteristics of veterans in Hawaii with and without diagnoses of post-traumatic stress disorder, 53(11):314 RUSSO RD JR. Colonic sphincters revisited: simulators of organic disease, 53(10):278 SAMLASKA CP. Diffuse venous malformation with intraosseous in· volvement, 53(8):218 SATO A. Waianae diet program: a culturally sensitive, community-based obesity and clinical intervention program for the native Hawaiian popu· lation, 53(5): 136 SCHATZ U. On the quest for the humane physician, 53(7): 196 SHEN EN. Low predictive value of an elevated prothrombin time for bleeding on oral anticoagulation, 53(10):284 - Radiofrequency catheter cure of idiopathic ventricular tachycardia­first experience in Hawaii, 53(11):310 SHERIDAN MS. Parents' reporting of symptoms in their children: physicians' perceptions, 53(8):216 SHINT ANI T. Waianae diet program: a culturally sensitive, community· based obesity and clinical intervention program for the native Hawaiian population, 53(5): 136 SINGER F. Treatment options for postmenopausal osteoporosis,53(9):256 SROATD. Retinopathy of prematurity: incidence and severity in Hawaii, 53(1):12 STODD RT. Weathervane, 53(2):50 - Weathervane, 53( 4): 124 - Weathervane, 53(3):98 - W eathervane, 53(1 ):26 - Weathervane, 53(5):152 - Weathervane, 53(6):176 - Weathervane, 53(7):204 - weathervane, 53(8):228 - Weathervane, 53(9):264 - W eathervane, 53(1 0):292 - Weathervane, 53(11):320 - Weathervane, 53(12):368 TABRAH FL. Baromedicine today-ntional uses of hyperbaric oxygen therapy, 53(4):112 TAKEMOTO-GENTILE C. Medical school hotline, 53(10):272 TANNER R. Baromedicine today-ntional uses of hyperbaric oxygen therapy. 53(4): 112 TOKUMINE T. Ethnic differences in the recurrence of adenomatous polyps aftercolonoscopic polypectomy, 53(1):16 TSAI NC. Liver transplantation in Hawaii, 53(3):86 V AREZ D. Birth of Molol:a'i, 53(2):33 - Hina-lhe goddess, 53(1):2 -Birth of Maui, 53(4): 103 -Birth of Molol:a 'i [Kamapua 'a], 53(3):57 -Birth of Palila, 53(5): 128 -Many forms of Hina, 53(6): 157 - Aeeing of Hina, 53(7): 181 - Hina and the Hana fishermen, 53(8):209 - Hina--the goddess of food plants, 53(9):234 -Conflict of Kamapua'a, 53(10):269 - Slowing of the sun, 53(11 ):297 - Hina-lhe goddess of fishermen, 53(12):325

VEGA R. Baromed.icine today-rational uses of hyperbaric oxygen therapy. 53( 4): 112 WALDRON JA. NorHraditi-onal and traditional treatment of Hawaiian and non-Hawaiian adolescents, 53( 12):344 WALLACH VA. Home-based family support services: part of the comprehensive national plan to improve overall health and safety of children, 53(9):252 WHEELER MS. 25 years of kidney transplantation in Hawaii, 53(3):64 -Need for organ donation in Hawaii, 53(3):94 WILKINSON RW. Allogenic and autologous bone marrow transplant experiences in Hawaii, 53(3):72 WONG B. Retinopathy of prematurity: incidence and severity in Hawaii. 53(1):12 WONG DK. Accessory bile duct of Luschka and bile leakage in laparoscopic cholecystectomy, 53( 6): 164 WONG LL. 25 years of kidney transplantation in Hawaii, 53(3):64 -Liver transplantation in Hawaii, 53(3):86 -Pancreas transplantation for diabetic patients in Hawaii, 53(3):90 WONG LM. Organ transplantation overview, 53(3):56 -25 years of kidney transplantation in Hawaii, 53(3):64 - Allogenic and autologous bone marrow transplant experiences in Hawaii, 53(3):72 WONG RT. Hawaiian medicine, 53(12):358

WONG SC. HMA alliance, 53(3):62 YANG HY. Helicobacter pylori infection and chronic active gastritis, 53(4):116 YATES A. Non-traditional and traditional treatment of Hawaiian and non-Hawaiian adolescents, 53(12):344 YOKOYAMA H. Secret life of John Alfred Burden MD, 53(2):32 -News and notes, 53(2):47 -News and notes, 53( 4): 121 -News and notes, 53(1 ):24 -News and notes, 53(3):74 -News and notes, 53(5):150 -News and notes, 53(6): 174 -News and notes, 53(7):202 -News and notes. 53(8):226 -News and notes, 53(9):262 -News and notes, 53(10):289 -News and notes. 53(11):319 -News and notes, 53(12):366 YUEN N. Non-traditional and traditional treatmentofHawaiian and non· Hawaiian adolescents, 53( 12):344

ONI: or Til[ RJ::ST RJ::ASONS toR PRAGIONG AS A CORPORATION

W[ CAN m:SIGN PROGRAMS & TAILOR TIUO:M TO MIIT YOUR:

<t [STAT[ PLANNING GOAlS

(t SUPPl[M[NTAl RITIR[M[NT INCOM[ DJ::SIR[S

<t RUY-SAl[ AND STOCK RJ::DJ::MPTION PROGRAMS

(t Assrr PROTJ::GION RJ::OmRJ::MJ::NTS

YOU CAN [NJOY UI[S[ RJ::NHITS:

<t TAX DJ::DUQIRl[ CONTRIRliTIONS

<t I.='U::XIRl[ tUNDING

<t DJ::ATII AND OTII[R RJ::NHITS

<t RACK[D RY INSURANCJ:: COMPANY GUARANTHS

<t (OMPATIRl[ WITII PJ::NSION PROGRAMS

-

CALL OUR PROGRAM COORDINATORS:

fRANC[S LntANI

(808)282-6000 OR (808)735 0286

tR[D[RICil J. lUNING

(808)523-1880

HAWAII MEDICAL JOURNAL, VOL 54, DECEMBEA1995 823

INDEX to the Hawaii Medical Journal, Volume 54, 1995

Compiled by Suzanne M. Carnes and Carolyn S.H. Ching of the Hawaii Medical Library

Keyword Index

ACCIDENTS. OCCUPATIONAL. Trends in workers compensation costs in a hotel·operating company over a six·year period. 54(3):439 ACHIEVEMENT. The pursuit of excellence. 1962 [classical article], 54(6):640 ADOLESCENCE. Organizational response to adolescent HIV risk, 51(1):386 - Bone mineral content in Hawaiian, Asian, and Filipino children, 54(I):388 -Adequacy of a pre·participation examination fonn: a study of Hawaii physicians, 54(2):4IO -Pre· participation examination: a new fonn for Hawaii, 54(3):434 -Survey of lead levels in patients presenting to Child and Adolescent Psychiatry, 54(7):67I ADVANCE DIRECTIVES. Some ethical principles for adult critical care, 54(4):482 AGE FACTORS. Age-based rationing of health care, 54( 4):507 - Prostate·specific antigen concentration: influence of age and ethnicity, 54(6):606 -Graves' disease influence of age on clinical findings. 1988 [classical article; abstract], 54(6):613 AGED. Age-based rationing of health care, 54( 4):507 -Have physicians abdicated their role?, 54(4):523 -appropriate use of technology (particularly in medlcal problems of the elderly). I990 [classical article], 54(6):63I ALLIED HEALTH PERSONNEL. Screening of chest roentgenograms by a radiological assistant. 1971 [classical article], 54(6):618

Allied health personnel in cancer detection. Utilization of proctosigmoidoscopic technicians in detecting abnormalities .... 1974 [classical article], 54(6):620 ALZHEIMER'S DISEASE. Alzheimer's disease: etiology? prevention? treatment efficacy? [abstract], 54(9):7I9 AMB ULA TORY CARE. Outcome-oriented quality assurance in an ambulatory setting, 54(5):552 AMBULATORY CARE FACILITIES. Share-care clinics. 1976 [classi­cal article], 54(6):626 AMERICAN MEDICAL ASSOCIATION. Straight and true: setting medicine's course for the 21st century, 54(1 ):374 -Built to last: power tools, old saws, and a new AMA, 54(1):377 AMERICAN MEDICAL ASSOCIATION ALLIANCE. HMA alliance, 54(4):453 ANESTHESIA. Medical progress in a remote archipelago, 54(11):770 ANGEL'S TRUMPET TREE. Acute anticholinergic syndrome follow­ing ingestion of Angel's Trumpet tea, 54(7):669 ANTI-INFECTIVE AGENTS, LOCAL. Medical progress in a remote archipelago, 54(II):770 ANTIBIOTICS. From Prontolyn to Biaxin: the half-century of antibiot­ics, 54(5):542 -Medical progress in a remote archipelago, 54( II ):770 ANTIVIRAL AGENTS. The HIV positive patient -does treatment with antiviral agents alter the course? {abstract}, 54(9):719 ARCHIVES. Historical notes, 54(1I):779 ASEPSIS. From Prontolyn to Biaxin: the half-century of antibiotics, 54(5):542 ASIAN AMERICANS. Bone mineral content in Hawaiian, Asian, and Filipino children, 54(I):388 - Prevalence of systemic lupus erythematosus in Hawaii: is there a difference between ethnic groups?, 54(2):406 -Prostate-specific antigen concentration: influence of age and ethnicity, 54(6):606 ASlliMA. Pediatric asthma-a correlation of clinical treatment and oxygen saturation, 54(7):665 A 'IROPINE. Acute anticholinergic syndrome following ingestion of Angel's Trumpet tea, 54(7):669 A TI1TUDE OF HEALTH PERSONNEL. Hawaii HealthQUEST: a managed care demonstration project, 54(9):720 - pursuit of excellence. I 962 [classical article], 54(6 ):640 -SuiVey ofHawaii physicians' attitudes on health care reform, 54( 1 0):7 40 A TI1TUDE TO HEALTH. High mortality rates in Native Hawaiians, 54(9):723 AUTOANTIBODIES. The superiority of antimicrosomal over anti thyroglobulin antilxxlies for detecting Hashimoto's thyroiditis. 1993 [classical article; abstract], 54(6):6I3 AUTOBIOGRAPHY. From Prontolyn to Biaxin: the half-century of antibiotics, 54(5):542 BEHAVIORAL AND MENTAL DISORDERS. Survey of lead levels in patients presenting to Child and Adolescent Psychiatry, 54(7):671 BIOElliiCS. Bioethics and the new medicine: an oveiView, 54(4):458 -Hybridizing the health care plans of Hawaii, Oregon, and Singapore, 54(4):464 -Must theology remain silent in bioethics?, 54( 4):468 -Medical decisions at the end-of-life: lessons from America, 54( 4):514 BONE DENSITY. Bone mineral content in Hawaiian, Asian, and Fili­pino children, 54(I):388 BOOK REVIEWS. Legal, ethical, and political issues in nursing [Book review], 54(4):453 BRAINARD, SCOTT C .. About the authors, 54( II ):762 BREAST CANCER DETECTION DEMONSTRATION PROJECT. What have we learned from the Breast Cancer Detection Demonstration Project? 1986 [classical article], 54(6):6I5 BREAST NEOPLASMS. What have we learned from the breast cancer detection demonstration project? 1986 [classical article], 54(6):615

BUSHNELL. O.A .. About the author.;, 54(II):762 CARCINOMA, SQUAMOUS CELL. Squamous cell carcinoma of the ovary, 54(8):704 CASTI.E MEDICAL CENTER. Medicaid recipients and psychiatric treatment, 54(1):390 CA TIS, ANN B .. About the authors, 54( II ):762 CEREBROVASCULAR DISORDERS. Treatment options in the acute stroke patient [abstract], 54(9):718 CHAMPUS. Military medicine, 54( 4):454 CHILD. Bone mineral content in Hawaiian, Asian, and Filipino children, 54(1):388 -Consent for children as organ donors, 54( 4):498 - Pediatric asthma-a correlation of clinical treatment and oxygen saturation, 54(7):665 -Survey of lead levels in patients presenting to Child and Adolescent Psychiatry. 54(7):67I CHILD HEALTH SERVICES. The role of the medical home and interprofessional collaboration, 54(5):549 CHRONIC DISEASE. Share-care clinics. 1976 [classical article], 54(6):626 CHYLOTHORAX. Recurrent chylothorax associated with sarcoidosis, 54(12):817 CLINICAL COMPETENCE. Nonclinical use of medical skills: benefi­cence lost?. 54( 4):497 -Thoughts of the relevance of medical history, 54(11):768 CLINICAL PROTOCOLS. 16 tips for better resean:h protocol writing, 54(7):674 COLONIC NEOPLASMS. Allied health personnel in cancer detection. Utilization of proctosigmoidoscopic technicians in detecting abnormali~ ties .... 1974 [classical article], 54(6):620 COMMITMENT OF MENTALLY ILL. Characteristics of long-term mentally ill patient-,: policy implications, 54(2):412 COMPARATIVE STUDY. Prostate-specific antigen concentration: in­fluence of age and ethnicity, 54(6):606 -Comparison of health appraisals by nurses and physicians. 1970 [classical article; abstract], 54(6):626 COMPUTERS. Computers in medicine: emergence of a new technology. 1978 [classical article], 54(6):609 CONGRESSES. Controversies in medicine: abstracts of the !39th annual meeting and scientific session, 54(9):718 CONTRACEPTION. Historical notes, 54(2):402 CORONARY DISEASE. Invasive versus noninvasive treatment of coro­nary artery [abstract], 54(9):718 COST CONTROL. Military medicine, 54(4):454 -Trends in workers compensation costs in a hotel-operating company over a six~year period, 54(3):439 -Caring for patients with fatal illnesses with compassion ... [abstract], 54(9):719 COSTS AND COST ANALYSIS. Characteristics oflong-term mentally ill patients: policy implications. 54(2):412 COVER ILLUSTRATIONS. A chant for the three winds of Molokai, 54(1):373 -fishhook of Maui, 54(2):401 - art of making kapa, 54(3 ): 425 -art of making canoes, 54(4):449 - Rodricidium Memoria JJ. Frederick Reppun MD [On the cover], 54(5):533 -Tripier Army Medical Center, [About the cover], 54(7):653 - Hina goddess, 54(8):689 - Hina the goddess, 54(9):713 -Young Maui and Hina the goddess, 54(10):737 -Celebrating I 00 years of community service, 54( II ):757 - Pele at Haleakala, 54(I2):805 CRffiCAL CARE. Some ethical principles for adult critical care, 54( 4):482 -new Hawaii Comfort Care Only-Do Not Resuscitate law, 54(4):506 -Age-based rationing of health care, 54(4):507 CRITICAL ILLNESS. Honoring the right to die in medical emergencies, 54(4):476 -decision to withdraw tube feeding, 54( 4):485 -Psychiatric assessment of the suicidal terminally ill, 54(4):510 CROSS-CULTURAL COMPARISON. Bone mineral content in Hawai­ian, Asian, and Filipino children, 54( I ):388 - Prevalence of systemic lupus erythematosus in Hawaii : is there a difference between ethnic groups?, 54(2):406 CROSS-SECTIONAL STUDIES. Medicaid recipients and psychiatric treatment, 54( I ):390 - Trends in workers compensation costs in a hotel-operating company over a six-year period, 54(3):439 -Prostate-specific antigen concentration: influence of age andethnicity, 54(6):606 CRYOSURGERY. Hepatic cryosurgery: early experience in Hawaii, 54(I2):8II CURRICULUM. Empathy and medical education, 54(4):495 CYSTIC FIBROSIS. Hawaii's Cystic Fibrosis Center [Military medi­cine], 54(2):403 CYSTS. Testicular cysts: a case report and review of a recent Tripier experience, 54(7):678 DECISION MAKING. Some ethical principles for adult critical care, 54(4):482 -decision to withdraw tube feeding, 54( 4):485 -Consent for children as organ donor.;, 54( 4):498 -Toward an exit visa-regulating health care decision-making, 54( 4):501 - Age-based rationing of health care, 54( 4):507 -Medical decisions at the end-of~ life: lessons from America, 54( 4):514 -HAWAII MEDICAL JOURNAL, VOL 54, DECEMBER 1995

824

-laparoscopic dilemma: which is the best operation? [abstract], 54(9):7I8 -Invasive versus noninvasive treatment of coronary artery [abstract], 54(9):718 DELIVERY OF HEALTH CARE. Informed consent: its legal history and impact on medicine, 54(4):472 -Survey ofHawaii physicians' attitudes on health care refonn, 54( I 0):740 DEMOGRAPHY. Student profile of the Class of 1988 [Medical school hotline ], 54( I ):378

Student profile (Class of 1999) at the John A. Bums School of Medicine [Medical school hotline]. 54(10):739 DENTISTRY. Historical notes, 54(3):428 DEPRESSION. Psychiatric assessment of the suicidal tenninally ill, 54(4):510 DIABETES MELLITUS, INSULIN DEPENDENT. My guardian angel, 54(6):575 DOSE RESPONSE RELATIONSHIP, RADIATION. Optimal iodine-131 dose for eliminating hyperthyroidism in Graves' disease. 1991 [classical article; abstract], 54(6):6I4 DRUG THERAPY. The HIV positive patient --does treatment with antiviral agents alter the course? {abstract], 54(9):7I9 ECONOMIC VALUE OF LIFE. An efficient way to do the wrong thing, 54(4):478 EDITORIALS. Our first year [Editorial], 54(1):374 -February issue [Editorial], 54(2):402 -Memorial festschrift-May I995, Fred Gilbert Jr, MD [Editorial], 54(3):426 -Our next issue of the journal: medicine, law ... {Editorial], 54(3):426 -Guest editorial: epinephrine for anaphylaxis, 54(3):426 -Words of wisdom [Editorial], 54( 4):451 -Editorial, 54(5):534 -Festschrift for Dr Fred I. Gilbert, Jr [Editorial], 54(6):567 -Editorial, 54(7):655 -Editorial, 54(8):690 -Fred Reppun'sSeptember 1993 editorial-HMSA, 54(8):703 -Editorial, 54(9):714 -Editorial, 54( 10):738 -History of medicine in Hawaii [Editorial], 54( II ):759 -Editorial, 54( 12):807 EDUCATION, MEDICAL. The role of ethics and law in medical education [Medical school hotline], 54(4):451 -Empathy and medical education, 54(4):495 - role of geriatrics in medical education [Medical school hotline], 54(5):536 -Medical school hotline, 54(7):657 - role of sports medicine in academic medical education [Medical school hotline], 54(8):694 -Controversies in medical education [Medical school hotline ]. 54(9):716 EDUCATION, MEDICAL, CONTINUING. The role of genetics in (continuing) medical education in Hawaii {Medical school hotline], 54(3):429 EMERGENCY MEDICAL SERVICES. Honoring the right to die in medical emergencies, 54( 4):476 -new Hawaii Comfort Care Only-Do Not Resuscitate law, 54(4):506 EMPATHY. Empathy and medical education, 54(4):495 -Caring for patients with fatal illnesses with compassion ... [abstract], 54(9):719 ENTERAL NliTRITION. The decision to withdraw tube feeding, 54(4):485 EPINEPHRINE. Guest editorial: epinephrine for anaphylaxis, 54(3 ):426 ERYTHROMYCIN ESTOLA TE. Cholestatic hepatitis caused by esters of erythromycin and oleandomycin. 1962 [classical article], 54(6):603 ESOPHAGEAL AND GASTRIC VARICES. Trans jugular intrahepatic portosystemic shunt (TIPS): treatment of esophageal variceal bleeding, 54(I):382 ETHICS COMMITTEES. Medical decisions at the end-of-life: lessons from America, 54( 4):5I4 ETHICS, MEDICAL. Historical notes, 54( 4):451 --role of ethics and law in medical education [Medical school hotline], 54(4):45I -Ethics, standards, and TQM, 54(4):469 -Some ethical principles for adult critical care, 54( 4):482 -decision to withdraw tube feeding, 54( 4):485 - Nonclinical use of medical skills: beneficence lost?, 54(4):497 -Consent for children as organ donors, 54( 4):498 -Ethical issues-physicians and managed care, 54( 4):523 ETHNIC GROUPS. Student profile of the Class of I988 [Medical school hotline], 54(I):378 - Student profile (Class of I999) at the John A. Bums School of Medicine [Medical school hotline], 54(10):739 EUTHANASIA. Medical decisions at the end-of-life: lessons from America, 54(4):5I4 -Caring for patients with fatal illnesses with compassion ... [abstract], 54(9):719 EXERCISE TEST. The physician as patient: the thallium treadmill stress test, 54(5):547 FILIPINOS. Bone mineraJ content in Hawaiian, Asian, and Filipino children, 54(I):388 ANANCIAL MANAGEMENT. Controversies in medical education [Medical school hotline], 54(9):716 -Private sector to finance a greater share of Hawaii's medical education [Medical school hotline], 54(I2):810 FOLLOW-UP STUDIES. Trans jugular intrahepatic portosystemic shunt (TIPS): treatment of esophageal variceal bleeding, 54(I):382

FORENSIC MEDICINE. Nonclinical use of medical skills: beneficence lost?, 54(4):497 FORT SHAFTER POST HOSPITAL. From a renovated dance pavil­ion-the progress of Anny medical facilities in the Pacific [Historical notes], 54(7):660 FREEDOM. Toward an exit visa-regulating health care decision­making, 54(4):501 -Age-based rationing of health care, 54( 4):507 FUND RAISING. Private sector to finance a greater share of Hawaii's medical education [Medical school hotline], 54(12):810 GASTROESOPHAGEAL REFLUX. Conservative therapy for gastroe­sophageal reflux in infants with obstructive pulmonary disease, 54(7):675 GASTROINTESTINAL HEMORRHAGE. Transjugular intrahepatic portosystemic shunt (TIPS): treatment of esophageal variceal bleeding, 54(1):382 GENE THERAPY. Entering the age of the new genetics with eyes wide open, 54(4):464 GENETIC COUNSELING. Entering the age of the new genetics with eyes wide open, 54(4):464 GENETIC SCREENING. Entering the age of the new genetics with eyes wide open, 54( 4): 464 GENETICS. The role of genetics in (continuing) medical education in Hawaii [Medical school hotline], 54(3):429 GENETICS, MEDICAL. Bioethics and the new medicine: an overview, 54(4):458 GERIATRICS. The role of geriatrics in medical education [Medical school hotline], 54(5):536 Gll.BERT, FRED 1., JR .. Memorial festschrift-May 1995, Fred Gilbert Jr, MD [Editorial], 54(3):426 -Festschrift: in memory of Dr Fred I. Gilbert, Jr, MD, 54(6):567 -Memorial service [re: Fred I. Gilbert, Jr, MD], 54(6):569 -My guardian angel, 54(6):575 -Letters from the family [re: Fred I. Gilbert, Jr, MD], 54(6):577 -Letters from longtime friends [re: Fred I. Gilbert, Jr, MD], 54(6):582 -Colleagues [re: Fred I. Gilbert, Jr, MD], 54(6):588 -Introduction to scientific section [re: Fred I. Gilbert, Jr, MD], 54(6):602 -Curriculum vitae [re. Fred I. Gilbert, Jr., MD], 54(6):641 GOODELL, LELA M .. About the authors, 54(11):762 GRAVES' DISEASE. Graves' disease influence of age on clinical findings. 1988 [classical article; abstract], 54(6):613 - Optimal iodine-131 dose for eliminating hyperthyroidism in Graves' disease. 1991 [classical article; abstract], 54(6):614 GREAT BRITAIN. An efficient way to do the wrong thing, 54( 4):478 HAm. Military medical operations in Haiti [Military medicine], 54(8 ):694 HAW All. Bone mineral content in Hawaiian, Asian, and Filipino chil­dren, 54(1):388 - Prevalence of systemic lupus erythematosus in Hawaii: is there a difference between ethnic groups?, 54(2):406 -Adequacy of a pre-participation examination form: a study of Hawaii physicians, 54(2):410 -Pre-participation examination: a new form for Hawaii, 54(3):434 -Hybridizing the health care plans of Hawaii, Oregon, and Singapore, 54(4):464 -Honoring the right to die in medical emergencies, 54(4):476 -Toward an exit visa-regulating health care decision-making, 54( 4):50 I -new Hawaii Comfort Care Only-Do Not Resuscitate Jaw, 54(4):506 -Painful subacute thyroiditis in Hawaii. 1991 [classical article; ab-stract], 54(6):613 -Health maintenance organizations in Hawaii. 1972 [classical article], 54(6):634- Military medicine, 54(7):656 -antiquarians, 54(11):765 -Medical progress in a remote archipelago, 54( II ):770 -Medical society in the early 1900s, 54(11 ):776 -epidemic that never was: yellow fever in Hawaii, 54(11):781 -Plantation medicine in Hawaii 1840 to 1964: a patient's perspective, 54(11):786 -Plantation doctor, 54(11):791 -How open heart surgery came to Hawaii, 54(11):794 -Hepatic cryosurgery: early experience in Hawaii, 54(12):811 -Kidney Stone Center of the Pacific: summary of operations 1986 to 1993, 54(12):814 . HAWAII MEDICAL ASSOCIATION. HMA council highlights, No­vember 4, 1994, 54(1):380 - HMA president's message, 54(2):403 - HMA council highlights, January 6, 1995, 54(2):404 - HMA president's message, 54(3):431 - HMA council highlights, February 3, 1995, 54(3):432 - HMA president's message, 54(4):454 - HMA council highlights, March 3, 1995, 54(4):456 - HMA president's message, 54(5):538 - HMA council highlights, April7, 1995, 54(5):539 - HMA president's message, 54(6):567 - HMA council highlights, May 5, 1995, 54(6):645 - HMA president's message, 54(7):656 - HMA council highlights, June 2, 1995, 54(7):680 - HMA president's message, 54(8):690 -Council highlights, July 7, 1995, 54(8):696 - HMA president's message, 54(9):714 -Controversies in medicine: abstracts of the I 39th annual meeting and scientific session, 54(9):718 - HMA president's message, 54( I 0):738 -Council highlights, September 15, 1995, 54(10):749 -President'sacceptance speech [HMA president's message ],54(11 ):759 - HMA president's message, 54(12):807 -Council highlights, October 29, 1995, 54(12):828 HAWAII MEDICAL ASSOCIATION ALLIANCE. HMA alliance, 54(3):431 - HMA alliance, 54( 4):453 -Alliance, 54(12):808 HAW All MEDICAL JOURNAL. Index to the Hawaii Medical Journal, volume 53, 1994, 54(12):821 -Index to the Hawaii Medical Journal, volume 54, 1995, 54(12):824 HAWAII MEDICAL LIBRARY. Historical notes, 54(11):779 HAWAII MEDICAL SERVICE ASSOCIATION. Health maintenance organizations in Hawaii. 1972 [classical article], 54(6):634 - HMSA 's HealthPass--a strategy for delivery of preventive services, 54(8):697 -Fred Reppun 's September 1993 editorial--HMSA, 54(8):703 HA WAil SOCIETY FOR THE HISTORY OF MEDICINE AND PUB­LIC HEALTH. The antiquarians, 54(11):765 HAW Ali TERRITORIAL MEDICAL SOCIETY. Medical society in the early 1900s, 54(11):776 HEALTH AND READY TO LEARN CENTER (HRTL). The role of the medical home and interprofessional collaboration, 54(5):549 HEALTH CARE COSTS. Hybridizing the health care plans of Hawaii,

Oregon, and Singapore, 54(4):464 -efficient way to do the wrong thing, 54( 4):478 -Ethical issues--physicians and managed care, 54( 4):523 -laparoscopic dilemma: which is the best operation? [abstract], 54(9):718 - After five decades, can health care costs be controlled without sacrificing quality?, 54(10):746 -Age-based rationing of health care, 54(4):507 HEALTH CARE RATIONING. Age-based rationing of health care, 54(4):507 -Medical decisionsat the end-of-life: lessons from America, 54( 4):514 HEALTH CARE REFORM. Bioethics and the new medicine: an over­view, 54(4):458 -Reorganization of medical practice: its influence on patient~physician relationships. 1969 [classical article], 54(6):636 -Suggestions for 1992 service and cost improvements. 1991 [classical article], 54(6):638 -Survey ofHawaii physicians' attitudes on health care reform, 54( I 0):740 HEALTH EDUCATION. Organizational response to adolescent HIV risk, 51(1):386 HEALTH EXPENDITURES. Legal liability under managed care, 54(4):490 HEALTH MAINTENANCE ORGANIZATIONS. Health maintenance organizations in Hawaii. 1972 [classical article], 54(6):634 -Insurers demand silence on myths of managed care [reprint], 54(8 ):691 HEALTH PERSONNEL. Suggestions for 1992 service and cost im­provements. 1991 [classical article], 54( 6):638 HEALTH POLICY. Hybridizing the health care plans of Hawaii, Or­egon, and Singapore, 54(4):464 -efficient way to do the wrong thing, 54(4):478 -Age-based rationing of health care, 54(4):507 -Legal liability under managed care, 54( 4):490 -Toward an exit visa-regulating health care decision-making, 54( 4):501 HEALTH PROMOTION. HMSA's HealthPass -a strategy for delivery of preventive services, 54(8):697 HEALTH SERVICES ACCESSIBILITY. Hybridizing the health care plans of Hawaii, Oregon, and Singapore, 54(4):464 -High mortality rates in Native Hawaiians, 54(9):723 HEALTH SERVICES FOR THE AGED. The appropriate use of technol­ogy (particularly in medical problems of the elderly). 1990 [classical article], 54(6):631 HEALTH SERVICES NEEDS AND DEMAND. Health care in the United States: the need for a new paradigm. 1993 [classical article; abstract], 54(6):637 HEALTHPASS. HMSA's HealthPass-a strategy for delivery of pre­ventive services, 54(8):697 -Fred Reppun's September 1993 editoriai-HMSA, 54(8):703 HEART. The physician as patient: the thaUium treadmill stress test, 54(5):547 HEART SURGERY. Invasive versus noninvasive treatment of coronary artery [abstract], 54(9):718 -How open heart surgery came to Hawaii, 54(11):794 HEPATITIS, TOXIC. Cholestatic hepatitis caused by esters of erythro­mycin and oleandomycin. 1962 [classical article], 54(6):603 HEREDITARY DISEASES. Entering the age of the new genetics with eyes wide open, 54( 4):464 Hll.LEBRAND SOCIETY. The antiquarians, 54(11):765 Hll.LEBRAND, Wll.LIAM. The antiquarians, 54(11):765 HISTORY. Palama Settlement: 100 years of serving a neighborhood's needs, 54(11):774 HISTORY OF MEDICINE. Historical notes, 54(2):402 -Historical notes, 54(3):428 -Historical notes, 54( 4):451 -Health care in the United States: the need for a new paradigm. 1993 [classical article; abstract], 54(6):637 - Suggestions for 1992 service and cost improvements. 1991 [classical article], 54(6):638 -antiquarians, 54(11 ):765 -Thoughts of the relevance of medical history, 54( II ):768 -Medical progress in a remote archipelago, 54( 11 ):770 -Medical society in the early 1900s, 54(11):776 -Plantation medicine in Hawaii 1840 to 1964: a patient's perspective, 54(11):786 -Plantation doctor, 54(11):791 HISTORY OF MEDICINE, 20TH CENT .. From Prontolyn to Biaxin: the half-century of antibiotics, 54(5):542 -Festschrift: in memory of Dr Fred I. Gilbert, Jr, MD, 54(6):567 - Cholestatic hepatitis caused by esters of erythromycin and oleandomycin. 1962 [classical article], 54(6):603

Computers in medicine: emergence of a new technology. 1978 [classical article], 54(6):609 -ups and downs of computers. 1980 [classical article], 54(6):609 -Using the computer in the doctor's office to enhance the quality of patient care. 1990 [classical article; abstract], 54(6):611 -Graves' disease influence of age on clinical findings. 1988 [classical article; abstract], 54(6):613 - Painful subacute thyroiditis in Hawaii. 1991 [classical article; ab­stract], 54(6):613 -superiority of antimicrosomal over antithyroglobulin antibodies for detecting Hashimoto's thyroiditis. 1993 [classical article; abstract], 54(6):613 -Optimal iodine-131 dose for eliminating hyperthyroidism in Graves' disease. 1991 [classical article; abstract], 54(6):614 -What have we learned from the breast cancer detection demonstration project? 1986 [classical article], 54(6):615 -Screening of chest roentgenograms by a radiological assistant. 1971 [classical article], 54(6):618 - Allied health personnel in cancer detection. Utilization of proctosigmoidoscopic technicians in detecting abnormalities .... 1974 [classical article], 54(6):620 -Health exam plans. 1967 [classical article], 54(6):622

Multiphasic screening cut down to size. 1968 [classical article], 54(6):623

Hawaii carrel-a modular approach to multiphasic screening. 1970 [classical article], 54(6):624 - Comparison of health appraisals by nurses and physicians. 1970 [classical article; abstract), 54(6):626 -Share-care clinics. 1976 [classical article], 54(6):626 -appropriate use of technology (particularly in medical problems of the elderly). 1990 [classical article], 54(6):631 -Health maintenance organizations in Hawaii. 1972 [classical article]. 54(6):634 -Reorganization of medical practice: its influence on patient~physician relationships. 1969 [classical article], 54(6):636 -pursuit of excellence. 1962 [classical article], 54(6):640 - From a renovated dance pavilion-the progress of Army medical -HAWAII MEDICAL JOURNAL, VOL 54, DECEMBER1995

825

facilities in the Pacific [Historical notes], 54(7):660 -epidemic that never was: yellow fever in Hawaii, 54(11):781 -How open heart surgery came to Hawaii, 54(11):794 HISTORY OF NURSING. Comparison of health appraisals by nurses and physicians. 1970 [classical article; abstract], 54(6):626 HIV INFECTIONS. Organizational response to adolescent HIV risk, 51(1):386 - HIV positive patient-does treatment with antiviral agents alter the course? [abstract], 54(9):719 HONOLUI.U COUNTY MEDICAL SOCIETY. Health maintenance organizations in Hawaii. 1972 [classical article], 54(6):634 HYPERTHYROIDISM. Optimal iodine-131 dose for eliminating hyperthyroidism in Graves' disease. 1991 [classical article; abstract], 54(6):614 IN MEMORIAM. Memorial festschrift-May 1995, Fred Gilbert Jr, MD [Editorial], 54(3):426 -In memoriam-J.I. Frederick Reppun MD, 54( 4):450 -Fred Reppun MD is gone, 54(4):450 INDEX. Index to the Hawaii MedicaiJournal, volume 53, 1994,54(12):821 -Index to the Hawaii Medical Journal, volume 54, 1995, 54( 12):824 INFANT. Conservative therapy for gastroesophageal reflux in infants with obstructive pulmonary disease, 54(7):675 INFORMED CONSENT. Informed consent: its legal history and impact on medicine, 54(4):472 -Some ethical principles for adult critical care, 54(4):482 -Consent for children as organ donors, 54( 4):498 -Toward an exit visa-regulating health care decision-making, 54( 4):501 -Psychiatric assessment of the suicidal terminally ill, 54( 4):51 0 INOUYE, DANIEL K .. Dedication, 54(7):655 INSTRUCTIONS TO AUTIIORS. Hawaii Medical Journal instructions to authors, 54(2):421 INSURANCE CARRIERS. Insurers demand silence on myths of man­aged care [reprint], 54(8):691 INSURANCE, HEALTH. Hybridizing the health care plans of Hawaii, Oregon, and Singapore, 54( 4):464

Hawaii HealthQUEST: a managed care demonstration project, 54(9):720 INTELLIGENCE TESTS. Psychiatric assessment of the suicidal termi­nally ill, 54(4):510 INTERNATIONAL EDUCATIONAL EXCHANGE. Military medi­cine, 54(12):808 INTERPROFESSIONAL RELATIONS. The role of the medical home and interprofessional collaboration, 54(5):549 IODINE RADIOISOTOPES. Optimal iodine-131 dose for eliminating hyperthyroidism in Gntves' disease. 1991 [classical article; abstract], 54(6):614 JAPANESE. Prostate-specific antigen concentration: influence of age and ethnicity, 54(6):606 JOHN A BURNS SCHOOL OF MEDICINE. Student profile of the Class of 1988 [Medical school hotline], 54(1):378 -role of genetics in (continuing) medical education in Hawaii [Medical school hotline], 54(3):429 -role of ethics and law in medical education [Medical school hotline], 54(4):451

role of geriatrics in medical education {Medical school hotline], 54(5):536 - Student profile (Class of 1999) at the John A. Bums School of Medicine [Medical school hotline], 54(10):739 -Private sector to finance a greater share of Hawaii's medical education [Medical school hotline], 54(12):810 JUGUI.AR VEINS. Transjugularintrahepaticportosystemic shunt(TIPS): treatment of esophageal variceal bleeding, 54(1):382 JURISPRUDENCE. The role of ethics and law in medical education [Medical school hotline], 54(4):451 KAISER PLAN. Health maintenance organizations in Hawaii. 1972 [classical article], 54(6):634 KALIHI-PALAMA. Organizational response to adolescent HIV risk, 54(1):386 -PaJama Settlement: 100 years of serving a neighborhood's needs. 54(11):774 KIDNEY CALCULI. Kidney Stone Center of the Pacific: summary of operations 1986to 1993, 54(12):814 KIDNEY STONE CENTER OF THE PACIFIC. Kidney Stone Center of the Pacific: summary of operations 1986to 1993, 54(12):814 LEAD POISONING. Survey of lead levels in patients presenting to Child and Adolescent Psychiatry, 54(7):671 LEGAL GUARDIANS. Toward an exit visa-regulating health care decision-making, 54(4):501 LEGISLATION, MEDICAL. Informed consent: its legal history and impact on medicine, 54(4):472 -Toward an exit visa-regulating health care decision-making. 54( 4):501 LETTERS TO THE EDITOR. Wonder what Hippocrates would say?, 54(3):428 - [re: Hawaiian medicine and health, HMJ, 12/94), 54(5):534 - [re: Festschrift: in memory of Fred I. Gilbert, Jr., MD], 54(8):692 - [re: Festschrift: in memory of Fred I. Gilbert, Jr., MD], 54(8):693 LIABll.ITY, LEGAL. Legal liability under managed care, 54(4):490 -Key facts about liability, 54(5):541 LIFE SUPPORT CARE. The decision to withdraw tube feeding, 54( 4):485 LITHOTRIPSY. Kidney Stone Center of the Pacific: summary of opera­tions 1986to 1993, 54(12):814 LIVER. Transjugular intrahepatic portosystemic shunt (TIPS): treatment of esophageal variceal bleeding, 54( I ):382 LIVER NEOPLASMS. Hepatic cryosurgery: early experience in Hawaii, 54(12):811 LIVING WlLLS. Toward an exit visa-regulating health care decision­making, 54(4):501 -Psychiatric assessment of the suicidal terminally ill, 54( 4):510 -Medical decisions at the end-of~life: lessons from America, 54( 4):514 -Have physicians abdicated their role?, 54(4):523 LONG-TERM CARE. Characteristics of long-term mentally ill patients: policy implications, 54(2):412 LUNG DISEASES, OBSTRUCTIVE. Conservative therapy for gastroe­sophageal reflux in infants with obstructive pulmonary disease, 54(7):675 LUPUS ERYTHEMATOSUS, SYSTEMIC. Prevalence of systemic lupus erythematosus in Hawaii: is there a difference between ethnic groups?, 54(2):406 MAMMOGRAPHY. What have we learned from the breast cancer detection demonstration project? 1986 [classical article], 54(6):615 MANAGED CARE PLANS. Insurers demand silence on myths of managed care [reprint], 54(8):691 MANAGED CARE PROGRAMS. Legal liability under managed care, 54(4):490 -Ethical issues-physicians and managed care, 54(4):523 MASS SCREENING. What have we learned from the breast cancer

detection demonstration project? 1986 [classical article], 54(6):615 MAUl MEDICAL GROUP. Health maintenance organizations in Ha­waii. 1972 [classical article], 54(6):634 MEDICAID. Medicaid recipients and psychiatric treatment, 54( 1 ):390 -Hybridizing the health care plans of Hawaii, Oregon, and Singapore, 54(4):464 MEDICAL ASSISTANCE. After five decades, can health care costs be controlled without sacrificing quality?, 54(10):746 MEDICAL FUTILITY. Age-based rationing of health care, 54( 4):507 -Medical decisions at the end-of-life: lessons from America, 54( 4):514 MEDICAL HISTORY TAKING. Pre-participation examination: a new form for Hawaii, 54(3):434 MEDICAL RECORDS SYSTEMS, COMPUTERIZED. The ups and downs of computers. 1980 [classical article], 54(6):609 - Using the computer in the doctor's office to enhance the quality of patient care. 1990 [classical article: abstract], 54(6):611 MELANOMA. Cutaneous melanoma in an active duty soldier, 54(7):673 MENTAL DISORDERS. Medicaid recipients and psychiatric treatment, 54(1):390 -Characteristics of long-term mentally iH patients: policy implications, 54(2):412 MICROSOMES.Thesuperiorityofantimicrosomaloverantithyroglobulin antibodies for detecting Hashimoto's thyroiditis. 1993 [classical article; abstract], 54(6):613 MILITARY MEDICINE. Tripier's travels: reports from the field [Mili· tary medicine], 54(3):430 -Military medicine, 54(7):656 -Medical school hotline, 54(7):657

From a renovated dance pavilion-the progress of Army medical facilities in the Pacific [Historical notes], 54(7):660 -Military medical operations in Haiti [Military medicine], 54(8):694 MILITARY PERSONNEL Cutaneous melanoma in an active duty soldier, 54(7):673 -Military medical operations in Haiti [Military medicine], 54(8):694 MILLER, RODMAN. About the authors, 54(11):762 MODELS, THEORETICAL. Hybridizing the health care plans of Ha­waii, Oregon, and Singapore, 54( 4):464 MONGOLIA. Military medicine, 54(12):808 MORALS. Must theology remain silent in bioethics?, 54(4):468 MORENS, DAVID M .. About the authors, 54(11):762 MORRIS, ALFRED D .. About the authors, 54( 11 ):762 MORTALITY. High mortality rates in Native Hawaiians, 54(9):723 MULTIPHASIC SCREENING. Multiphasic screening cut down to size. 1%8 [classical article], 54(6):623 -Hawaii carrel-a modular approach to multiphasic screening. 1970 [classical article], 54(6):624 NATIVE HAWAIIANS. Bone mineral content in Hawaiian, Asian, and Filipino children, 54(1 ):388 -High mortality rates in Native Hawaiians, 54(9):723 - Prevalence of systemic lupus erythematosus in Hawaii : is there a difference between ethnic groups?, 54(2):406 NORWAY. An efficient way to do the wrong thing, 54(4):478 NURSING. Legal, ethical, and political issues in nursing [Book review], 54(4):453 OAHU. Medicaid recipients and psychiatric treatment, 54(1):390 OBSTETRICS. Historical notes, 54(2):402 -From Prontolyn to Biaxin: the half~century of antibiotics, 54(5):542 OREGON. Hybridizing the health care plans of Hawaii, Oregon, and Singapore, 54( 4):464 OVARY. Squamous cell carcinoma of the ovary, 54(8):704 OXYGEN. Pediatric asthma-a correlation of clinical treatment and oxygen saturation, 54(7):665 PACIFIC BASIN MEDICAL ASSOCIATION. HMA president's mes· sage, 54(7):656 PALAMA SETILEMENT. Palama Settlement: 100 years of serving a neighborhood's needs, 54(11):774 PARENTS. Consent for children as organ donors, 54(4):498 PATIENT ADVOCACY. Toward an exit visa-regulating health care decision·making, 54(4):501 -Psychiatric assessment of the suicidal terminally ill, 54( 4):5 10 -Ethical issues-physicians and managed care, 54( 4):523 PATIENT CARE TEAM. Organizational response to adolescent HIV risk, 51(1):386 -Share-care clinics. 1976 [classical article], 54(6):626 PEERREVIEW,HEALTHCARE.Ethics,standards,andTQM,54(4):469 PHILOSOPHY, MEDICAL. The pursuit of excellence. 1%2 [classical article], 54(6):640 PHYSICAL EXAMINATION. Adequacy of a pre-participation exami· nation form: a study of Hawaii physicians, 54(2):410 -Pre-participation examination: a new form for Hawaii, 54(3):434 -Health exam plans. 1%7 [classical article], 54(6):622 - Comparison of health appraisals by nurses and physicians. 1970 [classical article; abstract], 54(6):626 -Cutaneous melanoma in an active duty soldier, 54(7):673 PHYSICIAN -PA TIENTRELA TIONS. Reorganization of medical prac· tice: its influence on patient-physician relationships. 1969 [classical article], 54(6):636 PHYSICIAN'S PRACTICE PATTERNS. Thoughts of the relevance of medical history, 54( 11 ):768 PHYSICIAN'S ROLE. Have physicians abdicated their role?, 54(4):523 PHYSICIAN-PATIENT RELATIONS. Empathy and medical educa­tion, 54( 4):495 -My guardian angel, 54(6):575 -Ethical issues-physicians and managed care, 54( 4):523 PHYSICIANS. Comparison of health appraisals by nurses and physi· cians. 1970 [classical article; abstract], 54(6):626 -Survey ofHawaii physicians' attitudes on health care reform,54(1 0):7 40 -Plantation doctor, 54(11):791 - Hawaii HealthQUEST: a managed care demonstration project, 54(9):720 PLANTATION MEDICINE. Plantation medicine in Hawaii 1840 to 1964: a patient's perspective, 54(11):786 -Plantation doctor, 54(11):791 PORTAL VEIN. Trans jugular intrahepatic portosystemic shunt (TIPS): treatment of esophageal variceal bleeding, 54( 1 ):382 PORTASYSTEMIC SHUNT, SURGICAL. Transjugular intrahepatic portosystemic shunt (TIPS): treatment of esophageal variceal bleeding, 54(1):382 PRACTICE MANAGEMENT, MEDICAL. Using the computer in the doctor's office to enhance the quality of patient care. 1990 [classical article: abstract], 54(6):611 PREVENTIVEHEALTHSERVICES.HMSA'sHealthPass-astrategy for delivery of preventive services, 54(8):697 PREVENTIVE MEDICINE. Health exam plans. 1%7 [classical article], 54(6):622

PRIMARY HEALTH CARE. Health care in the United States: the need for a new paradigm. 1993 [classical article; abstract], 54(6):637 PRISONS. Nonclinical use of medical skills: beneficence lost?, 54( 4):497 PRIVATE SECTOR. Private sector to finance agreatershareofHawaii's medical education [Medical school hotline], 54(12):810 PROFESSIONAL PRACTICE. Reorganization of medical practice: its influence on patient-physician relationships. 1969 [classical article], 54(6):636 PROGRAM EVALUATION. Organizational response to adolescent HIV risk, 54(1):386 PROSPECTIVE STUDIES. Graves' disease influence of age on clinical findings. 1988 [classical article; abstract], 54(6):613 -Painful subacute thyroiditis in Hawaii. 1991 [classical article; ab­stract], 54(6):613 PROSTATE-SPECIFIC ANTIGEN. Prostate-speeific antigen concen­tration: influence of age and ethnicity, 54(6):606 PSYCHIATRIC DEPARTMENT. Medicaid recipients and psychiatric treatment, 54( 1 ):390 PSYCHOSES, SUBSTANCE INDUCED. Acute anticholinergic syn­drome following ingestion of Angel's Trumpet tea, 54(7):669 QUALITY ASSURANCE, HEALTH CARE. Outcome-oriented quality assurance in an ambulatory setting, 54(5):552 QUALITY OF HEALTH CARE. Using the computer in the doctor's office to enhance the quality of patient care. 1990 [classical article; abstract], 54(6):611 - After five decades, can health care costs be controlled without sacrificing quality?, 54(10):746 -Ethical issues-physicians and managed care, 54( 4):523 QUEEN'S MEDICAL CENTER. Medicaid recipients and psychiatric treatment, 54( 1 ):390 QUEST PROGRAM (HAW All). Hybridizing the health care plans of Hawaii, Oregon, and Singapore, 54(4):464 - Hawaii HealthQUEST: a managed care demonstration project. 54(9):720 RADIOTHERAPY DOSAGE. Optimal iodine-131 dose for eliminating hyperthyroidism in Graves' disease. 1991 [classical article; abstract], 54(6):614 RATH, PAULA. About the authors, 54(11):762 REFERENCEST ANDARDS. Bone mineral content in Hawaiian, Asian, and Filipino children, 54(1):388 RELIGION AND MEDICINE. Must theology remain silent in bioeth­ics?, 54(4):468 REPPUN,J.I. FREDERICK. In memoriam-J.I. Frederick Reppun MD, 54(4):450 -Fred Reppun MD is gone, 54( 4):450 -Historical notes, 54(5):538 -From Prontolyn to Biaxin: the half-century of antibiotics, 54(5):542 -physician as patient: the thallium treadmill stress test, 54(5):547 RESUSCITATION ORDERS. Honoring the right to die in medical emergencies, 54( 4):476 -Some ethical principles for adult critical care, 54(4):482 -decision to withdraw tube feeding, 54( 4):485 -new Hawaii Comfort Care Only-Do Not Resuscitate law, 54( 4):506 -Have physicians abdicated their role?, 54(4):523 RE1ROSPECfiVE STUDIES. Prostate~specific antigen concentration: influence of age and ethnicity, 54(6):606 RIGHT TO DIE. Bioethicsand the new medicine: an overview, 54( 4):458 -Honoring the right to die in medical emergencies, 54( 4):476 -decision to withdraw tube feeding, 54( 4):485 -new Hawaii Comfort Care Only-Do Not Resuscitate law, 54( 4):506 -Psychiatric assessment of the suicidal terminally ill, 54( 4):51 0 -Medical decisions at the end-of-life: lessons from America, 54(4):514 RISK FACTORS. Organizational response to adolescent HIV risk, 54(1):386 - Prevalence of systemic lupus erythematosus in Hawaii: is there a difference between ethnic groups?. 54(2):406 -Pre-participation examination: a new form for Hawaii, 54(3):434 RISK MANAGEMENT. Trends in workers compensation costs in a hoteJ.operating company over a six·year period, 54(3):439 RURAL HEALTH. Health maintenance organizations in Hawaii. 1972 [classical article], 54(6):634 -Plantation medicine in Hawaii J 840 to 1964: a patient's perspective, 54(11):786 -Plantation doctor, 54(11):791 SARCOIDOSIS. Recurrent chylothorax associated with sarcoidosis, 54(12):817 SCHMITT, ROBERT C .. About the authors, 54(11):762 SCHOOLS, MEDICAL. Controversies in medical education [Medical school hotline], 54(9):716 SCOPOLAMINE. Acute anticholinergic syndrome following ingestion of Angel's Trumpet tea, 54(7):669 SIGMOIDOSCOPY. Allied health personnel in cancer detection. Utili~ zation of proctosigmoidoscopic technicians in detecting abnormalities .... 1974 [classical article], 54(6):620 SINGAPORE. Hybridizing the health care plans of Hawaii, Oregon, and Singapore, 54( 4):464 SKIN NEOPLASMS. Cutaneous melanoma in an active duty soldier, 54(7):673 SOCIETIES, MEDICAL. The antiquarians, 54(11):765 SPORTS. Adequacy of a pre· participation examination form: a study of Hawaii physicians, 54(2):410 -Pre-participation examination: a new form for Hawaii, 54(3):434 SPORTS MEDICINE. The role of sports medicine in academic medical education [Medical school hotline], 54(8):694 STATE HEALTH PLANS. Hawaii HealthQUEST: a managed care demonstration project, 54(9):720 STATE MEDICINE. An efficient way to do the wrong thing, 54( 4):478 - After five decades, can health care costs be controlled without sacrificing quality?, 54(10):746 STENTS. Transjugular intrahepatic portosystemic shunt (TIPS): treat· ment of esophageal variceal bleeding, 54(1):382 STRAUB CLINIC. Screening of chest roentgenograms by a radiological assistant. 1971 [classical article], 54(6):618 - Allied health personnel in cancer detection. Utilization of proctosigmoidoscopic technicians in detecting abnormalities .... 1974 [classical article], 54(6):620 -Health exam plans. 1%7 [classical article], 54(6):622

Multiphasic screening cut down to size. l%8 [classical article], 54(6):623 - Hawaii carrel-a modular approach to multiphasic screening. 1970 [classical article], 54(6):624 - Comparison of health appraisals by nurses and physicians. 1970 [classical article; abstract], 54(6):626 -Share-care clinics. 1976 [classical article], 54(6):626 STRAUB CLINIC & HOSPITAL. Suggestions for 1992 service and cost -HAWAII MEDICAL JOURNAL, VOL 54, DECEMBER 1995

826

improvements. 1991 [classical article], 54(6):638 SUBSTANCE ABUSE. Medicaid recipients and psychiatric treatment, 54(1):390 SUICIDE. Psychiatric assessment of the suicidal terminally ill, 54( 4):51 0 SUICIDE, ASSISTED. Caring for patients with fatal illnesses with compassion ... [abstract], 54(9):719 SURGERY, LAPAROSCOPIC. The laparoscopic dilemma: which is the best operation? [abstract], 54(9):718 TECHNOLOGY, HIGH COST. The appropriate use of technology (particularly in medical problems of the elderly). 1990 [classical article], 54(6):631 TECHNOLOGY, MEDICAL. The laparoscopic dilemma: which is the best operation? [abstract], 54(9):718 TERATOMA. Squamous cell carcinoma of the ovary, 54(8):704 TERMINAL CARE. Caring for patients with fatal illnesses with compas­sion ... [abstract], 54(9):719 TESTICULAR DISEASES. Testicular cysts: a case report and review of a recent Tripier experience, 54(7):678 THALLIUM RADIOISOTOPES. The physician as patient: the thallium treadmill stress test, 54(5):547 THORACIC RADIOGRAPHY. Screening of chest roentgenograms by a radiological assistant. 1971 [classical article], 54( 6):618 THYROGLOBULIN. The superiority of antimicrosomal over anti thyroglobulin antibodies for detecting Hashimoto's thyroiditis. 1993 [classical article; abstract], 54(6):613 THYROIDITIS, AUTOIMMUNE. The superiority of antimicrosomal over anti thyroglobulin antitxxiies for detecting Hashimoto's thyroiditis. 1993 [classical article; abstract], 54(6):613 THYROIDmS, SUBACUTE. Painful subacute thyroiditis in Hawaii. 1991 [classical article; abstract], 54(6):613 TISSUE DONORS. Consent for children as organ donors, 54( 4):498 TOTAL QUALITY MANAGEMENT. Ethics, standards, and TQM, 54(4):469 TOURIST TRADE. Trends in workers compensation costs in a hotel~ operating company over a six-year period, 54(3):439 TREATMENT OUTCOME. Outcome~oriented quality assurance in an ambulatory setting, 54(5):552 TRIPLER ARMY MEDICAL CENTER. Hawaii's Cystic Fibrosis Cen­ter [Military medicine], 54(2):403 -Tripier's travels: reports from the field [Military medicine], 54(3):430 -Military medicine, 54(4):454 -Medical school hotline, 54(7):657

From a renovated dance pavilion--the progress of Army medical facilities in the Pacific [Historical notes]. 54(7):660 TRIPLER GENERAL HOSPITAL. From a renovated dance pavilion­the progress of Army medical facilities in the Pacific [Historical notes], 54(7):660 TROLEANDOMYCIN. Cholestatic hepatitis caused by esters of eryth­romycin and oleandomycin. 1962 [classical article], 54(6):603 U.S. AGENCY FOR HEALTH CARE POLICY & RESEARCH. Legal liability under managed care, 54( 4):490 UNITED STATES. An efficient way to do the wrong thing, 54( 4):478 -Medical decisions at the end~of-life: lessons from America, 54( 4):514 -Health care in the United States: the need for a new paradigm. 1993 [classical article: abstract], 54(6):637 URBAN POPULATION. Organizational response to adolescent HIV risk, 54(1):386 VACCINATION. Medical progress in a remote archipelago, 54(11 ):770 WAIALUA CLINIC. Plantation doctor, 54(11):791 WAIANAE COAST COMMUNITY HEALTH CENTER. Outcome· oriented quality assurance in an ambulatory setting, 54(5):552 WHITES. Prostate-specific antigen concentration: influence of age and ethnicity, 54(6):606

Prevalence of systemic lupus erythematosus in Hawaii : is there a difference between ethnic groups?, 54(2):406 WORKERS' COMPENSATION. Trends in workers compensation costs in a hotel~operating company over a six-year period, 54(3):439 WOUNDS AND INJURIES. Trends in workers compensation costs in a hotel~operating company over a six-year period, 54(3):439 WRITING. 16 tips for better research protocol writing, 54(7):674 X-RAYS. Medical progress in a remote archipelago, 54(11):770 YELLOW FEVER. The epidemic that never was: yellow fever in Hawaii, 54(11):781

Author Index

AMERICAN MEDICAL ASSOCIATION. Key facts about liability, 54(5):541 ANDERS RL. Characteristics of long-term mentally ill patients: policy implications, 54(2):412 ANEMA RJ. Allied health personnel in cancer detection. Utilization of proctosigmoidoscopic technicians in detecting abnormalities ... 1974 [classical article], 54(6):620 AOKI M. Must theology remain silent in bioethics?, 54(4):468 A Y ABE SS. Entering the age of the new genetics with eyes wide open, 54(4):464 BATZER W. Survey of lead levels in patients presenting to Child and Adolescent Psychiatry, 54(7):671 BEDDOW RM. Colleagues [re: Fred I. Gilbert, Jr, MD], 54(6):588 BERG BW. Hawaii's Cystic Fibrosis Center [Military medicine]. 54(2):403 -Tripier's travels: reports from the field [Military medicine], 54(3):430 -Military medicine, 54( 4):454 -Military medicine, 54(12):808 BIDWELL R. Organizational response to adolescent HIV risk, 51(1):386 BLANCHETTE PL. Age-based rationing of health care, 54(4):507 -role of geriatrics in medical education [Medical school hot line], 54(5):536 -Colleagues [re: Fred I. Gilbert, Jr, MD], 54(6):588 BOTTI CELLI MG. Ethics, standards, and TQM, 54( 4):469 -Colleagues [re: Fred I. Gilbert, Jr, MD], 54(6):588 BRAINARD SC. How open heart surgery came to Hawaii, 54( 11 ):794 BRAUN KL. High mortality rates in Native Hawaiians, 54(9):723 BREINICH JA. Historical notes, 54(2):402 -Historical notes, 54(3):428 -Historical notes, 54( 4):451 -Historical notes, 54(5):538 -Historical notes, 54(11):779 BRIZZOLARA S. Bone mineral content in Hawaiian, Asian, and Filipino children, 54(1 ):388 BUDDE JC. Hawaii HealthQUEST: a managed care demonstration project, 54(9):720 BUDDE MT. Hawaii HealthQUEST: a managed care demonstration

project, 54(9):720 BURNELL GM. Psychiatric assessment of the suicidal tenninally ill. 54(4):510 BUSHNELL OA. antiquarians, 54( 11 ):765 BUSSEY GD. Informed consent: its legal history and impact on medicine, 54(4):472 BUXTON BP. Adequacy of a pre~ participation examination form: a study of Hawaii physicians, 54(2):410 -Pre· participation examination: a new fonn for Hawaii, 54(3):434 CALLAHAN CW. Conservative therapy for gastroesophageal reflux in infants with obstructive pulmonary disease, 54(7):675 CARNES SM. Index to the Hawaii Medical Journal, volume 53, 1994, 54(12):821 -Index to the Hawaii Medical Journal, volume 54, 1995, 54(12):824 CARROTHERS S. HMA alliance, 54(4):453 CAS1LE A. Private sector to finance a greater share of Hawaii's medical education [Medical school hotline], 54(12):810 CA TIS AB. Medical society in the early 1900s, 54( II ):776 CHAN DS. 16 tips for better research protocol writing. 54(7):674 CHANG V. Letters from the family [re: Fred I. Gilbert, Jr. MD]. 54(6):577 CHAPLIN G. Colleagues [re: Fred I. Gilbert, Jr, MD], 54(6):588 CHERRY JW. Allied health personnel in cancer detection. Utilization of proctosigmoidoscopic technicians in detecting abnormalities ... 1974 [classical article], 54(6):620 CHEUNG AHS. Hepatic cryosurgery: early experience in Hawaii, 54(12):811 CHIBANA R. Kidney Stone Center of the Pacific: summary of operations 1986 to 1993, 54(12):814 CHING CSH. Index to the Hawaii Medical Journal. volume 54, 1995, 54(12):817 CHUN WKC. Medicaid recipients and psychiatric treatment, 54(1):390 CHUNG R. Colleagues [re: Fred I. Gilbert, Jr, MD], 54(6):588 COLLEN MF. Colleagues [re: Fred I. Gilbert, Jr, MD], 54(6):588 COOK T. Pediatric asthma-a correlation of clinical treatment and oxygen saturation, 54(7):665 CORNUELLE HC. Memorial service [re: Fred I. Gilbert, Jr, MD], 54(6):569 CRABTREE JP. Honoring the right to die in medical emergencies, 54(4):476 DAMON CF JR. Letters from longtime friends [re: Fred I. Gilbert, Jr, MD], 54(6):582 DANG S. Letters from longtime friends [re: Fred I. Gilbert, Jr, MD], 54(6):582 DE LEON PH. [re: Festschrift: in memory of Fred I. Gilbert, Jr., MD], 54(8):693 DENNIS R. Letters from longtime friends [re: Fred I. Gilbert, Jr, MD]. 54(6):582 DIMLER RG. Letters from longtime friends [re: Fred I. Gilbert, Jr, MD], 54(6):582 DOWNING DE. Allied health personnel in cancer detection. Utilization of proctosigmoidoscopic technicians in detecting abnormalities ... !974 [classical article], 54(6):620 ELG SA. Squamous cell carcinoma of the ovary, 54(8):704 ELLIS JR. Squamous cell carcinoma of the ovary, 54(8):704 EVANS R. Letters from longtime friends [re: Fred I. Gilbert, Jr, MD], 54(6):582 FAN FL. Hepatic cryosurgery: early experience in Hawaii, 54(12):811 FERN M. Kidney Stone Center of the Pacific: summary of operations 1986 to 1993, 54(12):814 FLEURY KA. superiority of antimicrosomal over antithyroglobulin antibodies for detecting Hashimoto's thyroiditis. 1993 [classical article; abstract], 54(6):613 FRAZIER CA. Guest editorial: epinephrine for anaphylaxis, 54(3):426 GANGE SN. Testicular cysts: a case repclrt and review of a recent Tripier experience, 54(7):678 GERHARD A. Some ethical principles for adult critical care, 54( 4):482 GIFFORD GC. new Hawaii Comfort Care Only-Do Not Resuscitate law, 54(4):506 GILBERT Filii. Memorial service [re: Fred I. Gilbert, Jr, MD], 54(6):569 GILBERT FI JR. Cholestatic hepatitis caused by esters of erythromycin and oleandomycin. 1962 [classical article], 54(6):603 - Prostate-specific antigen concentration: influence of age and ethnicity, 54(6):606 -Computers in medicine: emergence of a new technology. 1978 [classical article], 54(6):609 -ups and downs of computers. 1980 [classical article], 54(6):609 -Using the computer in the doctor's office to enhance the quality of patient care. 1990 [classical article; abstract], 54(6):611 -Graves' disease influence of age on clinical findings. 1988 [classical article; abstract], 54(6):613 -Painful subacute thyroiditis in Hawaii. 1991 [classical article; abstract], 54(6):613 -superiority of antimicrosomal over antithyroglobulin antib<xlies for detecting Hashimoto's thyroiditis. 1993 [classical article; abstract], 54(6):613 - Optimal iodine-131 dose for eliminating hyperthyroidism in Graves' disease. 1991 [classical article; abstract], 54(6):614 - What have we learned from the breast cancer detection demonstration project? 1986 [classical article], 54(6):615 - Screening of chest roentgenograms by a radiological assistant. 1971 [classical article], 54(6):618 - Allied health personnel in cancer detection. Utilization of proctosigmoidoscopic technicians in detecting abnonnalities ... 1974 [classical article], 54(6):620 -Multiphasic screening cut down to size. 1968 [classical article], 54(6):623 -Hawaii carrel-a modular approach to multiphasic screening. 1970 [classical article], 54(6):624 - Comparison of health appraisals by nurses and physicians. 1970 [classical article; abstract], 54(6):626 -Share-care clinics. 1976 [classical article], 54(6):626 -appropriate use of technology (particularly in medical problems of the elderly). 1990 [classical article], 54(6):631 -Health maintenance organizations in Hawaii. 1972 [classical article], 54(6):634 -Reorganization of medical practice: its influence on patient­physician relationships. 1969 [classical article], 54(6):636 - Health care in the United States: the need for a new paradigm. 1993 [classical article; abstract], 54(6):637 -Suggestions for 1992 service and cost improvements. 1991 [classical article], 54(6):638 -pursuit of excellence. 1962 [classical article], 54(6):640 GILBERT G. Letters from the family [re: Fred I. Gilbert, Jr. MD],

54(6):577 - [re: Festschrift: in memory of Fred I. Gilbert, Jr., MD], 54(8):692 GILBERT K. Letters from the family [re: Fred I. Gilbert, Jr. MD], 54(6):577 GOLDSTEIN N. Our first year [Editorial], 54(1):374 -February issue [Editorial], 54(2):402 -Memorial festschrift-May 1995, Fred Gilbert Jr. MD [Editorial], 54(3):426- Our next issue of the journal: medicine, law .. [Editorial], 54(3):426 -Fred Reppun MD is gone, 54(4):450 -Words of wisdom [Editorial], 54(4):451 -Editorial, 54(5):534 -Festschrift for Dr Fred I. Gilbert, Jr [Editorial], 54(6):567 -Editorial, 54(7):655 -Editorial, 54(8):690 -Editorial, 54(9):714 -Editorial, 54( 10):738 -History of medicine in Hawaii [Editorial], 54( II ):759 -Editorial, 54( 12):807 GOODELL LM. Plantation medicine in Hawaii 1840 to 1964: a patient's perspective, 54(11):786 GOODMAN MJ. Colleagues [re: Fred I. Gilbert, Jr. MD], 54(6):588 GRAMLICH EP. Colleagues [re: Fred I. Gilbert, Jr, MD], 54(6):588 GRIFFIN M. Letters from longtime friends [re: Fred I. Gilbert, Jr, MD], 54(6):582 GULBRANDSEN CL. Colleagues [re: Fred I. Gilbert, Jr, MD], 54(6):588 -Controversies in medical education [Medical school hotline], 54(9):716 GUTTELING C. Alliance, 54( 12):808 HARADA ASM. Graves' disease influence of age on clinical findings. 1988 [classical article; abstract], 54(6):613 HASSELL LH. Acute anticholinergic syndrome following ingestion of Angel's Trumpet tea, 54(7):669 HASTINGS JE. Military medicine, 54(7):656 HEIN1Z L. efficient way to do the wrong thing, 54(4):478 HELDMAN LS. Testicular cysts: a case report and review of a recent Tripier experience, 54(7):678 HERRING E. Index to the Hawaii Medical Journal, volume 53, 1994, 54(12):821 HILLER WDB. Adequacy of a pre-participation examination form: a study of Hawaii physicians, 54(2):410 HINOHARA S. Colleagues [re: Fred I. Gilbert, Jr, MD], 54(6):588 HO KW. Adequacy of a pre-participation examination fonn: a study of Hawaii physicians, 54(2):410 -Pre-participation examination: a new form for Hawaii. 54(3):434 HO RCS. Colleagues [re: Fred I. Gilbert, Jr. MD], 54(6):588 HOLSCHUH FC. HMA president's message, 54(2):403 - HMA president's message, 54(3):431 - HMA president's message, 54( 4):454 - HMA president's message, 54(5):538 - HMA president's message, 54(6):567 - HMA president's message, 54(7):656 - HMA president's message, 54(8):690 - HMA president's message, 54(9):714 - HMA president's message, 54(10):738 HOWARD-JONES A. role of the medical home and interprofessional collaboration, 54(5):549 HSIA YE. role of genetics in (continuing) medical education in Hawaii [Medical school hotline], 54(3):429 HUMPHRY JW. Outcome-oriented quality assurance in an ambulatory setting, 54(5):552 INOUYE DK. Colleagues [re: Fred I. Gilbert, Jr. MD]. 54(6):588 ISSELL BF. Colleagues [re: Fred I. Gilbert, Jr, MD], 54(6):588 ITO TY. Kidney Stone Center of the Pacific: summary of operations 1986to !993, 54(12):814 IZl.ITSU S. Student profile of the Class of 1988 [Medical school hotline], 54(1):378 -Colleagues [re: Fred I. Gilbert, Jr. MD], 54(6): 588 -Student profile (Class of 1999) at the John A. Bums School of Medicine [Medical school hotline], 54(10):739 JOHNSON DB. Prostate-specific antigen concentration: influence of age and ethnicity, 54(6):606 KAKU K. Comparison of health appraisals by nurses and physicians. 1970 [classical article; abstract], 54(6):626 KATZ AR. Prevalence of systemic lupus erythematosus in Hawaii: is there a difference between ethnic groups?, 54(2):406 KELLEY CR. Trends in workers compensation costs in a hotel­operating company over a six-year period, 54(3):439 KIMURA RT. HMA council highlights, November 4, 1994, 54( I ):380 - HMA council highlights, January 6, 1995, 54(2):404 - HMA council highlights, February 3, 1995, 54(3):432 - HMA council highlights, March 3, 1995, 54(4):456 - HMA council highlights, April 7, 1995, 54(5):539 - HMA council highlights, May 5, 1995, 54(6):645 - HMA council highlights, June 2, 1995, 54(7):680 -Council highlights, July 7, 1995, 54(8):696 -Council highlights, September 15, 1995, 54(10):749 -Council highlights, October 29, 1995, 54(12):828 KIPNIS K. Some ethical principles for adult critical care, 54( 4):482 KISTNER RL. Colleagues [re: Fred I. Gilbert, Jr, MD], 54(6): 588 KNAEFLER TIC Health exam plans. 1967 [classical article], 54(6):622 KON KN. Trans jugular intrahepatic portosystemic shunt (TIPS): treatment of esophageal variceal bleeding, 54( I ):382 KRUPP MA. Letters from longtime friends [re: Fred I. Gilbert, Jr, MD], 54(6):582 KUMAR K. In memoriam -1.1. Frederick Reppun MD, 54(4):450 LALLY DA. Bone mineral content in Hawaiian, Asian, and Filipino childnen, 54( I ):388 LAU LDC. Trans jugular intrahepatic portosystemic shunt (TIPS): treatment of esophageal variceal bleeding, 54(1):382 LAU V. HMA alliance, 54(4):453 LAVIGNE K. Survey of lead levels in patients presenting to Child and Adolescent Psychiatry, 54(7):671 LEHMAN CW. President's acceptance speech [HMA president's message], 54(11):759 - HMA president's message, 54(12):807 LENGYEL RJ. Recurrent chylothorax associated with sarcoidosis, 54(12):817 LEW C. Painful subacute thyroiditis in Hawaii. 1991 [classical article; abstract], 54(6):613 LIEBOW E. Organizational response to adolescent HIV risk, 54(1):386 LIMM WML. Hepatic cryosurgery: early experience in Hawaii, -HAWAII MEDICAL JOURNAL, VOL 54, DECEMBER1995

827

54(12):811 LO AML. Honoring the right to die in medical emergencies, 54(4):476 LOOK MA. High mortality rates in Native Hawaiians, 54(9):723 LOVELY R. Organizational resjX)nse to adolescent HIV risk, 54(1 ):386 LOW G. What have we learned from the breast cancer detection demonstration project? 1986 [classical article]. 54(6):615 MACMILLAN MW. Acute anticholinergic syndrome following ingestion of Angel's Trumpet tea, 54(7):669 MADAN A Y LD. Prostate-specific antigen concentration: influence of age and ethnicity, 54(6):606 MANN E. Organizational response to adolescent HIV risk, 51 (I ):386 MARK CR. Trends in workers compensation costs in a hotel-operating company over a six-year period, 54(3):439 MASKARINEC G. Prevalence of systemic lupus erythematosus in Hawaii: is there a difference between ethnic groups?, 54(2):406 MCCARTIIY MR. Adequacy of a pre~participation examination fonn: a study of Hawaii physicians, 54(2):410 MCCORMACK MT. Military medical operations in Haiti [Military medicine], 54(8):694 MCCORRISTON CC. Colleagues [re: Fred I. Gilbert, Jr, MD], 54(6):588 MCGRADY G. Organizational response to adolescent HIV risk. 54(1):386 MCW ADE R. Legal, ethical, and political issues in nursing [Book review], 54( 4):453 MEGA MS. Treatment options in the acute stroke patient [abstract], 54(9):718- Alzheimer's disease: etiology? prevention? treatment efficacy? [abstract], 54(9):719 MEYER J. Letters from the family [re: Fred I. Gilbert, Jr. MD], 54(6):577 MILLER R. Plantation doctor, 54(11):791 MIYAMOTO LA. Prostate-specific antigen concentration: influence of age and ethnicity, 54(6):606 -superiority of anti microsomal over antithyroglobulin antibodies for detecting Hashimoto's thyroiditis. 1993 {classical article; abstract], 54(6):613 MORENS DM. Thoughts of the relevance of medical history, 54(11):768 MORRIS AD. epidemic that never was: yellow fever in Hawaii, 54(11):781 MOSER SS. Have physicians abdicated theirrole?, 54(4):523 MUELLER C. Organizational response to adolescent HIV risk. 51(1):386 MURAKAMI JF. decision to withdraw tube feeding, 54( 4):485 NICHOLS AW. Adequacy of a pre-participation examination fonn: a study of Hawaii physicians, 54(2):410 -Pre-participation examination: a new fonn for Hawaii, 54(3):434 -role of sports medicine in academic medical education [Medical school hotline], 54(8):694 NISHI L. HMA alliance, 54(3):431 NORDYKE RA. Memorial service [re: Fred I. Gilbert, Jr, MD], 54(6):569 -Introduction to scientific section [re: Fred I. Gilbert, Jr, MD], 54(6):602 -Using the computer in the doctor's office to enhance the quality of patient care. 1990 [classical article; abstract], 54(6):611 -Graves' disease influence of age on clinical findings. 1988 [classical article; abstract], 54(6):613 -Painful subacute thyroiditis in Hawaii. 1991 [classical article; abstract], 54(6):613 -superiority of anti microsomal over antithyroglobulin antibodies for detecting Hashimoto's thyroiditis. 1993 [classical article; abstract], 54(6):613 -Optimal iodine-131 dose for eliminating hyperthyroidism in Graves' disease. 1991 [classical article; abstract], 54(6):614 -Share-care clinics. 1976 [classical article], 54(6):626 NORTHFELT DW. Caring for patients with fatal illnesses with compassion .. [abstract], 54(9):719 - HIV positive patient-does treatment with antiviral agents alter the course? [abstract], 54(9):719 NOWACK MK. Bone mineral content in Hawaiian, Asian, and Filipino children, 54( I ):388 OFTEN JP. From a renovated dance pavilion -the progress of Anny medical facilities in the Pacific [Historical notes], 54(7):660 PARK G. HMSA 's HealthPass-a strategy for delivery of preventive services, 54(8):697 PATRICK WK. Hawaii Health QUEST: a managed care demonstration project, 54(9):720 PERREIRA RJ. Rodricidium Memoria J.l. Frederick Reppun MD [On the cover], 54(5):533 PERREIRA S. Rodricidium Memoria J.l. Frederick Reppun MD [On the cover], 54(5):533 PIETSCH JH. Toward an exit visa-regulating health care decision~ making, 54(4):501 POWELL B. role of genetics in (continuing) medical education in Hawaii [Medical school hotline], 54(3):429 PUE1Z K. Kidney Stone Center of the Pacific: summary of operations !986 to 1993, 54(12):814 RATH P. Palama Settlement: 100 years of serving a neighborhood's needs, 54(11):774 REPPUN JfF. [re: Hawaiian medicine and health, HMJ, 12/94], 54(5):534 -From ProntoJyn to Biaxin: the half-century of antibiotics, 54(5):542 -physician as patient: the thallium treadmill stress test, 54(5):547 -Fred Reppun's September 1993 editoriai-HMSA, 54(8):703 RIGLER RG. Screening of chest roentgenograms by a radiological assistant. 1971 [classical article], 54(6):618 ROBBINS KS. Legal liability under managed care, 54(4):490 ROGERS TA. Colleagues [re: Fred I. Gilbert, Jr. MD], 54(6):588 ROSENTHAL J. Letters from longtime friends [re: Fred I. Gilbert, Jr, MD], 54(6):582 SACHS RR. Comparison of health appraisals by nurses and physicians. 1970 [classical article; abstract], 54(6):626 SAMLASKA CP. Cutaneous melanoma in an active duty soldier, 54(7):673 SAUNTHARARAJAH Y. Hybridizing the health care plans of Hawaii, Oregon, and Singapore, 54(4):464 SCHATZ U. Empathy and medical education, 54( 4):495 -Invasive versus noninvasive treatment of coronary artery [abstract], 54(9):718 SCHMfTI RC. Medical progress in a remote archipelago, 54(11 ):770 SEWARD PJ. Built to last: power tools, old saws, and a new AMA, 54(1):377

Council Highlights

The HMA Council was called to order by Carl W. Lehman, President at 12:00 pm.

Present: J. Spangler, President-elect; F. Holschuh, Immediate Past President; R. Kimura, Secretary; L. Howard, Trea­surer; AMADelegates: C. Kam, R. Stodd; Alternate AMA Delegate: A. Kunimoto; Speaker: H.K.W. Chinn, Vice-Speaker and Honolulu County President: P. Blanchette; Component Society Presi­dents: M. Joshi, of Maui, T. Smith of West Hawaii; Councilors: T. Au, D. Canete,P.Chinn,W.Dang,Jr,P.DeMare, M. Shirasu, R. Wong, W. Young, J. Betwee, P. Kim, C. Kadooka; Past Presi­dents: W. Chang, A. Don, G. Goto, J. Kim, J. Lumeng, J. McDonnell, S. Wallach; Young Physicians Section: C. Goto; HMA Alliance President: C. Gutteling, President, K. Zelko, V. Lau, S. Lim, and L. Cecil.

HMA staff: Jon Won, N. Jones, B. Kendra, L. Tong, J. Asato, J. Estioko, P. Kawamoto, A. Rogness, recording sec­retary. • The HMA Alliance reported that the pace of the Alliance is changing on the Big Island. • There are active male members of the Alliance. The Alliance will be able to

SHAMBAUGH VL. Colleagues [re: Fred I. Gilbert, Jr, MD], 54(6):588 SHANLEY DJ. Recurrent chylothorax associated with sarcoidosis, 54(12):817 SHIOZAKI H. Letters from the family [re: Fred I. Gilbert, Jr, MD], 54(6):577 SHRAGG TA. Insurers demand silence on myths of managed care [reprint], 54(8):691 SIA CCJ. role of the medical home and interprofessional collaboration, 54(5):549 SIMPSON L. Kidney Stone Center of the Pacific: summary of operations 1986 to 1993, 54(12):814 STADLER FJ. Cutaneous melanoma in an active duty soldier, 54(7):673 STODD RT. weathervane, 54(1):396 - weathervane, 54(2):420 - weathervane, 54(3):444 - weathervane, 54(4):528 - weathervane, 54(5):560 - weathervane, 54(7):684 - weathervane, 54(8):708 - weathervane, 54(9):732 - weathervane, 54(10):752 - weathervane, 54(11):800 - weathervane, 54(12):820 STONE G. Pediatric asthma-a correlation of clinical treatment and oxygen saturation, 54(7):665 STRODE WS. Colleagues [re: Fred I. Gilbert, Jr, MD], 54(6): 588 SUNDERLAND P. Survey of Hawaii physicians' attitudes on health care refortn, 54(10):740 TABA SC. role of the medical home and interprofessional collaboration, 54(5):549 TABRAH F. Colleagues [re: Fred I. Gilbert, Jr, MD], 54(6):588

October 29, 1995 Roger T. Kimura MD, Secretary

help HMA physicians in community rela­tions and is looking forward to a working partnership with the HMA.

For Action A motion was carried that the provision in

the No-Fault law presented by Dr B. Portner be referred to the No-Fault and Legislative Committees for study for a report to Council or the Executive Committee.

A motion was carried that the HMA main­tain the five year increment membership dues system for physicians in first year practice.

Physicians were alerted that they would be receiving a letter from the Montana­Wyoming PRO asking for their support.

A motion was carried that Dr Holschuh and Mr Won write a resolution on blood alcohol levels to be presented at the AMA Interim meeting in December. The resolu­tion would request that the AMA look at the policies of the Scandinavian countries. Their data could be used nationally for educa­tional purposes.

A motion was carried that the dean of the medical school meet with the HMA Execu­tive Committee and vice-chairs of the CME Committee to work out a suitable financial arrangement.

TAMURA PY. After five decades, can health care costs be controlled without sacrificing quality?, 54(10):746 TANSY. role of ethics and law in medica] education [Medical school hotline], 54(4):451 - Bioethics and the new medicine: an ovetview, 54(4):458 -Entering the age of the new genetics with eyes wide open, 54(4):464 -Hybridizing the health care plans of Hawaii, Oregon, and Singapore, 54( 4):464 -Medical decisions at the end-of~life: lessons from America. 54(4):514 THORNBURN KM. Nonclinical use of medical skills: beneficence lost?, 54(4):497 TODD JS. Straight and true: setting medicine's course for the 21st century, 54(1):374 TSAI NCS. Trans jugular intrahepatic portosystemic shunt (TIPS): treatment of esophageal variceal bleeding, 54( I ):382 TSARK JU. High mortality rates in Native Hawaiians, 54(9):723 V AREZ D. chant for the three winds of Molokai, 54( I ):373 -fishhook of Maui, 54(2):401 -art of making kapa, 54(3):425 -art of making canoes, 54(4):449 - Hina goddess, 54(8):689 - Hina the goddess, 54(9):7 13 -Young Maui and Hina the goddess, 54(10):737 - Pele at Haleakala, 54(12):805 VERA M. Organizational response to adolescent HIV risk, 51 (I ):386 WALLACH SJ. Ethical issues-physicians and managed care, 54(4):523 WATERHOUSE BE. Memorial service [re: Fred I. Gilbert, Jr, MD], 54(6):569 WELLINGTON JS. Letters from longtime friends [re: Fred I. Gilbert, -HAWAII MEDICAL JOURNAL, VOL 54, DECEMBER 1995

828

For Information AHEC.-The federal government has

granted $2 million in AHEC funds for the State of Hawaii. The AHEC program will improve primary care services for underserved populations by training health profession students in community settings.

CIVS.-The HMA has been working with two organizations who have com­pleted a business plan and the CIVS steering committee has reviewed the in­formation. It is complete and very rea­sonable. As soon as Mr Won has put figures together, he will meet with the Steering Committee.

Alternative Healing Seminar.-Dr Holschuh reported that the seminar was impressive. He will do a write-up on the seminar and plans to suggest that HMA have a few of the speakers at the HMA Annual Meeting.

Medicare.-The AMA sent a memo to surgeons on the single conversion factor. According to OBRA 93, in seven years physicians reimbursements would be 30% to 40% lower than today. Based on a single conversion factor, physicians won't lose the 30% to 40% but will still be reimbursed lower than what they should be getting.

Jr, MD], 54(6):582 WHELAN TJ JR. Medical school hotline, 54(7):657 WILLIAMS WW. Consent for children as organ donors, 54(4):498 WILLIAMSON B. My guardian angel, 54(6):575 WONG BD. laparoscopic dilemma: which is the best operation? [abstract], 54(9):718 WONG LL. Hepatic cryosurgery: early experience in Hawaii. 54(12):811 WONG LMF. Trans jugular intrahepatic portosystemic shunt (TIPS): treatment of esophageal variceal bleeding, 54(1 ):382 -Hepatic cryosurgery: early experience in Hawaii, 54(12):811 WONG SC. Wonder what Hippocrates would say?, 54(3):428 WONG WF. decision to withdraw tube feeding, 54(4):485 WORTH RM. Colleagues [re: Fred I. Gilbert, Jr, MD], 54(6):588 YOKOYAMA HN. News and notes, 54(1):394 -News and notes, 54(2):418 -News and notes, 54(3):442 -News and notes, 54( 4):526 -News and notes, 54(5):557 - News and notes, 54(7):682 -News and notes, 54(8):706 -News and notes, 54(9):730 -News and notes, 54(10):750 -News and notes, 54(11):798 -News and notes, 54(12):819 YUILL SC. Testicular cysts: a case report and review of a recent Tripier experience, 54(7):678

Our Twentieth Anniversary, 1975-1995

Twenty years ago, when commercial carriers abandoned the medical professional liability insurance market, MIEC was formed by northern California medical societies and a group

of pioneering physicians. When this liability insurance crisis spread to Hawaii, the Hawaii Medical Association agreed that physicians should participate in their own professional liability insurance company. With HMA support and sponsorship, MIEC was licensed in Hawaii and has provided protection for its physicians since 1981.

In our twentieth anniversary year, MIEC covers 5,200 physicians in California, Alaska, Hawaii, Idaho and Nevada. Together with our wholly-owned subsidiary, Claremont liability Insurance Company, we can insure the liabilities of individual doctors and organizations involved in today's changing "managed care" environment.

MIEC has returned more than $115 million in premium credits to its policyholder owners. MIEC also has consistently earned A.M. Best Company's top rating of A+ (Superior) for its financial stability.

MIEC PROFESSIONAL LIABILITY INSURANCE EXCLUSIVELY

Medical Insurance Exchange of California 6250 Claremont Avenue, Oakland, California 94618

800-227-4527, or Fax 510-654-4634

HAWAIT ClAIMS OFFICE: 1360 S. Beretania, Suite 405, Honolulu, Hawaii 96814 Telephone 808-545-7231

"Hawaiian Trust, huh?"

"I spent a lot of time scoping out tht best 401 (K) for my

company, and their FubR ,_ J01 my VOlt."

" o way.

Wise choice. The Future Horizons 401(k) of Hawaiian Trust was developed specially to meet the retirement needs of Hawaii's people. It's flexible. Offers a variety of quality investments. And it's designed to take care of the details while you and your company's officers take care of business -- which makes it very, very cost effective.

The Future Horizons 401(k) is more tailored to Hawaii business than possibly any other 401 (k) plan in the state. To find out more, call the Retirement Experts, at Hawaiian Trust. (808) 538-4400. Or toll-free from the Neighbor Islands, 1-800-272-7262.

~ h Hawaiian Trust Company, Ud.

Any investments in stocks and bonds are subject to risks that may result in loss of principal, and are not deposits or obligations of, or endorsed or guaranteed by Bank of Hawaii or Hawaiian 'frost Company and are not insured by the FDIC, the Federal Reserve Board or any other government agency.