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Puhhshe.d monthly he thei-hiss ai Medical Assoeiat on

incorporated in $56 unde.r the .\iinarc.hyCOt Seth Heretania. Snte dill)i.e [iass::i: SiOs I)

i’huiie 5(0: C._n’- Fay 5(1’

EditorsIJ:tr: N nn.n Goldstein Mi)

Neo’. Editor: Henry N. ) okm lola N-IDContrihutine Editor: Russell F. Stodd Mi)

Editorial BoardJohn Bre nieh MLS. Satoru cuim Phi).

Doutrlas G Nlas’.ee \iI).N4vrnt, L Shirasu MD.Frank F Iahi.ih \ii). Adred I). ioiii Mi)

.1 ournal StallEditori,) \.ictant: [hake (hiiien

Officers

President Gerald MeKenna NI I)President-Elect: Calvin Wone Mi)

Seeretarv:Ali l3airos Mi)Trea.urer: Paul Deiviare Mi)

Past Pies ide it Philip Hell red It \ ii)

(nunt PresidentsHan iii. Jo—Ann Saruhi MI)

Honolulu Neil Eat, Mi)Maui: Jcph Kamaka MD

alt Au H.un \11)Katiei Gardner Quwton \ID

Ads ertising RepresentativeR ,t h Communication

Th)41i Alevva i)rtvciiinidriii, i—iasvati 905 i —

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ContentsEditorial: I)rug Compan Gifts to PhysiciansV ‘,,teot C Rti in 111) 5$

Oncologists’ Knowledge. Attituteds and PracticesRelated to Cancer Treatment Clinical TrialsMorn, Kooito/ Ill), Kathryn Braitit DrPH, Coroli ti Goiov Pit!).titd Lehno .4/’,ito 91

I aparoscopic l)onor Nephrcctoniy in HawaiiRn (on! /?tti’tto 111). Wiiit,t1 v li,itnt ill).

- -iintt ( 7, tote Mi).(Ill LOt/it ii ti C 111) 95

Medical School Hotline-‘i/an R. Kot ‘iii), MPH, eotd F l)i- Wolfh Miller I’ltl), MPH 102

Cancer Research Center HotlineS/tori st S/ti ee,iui so 1? N. MS itiul Car/-li il/to/rn na! .111), P/ti) 0-I

News and NotesHeitrv A’. kokositnto Mi) 107

Classified Notices 11)9

WeathervaneRussell P Said! MI) 11(7

Cover art by Dietrich Vare,. Volcano, Hawaii. All rights

1’(’h’ Surfing wit/i Aai,whoa!i ‘i

Pele ‘(ten surired with her shark-god broiher.

— — — _._._._.__._j •

reserved by the artist.

87

Editorial

Norman Goldstein MDEditor, Hawaii Medical Journal

Drug Company Gifts to Physicians

A recent article in the New York Times suggested that pharmaceutical corporations are spending too much mone on “gifts fordoctor,” Can any intelligent person really believe that a doctorwould prescribe a product because of a pen with the name of a drugcompany’s product on it’? Drug company ‘gifts’ arealittle more thanproduct introduction programs. There may he an oversupply ofproductomprinted pens, mugs. calendars or paper weights in adoctors othce, hut the days of company largesse have come to anend,

Years ago. some pharmaceutical companies did offer theatertickets or even hotel stays. To my knowledge this is no longer done.

Some pharmaceutical companies do present educational programsfor physicians at convention or hotel sites, hut these are adjuncteducational seminars and not vacation junkets.

The educational material presented in the doctor’s office by thedrug company rep is a form of CME. Doctors who do not meet withpharmaceutical representatives are missing an important part oftheir continuing education. As prescribing physicians, we write forthe best, most appropriate products to benefit our patients.

Medicine today is a team effort. Our medical schools give us thebasics, as well as the stimulus to study and to continue study. Thepharmacist interprets our prescriptions (rightfully questioning ourhandwriting), disseminates dosage instructions, and recently overtsees possible drug interactions. Our hospital and office nurses are

our right and left hands, carrying our orders and operations. Thepharmaceutical rep should continue to provide information aboutnew products. using samples, textbooks, audio tapes and CDROMS that the drug companies produce and distribute for ourcontinuing our studies.

The Wall Street Journal has reported, “The prescriptiondrugindustry’s main trade grortp has approved a voluntary code for itsmembers that would curtail many types of entertainment and giveawavs that salespeople use to win over doctors. The guidelineswould prohibit sales reps from currying favor with doctors in “dineand dash” events.” Last summer the AMA launched a nationaleducational initiative entitled “Communication of Ethical Guidelines for gifts to Physici.ans from I.n.du.stry.” Th.e init.iative isir.te.nded to help ed.uca te physicians from ir.dustry as part of markertin.g practic.es. Le.arn more about the A.].4A.’s e.ducationai campait•.nat http:J!www .atnarassn.org/amaipuh/category/5689.htmi.

E-8,061 Gifts to Physicians From Industry AMA E’mail NewsBriefts April 26, 2002:

I Ans gitt’ accLptLd hs hs SKI ins indis idu dis should pi imal ilsentai.l a hene.fitto patients ancI should notbe of substantial va.l.ue.Accordingly, te.xthooks, modest. rne.ais, a.nd et. er gifts areappropriate if they serve, a enuine. edna.ationai function. Cash..paytnents should not he acce.pted. The u.se. of drug samples farpersonal or family use is: permissible as long as thnse prac tices

do not interfere with patient access to drug samples. It wouldnot he acceptable for nonrtetired physicians to request freepharmaceuticals for personal use or use by family members.

2. Individual gifts of minimal value are permissible as long as thegifts are related to the physician’s work (e.g. pens and notepads).

3. The Council on Ethical and Judicial Affairs defines a legitimate“conference” or “meeting” as any activity, held at an approprft

Itc be ition ss here it the g ithat inc i Pt imal dx dedie ited inboth time and effort, to promoting objective scientific andeducational activities and discourse (one or more educationalpresent ittonsfat should hL the highlight of the g IthLrtngt and

(h) the main incentive for bringing attendees together is tofurther their know ledge on the topic(s) being presented. Anappropriate disclosure of’ financial support or conflict of inter’

est should he made.4. Subsidies to underwrite the costs of continuing medical educa

tion conferences or professional meetings can contribute to theimprovement of patient care and therel’ore are permissible.Since the giving of a subsidy directly to a physician by acompany’s representative may create a relationship that couldinfluence the use of the company’s products, any subsidyshould he accepted by the conference’s sponsor who in turn can

use the mone to reduce the conference’s registration fee.Payments to defray the costs of a conference should not heaccepted directly’ from the company by the physicians attending

the conference.5. Subsidies from industry should not he accepted directly or

indirectly’ to pay for the costs of travel, lodging, or otherpersonal expenses of physicians attending conferences or meet—ings. nor should subsidies he accepted to compensate for thephysicians time Subsidies for hospitality should not he ac—cepted outside of modest meals or social events held as a part of

a conference or meetings. It is appropriate for faculty at confer—ences or meetings to accept reasonable travel, lodging, andmeal expenses. It is also appropriate for consultants whoprovide genuine services to receive reasonable compensation

and to accept reimbursement for reasonable travel, lodging, and

meal expenses. Token consulting or advisory arrangementscannot he used to justify the compensation of physicians of theirtime or their travel, lodging, and other out—of-pocket expenses.

6. scholarship or other special funds to permit medical students.residents, and fellows to attend carefully selected educ—ational conferences may he permissible as long as the selection

of students, residents. or fellow who will receive the funds is

made by the academic ortraining institution. Carefully selectededucational conferences are generally defined as the maiorcdue itional seicntl I K oi polics m iking iT1eetlng of n ition dref..:i nab or spe.ciaity medical associations.

7. So gifts should he acc.epted ft the.re are string:s a.ttac.hed. Forex.ampie., physicians shouLd not accept gifts if they are given inrelation to the physician’s pre.scrihing practices. In addition,when compan:ies underwrite medica.i conference.s or ie.ctu:res:

other than their own, responsibility for and control over theselection of content. faculty, educational methods. and materi

als should helon.e to the orean:ize•rs () the confere.nc.es orle.ctu:res. (II’) Issues June 1992 based on th.e re.port, “Gifts toPhysicians from Industry’,” adopted December 1990: (JAMA1991 265’. 501 and Food and i)rug Law Journal. 1992:47:445—45fo- Updated June 1996 and June 1998.

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•

Oncologists’ Knowledge,Attitudes and Practices

Related to Cancer TreatmentClinical Trials

Mcmi Kaanoi MD, Kathryn L. Braun DrPH. Caro’yn C Gotay PhD. and Lehua Abrigo

Abstractl’.Ja live H.awalians hv vs h/oh incidence ies cli concers daa.nmeH

ec.dre. attitudes, and .o,acncee. cli Ha wa. 0! cO/c tus Is vvitli r.egardcancer trearmenr c/in/cal trials and Native Hawaiian participatbn id

them. Findinqs suggest that mnst cancer specialists are spopcrtiveof ciindai trials. However, physic ans ide.n ti/led a number .o.l barriers10 SJaIue/ Ian s:ao oarrc.caccr .n cvn:a Ira:. limvs to .ricreasvorsil.cQarc’ ymca nas a’s suooesed.

IntroductionNative Hawaiians have the second highest overall cancer incidencerates and the highest ace-adjusted cancer mortality rates in Hawai’i.When compared nationall\ Nativc Hass ailans have the fourthhighest incidence rates and the second highest mortality rates for allcancers combined. Higher rates of cancer mortality can be attributed, in part, to the fact that many Hawaiian cancer patients presentwith late-stage cancer and have poor access to state-of-the-art earlydetection and cancer care.

Advanccs in cancer treatment and pres ention can be achievedthrough neon ms scientific testing. of new cancer rreai men t andprevention strategies through randomi,ed clinical trials. Randomized clinical trials are controlled experiments that randomly assignpatients to one of two or more treatment groups for the purpose ofevaluating the most beneficial treatments or cancer detection and

erition methods. Clinical trials offer patients access n state—of—the-irt thcrap\ iii a reearc h cc mtext.

Corresrondence 1.0:Lehua AbrigoPaz Oia Lokahi.1394 Qierr 130cr:

A limiting factor in advancing cancer treatment and preventionhas been inadequate accrual ot patients onto clinical trials. Nation—ally, fewer than 30 of cancer patients enter onto clinical truils. andminority representation is much less: Locally, about 20 ol Hawaiiresidents diagnosed ss tb cancer participate in clinical trials.”

Previous studies have identified barriers to clinical trials.Borrowing from Gotav. \ve summarize three categories of variablesthat affect accrual to cancer treatment clinical trials— -physicianfactors, patient variables, and trial characteristics.

Phs sician Factors. Many phr sicians do not refer their patients toclinical trials hecause they lack support staff and/or have concernsabout cc ordination of and compensation for care if a patient joins aclinical trial. (.)thers may belies e that the answer to the researchquestion under studr is already known or mar has e a prel’erence fora specific treatment option Still others may perceis e a conflict inrole clinician \ ersus researchert. be concerned that the doctorpatientrelationship will he affected, ordishike discussions involvinguncertainty, which could undermine a patient’s confidence in thephysic ian. Ph sicians mar not refer because they feel a trial isinappropriate given a specitic patient’s phr sical. mental, and socialconditons. Ftnallv. ph sicians may be unass are of specifc trialsasailable to their patients - The most common physician factorinfluencing cancer patient enrollment, however, “is that the patient’sphysician made a decision not to enter the patient in a trial.”

Patient Barriers. Ritients mar not s’, ant to enter clinical trialsbecause ther do not has e enough information about the trial and/ordo not base eunuch time to make a decision about participation.Sonic patients do not ss am to be “guinea pig” in a test of an optionthat might not work or mriay he more burdensome or cause more sideeffects than standard treatment. Others distrust Western medicine.Oihem may has e limited insurance or income and or he dissuaded byPersonal tactoms such a’ aoe co-niorhiditie” and family opinion.

Trial Factors Accrual is also dependent on the characteristics ofthy tnt il includiny to d is uI ihilits cli eihihts dcsign informcdconsent procedures, and mode oh presentnmion of in formation.

A studa of physician knowledge, attitudes, and practices melatinctO linicai tmeik us conducted t gain inicht into specific uccruulissues in Hass ai’i. Our objeedves were to identify harriers tophysic.ian reforral of Native Hawaiian patie.nts to cancer cii.nical.trial’ and to recommend imems emions to increase accrual andrctcmitn ui,

91

MethodsSample and Survey i)istrihutionFollowing appros al of the \aii\ e Hawaiian Heahh Systems lnstiin

tional Re\ ca Board, a questionnaire was nailed to all X eaneer

spcciahv phr sicians prautienla it the state of Hawaii (ineludinc

medical one I gits. radiation therapists, and nraeons that perform

cancer-related ‘nraersi. a ith a stamped. cairn ens elope. F\vo

weeks later, an k’nticai qnc tinnaircaas mailed to non-respoit

dents and. beginning two a eeL. al/er that, thro e a more reminder

ph.one. calb.’ were made to the remain.i.ng non--respondents. Data

received h February 1, 200 1 were inc.iuded i.n t.he a.naiysis, Survey

e.nveiopm.: we-re c.oded so t.hat individual surveys we.re not linkedwith names.

\leasures.-\ t’eviea ot thc literature on patient accrual to elttiicai trials guided

the desien ci the 2a-i em. cr -‘ectional survey tool ne--pave anddouble-sided Dentoaraphic item’ taped cthnmeitv. medical spe

cialtr, years in practice, training experience. urrent practice bc a

non and sire, and percentage of Hawaiian/Part Hawaiian patients in

the physic.ian’ s prac.tiee. A defini.ti.on. for caticer tre.atmerit clinical

trials was provided. a.nd five items queri.ed i.nterest i’r. t.riai.s. comfort

wtth discus sing trials, number of cancer patients seen each month

and, of these. the numherofcanccr patients engaged in a clinical trial

discmmmon and number Ol patients that actuallr entered a trial. The

nextqucstmona’kcd t’oracrcentent iornot a th I 7 lactors that miket

deterphosicion’ tromn discussirs a treatment trial withapatient cc..

trials are not in want to m\ ractice. titer’ tke pc much tune. etc.:

see ‘Fable 4 tori cmtmpietc istu Another series of items asked hoacc cl informed phr stcians felt about available trials and othercancer

telated servtees. if they would like more information and, ml so.

which sources would he most influential, Open-ended qrtcstlons

provided opporlunities for respondents to write more about harriers

and to suggest a ha few Native Hawaiians parttei pate in trials

,-naiysisResponses a crc entered iwo [pt-Into .apmtblic-dontain provramtt

developed hr the Centers t a Disease Control and Pm’esenth mm -

\Icans and trcmucmtcmcs svcrc calculated.

ResultsRespondent CharacteristicsCompiete.d surveyr. were. returned by 47 (‘5320 of the car.cer speclait physicians, Approximately hal.f of the respondents were.

medical. oncole’ ists and:, one-third we-re.- cancer surceons: 81attended a residenco or tdlloccship pmocram cc oh : trune cninliaos

on cunical triats [able I ‘. \pnri’xintatc[ halt acme Caucasian andonly c’necc-a- Native Hacv:m:iami Nl’5t 0’ . s’cem’i-praetcmmtv n(t’,ihu Half 0 the ‘es ondent’ hod 2(1(1 to thIn isatmeimts in their

current. l.eaei:ce. and t.wo--thids 0’ rcsps. .nde fits estimated that

200/ . -f their patients were Native Hawaiian.

Participation in Cancer Treatment Clinical TrialsApprox.i.rnatelr, two-thi.rds 01 responde.nts sal. d the-y were “ver

in tereste.d” inca fleer treatment eh rt ical trials, and were “very c

fortuNe” diseussinu tt’ia Is with their patients- i10hle 21. N—lust

the rc’sponsh m1t 5uid that tires’ Ira di5crmscd linieal tt’ial -s dir

their patients in the past c-ear, and on as erage, these phr sici:ms had

disenssccl ‘lnieal trial’ a-nh about 4() patenls in the pa>t rear, Fut

ii phr ‘isians. boa cc ci’. none-cl the patients with o. hoimi rices-

discussed trials aetualls entered theni, The remaining 20 phr sicians

m’eported an average of patIent enterinc elmnical trial’ in the piws-ear, The number of patieitts with cc hun trmoils wem’e dieuseda’ud

the number of patiettts ettterimig trials dmt 1cm-ed by specialtr. highest

for nedieai oncologists attd lowe-st ‘for rad:ation oncolu ists. This

is not surprising, since most curre.nt clinical t.t’rals require radiatioi-r

oncologists- to refr-sr patients to medical oncologists lee study regis

tration, See. Table 2 om-m mmcx t page”I

Aw arcne%s and t,se of CancerReIated Ser icesOuR- ,ihont halt’ i5,t belt “very cceil” imt(’smm’mmred amn’Lmt a

caneermms’:mtmentc’imnmcai trials, armd NV cc ct-c interested it

nt ‘rn(timlon cmi trials lahle S a \‘lore tl’tair halt

pm-eterresl eermic’ ti.i : nllrrmrr:lti.on ftcsm the- (‘am:teer Reseauch Cetttet

of .Haa ad I (CRCHi,Respondents w-ere asked Of they were aware. of and had used three

cane-er-related programs s-ponsore.d and f/mnded by the N’ationa.l

Caric.er li-tstitute- (‘NCIi: the Cancer lit firmation Set-v ice (Cf-Si

Physician - s Data Quer— iPDQ/, and (“ate-er Re.searc- 0 C’enter of

H i rIft H I 20 II 0 N mci is tt

Table 1 -— Sample characteristics (n=471

chineSe

F/gino0/panes-cNative Hr-wa/anP4<0 Or other

0050<

How many patents are you stowonsibie(or in -our ourrent p-raotice?

<200200-- 50051:0-1,000

92

Table 2.— Interest, comfort. and participation in clinicalcancer treatment trials n=43i

What V vo•u< comfort level in disousrtno cancer treatmentclinical triais air your patients?Very interes.tedSomewhat interestedNot at at interested

Per pbs S eiapnsed anc se earn man

Suoeon

Per envsa tan tn$Ot, estimated rruniber caccer catients.in past ear with whom o)nical trias wers. discussed

Medical oncologists (n=22)Surgeons in..12)Radiation 0000logists (n=SiOvera) (n=40)

Per physioiarr in24), estimated number ot cancer patientswho entered c(nicai triais,

Medical oncologists (m16)Surgeons w1ORad anon orco:og vs

Peverms nay sum to iess than ‘tn me to rrnssvrg oats

care providers. iher also offer cancer information includinginformation about clinical trials) to the general public. palicnts. andfamil members, Most (81 V) ol’ph sicians said they a crc aware ofCIS, and 60<3 had used it. The PDQ is a Weh4sased resource thatprovides uptodate reviews of the scientific literature related tocancer prevention, detection, treatment, supportive care and genetics. as well a inventories and contact information t3r clinical trialsand cancer organizations, In all. Xl oti’espondents said they wereaware of Pl)Q and 62<3 had used it. The CRCH. through its

Minoritr bascd (‘ommunit\ Clinical Oncolog Program. cnipluvssupport siff ri< amlahle to help phn sicians present information ahoutcancer clinical trials to patients and to assist with the informedconsent po ‘ccss. Among onr respondents. ‘0<3- were ass arc of thisrorani utsl hadaccessed it. Additionally. P4C siid thee sscre

oaarc of limiT suppoi’t groups or cancer patients and their families.and 83< had referred patients to support groups.

Barriers to Discussing Clinical ‘TrialsPhy sicia.n.s we•re asked to atcree (or not) wit.h. state.me.nt.s re.Iate.cl. tophyt.rician. patient. a.nd tria.i •factors th.at mih.t. de.ter th.em fromdiscussing trials with their patients (Table $ .An peioendedquestion all aced them to give reasons he Native Ham aian partieCpation in trials mar he pamcul<irlr <‘a

Phsician_Factors, Ten pltr siciamorelated harriers were includedin the sun cv and agreement that these items a crc harriers a asgenei’allr low. In fact. onlr four ot the ten physican tactors wereseen as deterrents by 25’ or more of the rcspondine phssicmans. HI

these, three items had to do a th tune and cost i not having enouchcuppflm’t slaP’ to manage trials. not feeling adequately compensated.and feeling that it was too difficult and time consuming to providemnlormedconsent, The fmn’th physician factorconcernedphr sicianpreference for one of the treatment arms of a study. Additionally,I 9( felt that available clinical trials were not important to theirpractice.

Patient__Facs. Of the f3ur patient factors, 2503 or more ofphysicians agreed that three served as deterrents to trial accrual—patient refusal, patient cry morhidities, and lack of transportation.

[ii ill at Moi c th in of rvspond nis s im ala of thc. thrm.trial fdctors as detei’i’ent. Fhey felt clinical trials acre too timicconsuming. me rem 0 innosr<t\e. and did not address questionsivIes amit to their patients

I atoi I) t,rmtn., \atm\ H iii in P utijJ_jp’n ha pm andqriestion elicited a nunibcr f reasons for low clinical trial panticipation b\ Natis c- 1 laaaiian5. Sc’sei’ttl retVrred to cultural tactors. eu..that ati\ e l-lawaiians have <cultural bias against \\ estern medicinenm5 . tear diagnosis and theraps n3 rt and pi’eftr to try Hawaiiantraditi’..’nal remedies or other aite.rnative. appi’oaehes.. (n=4), Twophysicians conunented. on the difficulty in r’etti.nu i nfbi’me.d. c.onse.nt.and one of the.se physic.ians wrote, “It’ <•‘ hard for a ph.ysieian to ta.ikstory long enough for Nati v e Hawaiian patients to feel comfortableiominrt a n’iai.” Re.Iat:ed to this were two comments on quality ofi.ifd.A pli sician svrote that. to Native Hawaiians. “qua) ty of life is muchmime important than quanmitr ‘ Another noted that Natise Ham

Table 3.— Awareness and use of cancer-relatedinformation sources and services in=47i

- .‘, . - -,

Prom which sources?Cancer Research CenterTurn or boardsCon.terences

ServePhvsVtans Data Query tPDQSupport staff from CRCHCancer support groups52 rear

30. ‘earPtyear

40/year

93

inns were reluctant to join clinical trials because they had ‘‘witnessed

sutiering and lack ot improvement from chemotherap in their

families.”The second category encompassed access issues, including socio

economic barriers n=4 and lack of Native Ha aiian physicians.

especially in cancer specialties n=l A third categor concerned

edLication, cc., Native Hawaiians lacked infornmtion about cancer

and screening recommendations (n=3) and that they had a poor

understanding of the process and benefits of clinical trials (n=5.

A phsician commented that, “Most people. including Nati e

Hawaiians. would rather go ssiih pros en results.” sshile another

cited “guinea pig’’ mentality. Two noted that Native Hass aiian

patients often presented with a number of co—morbidities that made

them ineligible for trials Another physician wrote that. “Clinical

trials ma not he ihe best prescription tbr the patient”

The final category encompassed pbs siciau is’,ues, e.g., clinical

trials are not offered by doctors ( n=5 . physicians are not interested

in clinical trials u= I ), and clinical research is not supported h the

medical community (n=l .

DiscussionOur hndings suggc’t that most cancer spec ialt\ physicians ted

comfortable discussing clinical trials with patients and are aware of

the services provided through NCI and CRCH. However. generalimuons iruist he tempered since not all phr sicians returned surver

and we do nut knuss the kunwlcde. attitudes, and practices ut nun-

respondents. Hosvcs er. —ince statistics show [bitt participation in

clinical trials is low, it appears that clinical trial participation rates

can he improved.Barriers to clinical trial accrual identil ed by Hawai ‘i physicians

sseresinilartothusereported iii the literature. Additionally. Hassai’i

dues nut havc an intccrated staless ide s stein tur i mplcmcutino

clinical trials, most cancer specialists practice on O’ahu reducing

oppm’tunities for participation by neighbor islanders, and phvsi—

cians on O’ahu practice at a variety of hospitals with varying lex elsof support for clinical trials activities.

Programs to decrease barriers to clinical trial participation should

be implemented. ‘I he Governor’s Blue Ribbon Panel on Cancer

Care in Hawai ‘i. ss hic h issued a report in Au) I. made ts o sugges

tions that likel would help increase accrual to clinical trials,

• l—lasvai ‘i should establish an Outpatient Cancer Center, located

near mator hospitals. that would support the development ol’ a

comprehensive clinical treatment program in the state. This

center would oiler care coordination, health education, expedited

assessments (e.g., lab and imaging services), and multi-disciplin—

arv treatment planning. as well as clinical trial support. This one—

stop—shop approach would increase the efficiency and compre

hensiveness of cancer care, and save patients l’roin has ing to make

and keep multiple appointments in several diftdrent facilities.

• A statewide clinical trials system should he developed, supported

by this Outpatient Cancer Center and CRC’H. With this. Hass ai ‘i

could apply to beeome an NCI—designated Comprehensis e Can

cer Center, which would result in an increased as ailabil its’ of’ new

treatments and clinical trials A coordinated, statewide system for

accrual to clinical trials should offer support staff available at

times and louations convenient to patients, address physician

compensation concerns, and provide opportunities for public

recognition at conferences and profess ioual dinners.

Other strategies may be ti’uitful as well. The literature describes

ideas for increasing accrual of minority Americans to clinical trials,

sevei’al of ss hich ma svork in l-lawai ‘I.

* Native Hasvaiian health care providers could be enlisted to help

recruit Native Hawaiian participants to clinical trials. (Jufortu—

natelv. at the pi’esent time, only 4ff of Hussai ‘i ph\ sicians ate

Native Hawaiian and univ one oncologist is Native Ilasvaiian

Else ci al, y)(37 l’he oncology nurses socieE includes Natisc

l-law’aiian nurses who may also agree to assist in recruitment.

Scholarship programs. established to increase the number ofNatis e I law anans in the health pt’ufessions, are helping to correct

this disparity.

• Educational programs for clinical trials should provide culturally

appropriate informational materials in Ian’ language and should be

distributed at professiunal. church, and cummunitv uk’etings and

at health fairs and sportine events. Public sers ice annt uncemcntc

Iiould he pros ided tu Hawaiian music radio stations. newspapers.

and newsletters of Native Hays aiian organizations.

• \lan individuals are uit]uences by personal testtmonials, and

peer counseling has been effective in some minority cominnni -

ties. Such a pronrain in Hassai’i could link trial-eligible mdiv i5lu

als with current and former participants in clinical trials.

Although iUOt cancer patients in Flasvai’i do 1101 participate in

clinical trials, this tudr shorved that l-lawai’i onculocists liavv’

positive attitudes dout the value of clinical trials for their patients.

Table 4.— Barriers to discussing clinical cancertreatment trials with patients (n47)

Physician factorsNol n.a’.’e encuat succor: martPreference for one of the treatment arms in the sludyProviding informed consent too difficult, time consumingNot adequately compensatec.Irma no: noolan! mu o’acrce.Not cm’fo’:aoe suoeffrc oahenr.s to

Expiainmg treatment arms undermines patients conhdenci’n me.Trials interfere with the doctor/patient reiationship.Concerned my patient may transfer to another doctor,

Patient factorsPatients ‘euse to narlicioate. 23 42Patents “ave cc-rro’bioaes. ‘8 38Patents lack transportation. 12 2SPatients thck insurance. 8 )f 7)

Trial factorsCnn.cai tr.als are too time ccnsumn’c. 1532C/rica trials not “novaf:ve.T5as do not acdress questons ‘eeuan: :o mu palerns ‘2 26

94

. ha c sumc, i no r h of s th’it th process of clinicalttial, acctu il t mht h cnhlnc.Ld Th implementation of ‘,uchchat s coupled ith 0 itinr in’s phvsi iin support his the pot nti Ito e\pand din 11 i I particip itton to local cancer patients\ iti Has tii is n p ritculat

AcknowledgementsWe thank ,ne phy n whore ponded t he urey Ma y nns to Dr ClaytonCnong Pr r p In e g for o m Hal Nah e Ha saran Cancer AwarenesReserch& N HO nNCI ‘endedprojectto’creasecanc’caarenecmon No e H 0 H n oouraa ance’ recearo” :na ben& t NatHaA w as andtod;, a ‘eNtFvHaoawancarcer eceanbr Thankso c Do at’ C rç e Canc for a a’ Seracrr for afarmar cn,

sppo,t

Authors\Iottit Kaanot \l{). \lcdtcal E)iretor l—h’oia l.iltio !l,iuat 1.

its e F1as attan Health Cate Ss stetn. KanaiKalhr\ n aun Di P1—I. Professor. 1-nts ci sits ot Hass at John \.Burns School of \ledictne and Research Direciot liii, Hole\ati\ e I-law attan ( an ‘ci \ss at cues’, Reseat e h. and I rai it ne Netwot’kC at oh n ( iota\ PhI). \ssoctate Reseat cher. I. no erstt\ ot Hass au( ancet Researc Ii Ccii icr of Hass at and ( Ins e st ] e ak n IntlHole— -Nans c Hass ittan C ancet Ass ateness. Research. md Traintrig ‘setssorkLehua \htio. .\dnitntstritttse Stall. ‘hit, Hole——-\aits e Hassaitan

Cancet \ss atenes. Reseateh. and 1 famine \et\ ork

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Laparoscopic Donor Nephrectomyin Hawaii

Racquel Buena MD, Whitney Lirnrn MD, Alan Cheung MD. and Linda Wang MD

AbstractLaparoscopic donor npohrectomy for transplant Is a min/rrrallyInvasIve, effecliive, nod safe o errS/on that a/sn provides less costoranat’ve oar oar/ie ‘u .e-ccn sc:rrtv cc

vs rfrsr cases e ‘5c’ Oc!YOC5c’5 ccc

secee:r a.OC’a CrncCorn (5a.’ ceaCn:ne-

ICCOSSO, :;5,r- 0 tO5 cooccure aS a-sc

cerformed In hdvari and perhaps this will Impact the 330 par er:tscurrently awalhng renal trans/ant.

IntroductionEnd-stage renal disease (ESRD continues to be a major healthproblem and a significant financial burden in the US. In 995.

397.971 people had ESRD. The total number of ESRD patients

continues to gross at a rate of about lOP- per earL Caring for ESR1_costs the [S about Si S billion annually. As a slate. Haaii has thesecond highest incidence of ESRD at 20 per 100.000 in I 996 andcurrently about 2100 patIents are on some i\ pe of dialysis.

Renal transplant is considered the treatment of choice for selectedpatients with ESRD, but limited donor supply has been a majorfactor in preventing its widespread use. Patients receiving a kidneyIrom a living donor benefit from improved allograft function andsurvival, reduced length of time on dialysis and less rejectioncompared to cadaveric kidnes s. Unforttiuatel . onE I 3d of theESRD population in the [S have undergone living donor kidneytransplantation. Thirty percent of all transplanted kidneys are fromlive donors, while fOP- are cadas eric transplauts. [nderutiliiationoP-his precious resource translates into longer ss aiting periods on thecadaveric list median > 2 \eai’s). While waiting, ESRD patientsexperience the ongoing effects of theirprogressive disease and oftendie before a suitable organ becomes available.

On the other hand, potential living donors need to weigh theiraltruism against the consequences of havinc an operation. Majorconcerns include future health problems. postoperat ice pain. returning to pre—donation actvit - arid the fenancial burden in terms ofli wpi tal costs and the t me lost from prod ucti i t . The ad \ent of theI aparoscopic d nior nephrectoin\ in I 995 pros ided an equal l eli cctis e and Ic’’ ice asive oroceduic.

Correspondence to:L..ndaLWong, MD

L/Sa Street. S.te rep

Email: neoa:on-shrreecc:

Many transplant centers offering the laparoscopic approach havenoted significant increases in the number of living donors as well as

an increase in the number of unrelated living donors. The Transplant Centerat St. Francis Medical Centerhegan offtrrine laparoscopic

live donor nephrectomies in L)ecemher 2000. The aim ot the etude

was to ree iew our carE e\pericnee and its impact on lie e transplants

in Hac. au.

MethodsBetween December 20. 20(X) and August 15, 2001. 10 consecutivelaparoscopic donor nephrectornies were performed at St. FrancisMedical Ccntci Liliha \ll being donois un&rwcnt h md isistdlaparoscopic left sided nephrectomy using the transperitoneal approach. Donors were admitted on the cc cuing prior ti surgery for

aegressive fluid li dration. With the donor in the right lateraldeeuhitus position, a 6

— 7 cm pen—umbilical midline incision wasused for the hand port. The Dexterit Pneunio—Sleeee 5: was used

for all procedures. Pneuiuoperitoneum \‘ as established cc ith CO to

an intra—abdominal pressLire of 14 mm I—Ig. In addition to using the

hand port. three additional instrument trocar ports were required,Mobilization of the left colon medially by incising the lateral

peritoneal reflection allowed access to the left kidney. The gonadal

vein, adrenal vein, renal vein/artery and ureter were identified and

isolated. Care was taken to avoid dee ascularizing the ureter hedissecting it medial to the left gonadal vein. The ureter. renal artery

and em were then transected with the assistance of clips and

endovascular stab ,s. Once removed, all donor kidne s were

placed on ice and flushed with 500 cc Euro—Collins solution.

98

Kidneys were then transported to the adjoining operatmg room forimmediate transplant into the recipient within about 3() minutesfrom removal

We retrospect ivelv reviewed medical records of the donors and

recipients involved in these transplants. Data collected includeddonor demographics (age. sex. race), relationship to recipient.operative time, length of stay. serum creatinine (pre—operative and

discharge) and complications. For recipients, we looked at demographics, etiology of end stage renal disease, length of time onhemodialysis, creatinine (pre-operative. discharge, I and 3 months

post—operative), complications, and length of hospital stay.

We also reviewed the number of patients added annually to thecadaveric renal transplant list from 1997 to 2000. The number of

living related or unrelated were also noted from 1997 to20(1 to see if there was any increase in renal transplant sinceaddition of the laparoscopic procedure.

ResultsMean donor age was 40,4 years (range 26 to 54) and mean recipientage was 49.9 years (range 34 to 66). Male: Female ratio was 4:6 in

both donors and recipients. (Figure 2)The majority of patients did not have extended hemodialysis

times prior to transplantation: 5/10 recipients had ESRD hut werepre-hemodialysis: 4/1 (> were on hemodialysis for < 7 months: onepatient spent an extended period on hemodialysis (4 years, 3months).

The donor—recipient relationships among the laparoscopic donornephrectornies during this time period are as follows: 3 related (2child to parent, I sibling) and 7 unrelated (5- spouse: 2-friend). Themajority of recipients shared at least one HLA antigen with theirrespective donors: 4/10 shared 3 HLA antigens: 4/10 shared I HLAantigen: 2/10 were unmatched.

Mean operative time for the donor procedure was 5 hours and 1 5minutes (range 4— 6 hours). There were no intra-operative comphcations and no patient needed blood transfusion, No conversionsto the traditional open procedure were required.

With regards to donor renal function, mean serum creatinine was0.88 mg/dL preoperativel and I .28 mg/dL postoperatively. One ofthe 10 donors had transient elevation of his post-operative creatinine

to 2.1 mg/dL from a preoperative level of 1 .4 mg/dL. With moreaggressive intravenous hydration, creatinine decreased to 1 .9 mg/dL. This did not extend his hospital length of stay. There were nopostoperative complications. The average length of stay among thedonors was 3.7 days (range 3-4 days) following the procedure.

All transplanted kidneys lunctioned immediately in the postoperative period. Two kidneys required ex-vivo reconstruction ofmultiple renal arteries, No patient needed post-operative dialysis.Acute tubular necrosis and ureteral problems were not observed inany patient. Mean serum creatinine decreased from 6.98 mg/dLpreoperanvely to 1.2$ mg/dL at discharge, 1.32 mg!dL (n=9) at onemonth, and 1 .50 mg/dL n=7) at three months post-transplant

One recipient experienced an early rejection episode documentedby open renal biopsy. This rejection episode responded to high dosesteroids and she currently has excellent allograft function (3 monthcreatinine of I .3 mg/dL). Another patient developed a small woundseroma that was managed with local wound care and close outpatientlollow—up. Among the recipients, mean length of stay was 6.7 days(range 6— 10 days).

From 1997 to I 999, 64-66 new patients were added to thecadaveric renal transplant list annually, In the last 2 years. over 100new patients were added to the list ftr each year. As of SeptemberI, 2001, a total of 330 patients are waiting for cadaveric kidneys.During this time period, 28-60 renal transplants were performedannually, While the number of living renal transplants performedhas been somewhat variable, there has been a steady increase in thenumber of living unrelated transplants performed. Lip until August2001, 7 such living unrelated kidney transplants have already beenperformed for the year.

DiscussionThe number of patients suffering from ESRD and the number ofpatients on the transplant list here in Hawaii, as throughout the restof the US, continues to climb. As of September 2(101. more than78.000 patients are on the waiting list for cadaveric organ transplants. Nearly 50,000 of these patients are waiting for kidneys,N Akidney transplant. ideally from a living donor, is the therapeuticintervention of choice for selected patients with ESRD. The benefitso( cusing in organ tiom ha lug donor lnclud_ lmmcdlatc gi ilt

99

Figure 2.— Recipient data (HD = hemodialysis, LOS = length of stay in days. ATN- acute tubular necrosis. DC = discharge, Cr = creatinine in mgidL, mo = months)

Recipient Age Sex HD Time LOS ATN Pre-Op Cr DC Cr I mo Cr 3 ma Cr Rejection Complications

1 45 F 7 mo 7 no 84 07 0.9 14 no

2 53 M Pre HD 6 no 57 t7 14 2i no

53 F Pm HD 6 no 44 0.8 0.9 no

66 M. 4 mo 6 no 6.3 14 12 1.8 no

51 M Pre HD 6 no 47 1.3 1.5 1.6 no

42 F 4rno 10 no 6.4 22 12 1.1 ye.s openrenalbx

42 M Pre HO 7 no 82 14 1.6 t6 no

63 M PreHD 6 no 72 1 12

50 M 1 mo 7 no Fl t3 1.4

10 34 F 51 mo 6 no 94

function, improved graft survis al. and less time on dialysis. Unfor—tunatelv. the numbers ot donors.cadaveric or living. are not increas

ing sullicientlv enough to meet such a demand. Because the numberof cadas eric donors has not increased sienitkantlv in the pastdecade. patients are ss aiting longer and are thing while waitine.With the relatively fi’sedcadas erie rate. we can only hope to increasethe number of donors b\ increasing the number of living donorvolunteers.

Transplant professionals are doing cv er\ thing possible to confront this problem. Researchers are attempting to grow organs fromstem cells, transplant betsy een species (xenotransplant), and develop ness immunosuppressive drugs to eliminate rejection andminimize side effects. Organ procurement organizations continueefforts to promote organ donation in hopes of transplanting as manyorgans from as man\ suitable donors as possible. Transplantsurgeons are expandin criteria for cadaveric donors. using non-heart heating donors, splitting cadaveric livers fortwo patients each,and transplanting pancreatic islet cells. Clearly one of the niostimportant ways of decreasing the number of waiting patients is theuse of living donors.

Living donor volunteers are limited in supply because of significant concerns about the effect of kidney donation on future healthproblems, risk of death. postoperative pain, returning to pre-donation activity, scarring and the financial burden in terms of hospitalcosts and the time lost from productivity. Laparoscopic donornephrectomy can reduce these disincentives. With the laparoscopicapproach. the negative impact on the donor’s future health isminimized, there is less post-operative pain, less analgesic usage.decreased hospital sta\ . improved cosmesis, and earlier return topre—donation activities. The patients are able to return to afunctionaland productive life much sooner than the traditional open method.Overall, the cost to the donor and to society is decreased.

Reviess of the current experience with the laparoscopic donornephrectomv at the larger transplant centers have shown that it iscomparable to the standard open technique in terms of both donorsafet and allograft function. With the reports of their earlierexperienee’c. our center vs as able to lessen the negative effects of thesteep learning curve associated with the laparoscopic approach.Tee hnical modifications such as use of the hand—assist port makes

the procedure less technically challenging Additionally, avoidinguse of the right kidney with its shorter arterial and venous lengthsalso alloys ed br a sater procedure for donors and improved graftfunction br recipients. The ureteral stenosis and urinar leaks notedin the earl’. experience vs as basicall prevented with the increasedawareness to keep all dissection medial to the gonadal vein/ureteralbundle.

The recipients displa ed excellent allogratf tuncton with meancreatinine of I . ing!dL at three months follow —up. None of therecipients experienced allogralt ureteral problems. No donor experienced post—operatis e complications except for a transient increasein creatmine. Otherss ise. the post—operative course in all of thedonors vs as uncomplicated Most of the donors were dischargedwithin 3-4 da\ s (as erage 3.7 days.

Living kidne donation using the laparoscopic approach not onlyoffers the recipients excellent allograft function, but also provides aless invasive and more benign procedure for living donor volunteers. By alla\ ing the anxiety’ associated with living donation,laparoscopic donor nephrectomy quite possibly may be expandingthe living donor poo1. Several center offering this approach havealready noted impressive improvements in their living donor transplantation rate: 12

In conclusion. laparoscopic donor nephrectomy has truly emergedas one of the important techniques that not only minimizes pain anddisability. hut also increases living organ donation. This has beendone successfully in I Iawaii and we hope that living donation willcontinue to flourish and perhaps impact the 330 patients currentlyawaiting renal transplant.

ReferencesKIdney and Uroiogic Diseases Stat:stics fr the Utec States, httN-www.niddk.nh.oov

2. Natcnal Kidney Foundation End Staqe Renal Disease n the Unted States. http:,’7www nidney,c”a3 Nataral Center or Chro-Ic DIsease Prevent’on and Hea1n PromotIon, hf’www,cdc gov4 Scnweitzer. EJ. Increased rates of dca:sn an- ‘ananscop coosor nephrectom5 Ann Surg 2002’

232392-403.5 acoos. SC Lau’c’scoo c ce ccnc’ neynrecro.ny. The Unve’s U Mar land -YnOr spe’le5ce

‘164.6 Cadeac. JA Laparoscooc carol -eo’eotc’’. Se”a’n L,aoanoscooc

— Raise. LE. Laps’onccp: ‘c nonc’ eone.c:car Traaroia-’tacn.

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Figure 3.— Donor-Recipient relationships

Donor-Recipient Relationship

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Medical School Hotline

The role of epidemiology in graduatemedical education

Alan R. Katz MD, MPH, Associate Professor,and F DeWolfe Miller PhD, MPH, Professor and

Acting Chair, Department of Public Health Sciencesand Epidemiology

John A. Burns School of Medicine

The field of e)idelluoI0g

Epidemiology is the considered the toundation science of public

health Although a relatisely young science, epidemiology has

played an important role in the control of human epidemics. the

identification ol enologic factors in both infectious and chronic

diseases, and the provision ot tools necessar\ to evaluate publichealth c )ntrol programs.

Epideimolog has been defined as “the stLid\ ot the distribution

and determinants of health-related states or events in specified

populations. and the application of this study to control of health

problems’.- Epidemiologists focus on human populations rather

than on individuals. A basic tenet ot epidemioloov is that health

related es ents do not occur randoml in the population: b siud\ inghoss these events arc distributed in the population, one ma\ discover

etiologic clues.A central task in epidemiology is the measurement ot disease

occurrence within the population. The epidemiologist describes the

distribution of a health related event in terms ot pon. place. and

time. Hence information is needed not onl on the numberofdisease

cases. hut it is also necessar\ to identit\ and enunierate the popula

tion at risk.Epideiniolog compares diseased ss ith non-diseased persons in

the population to assess differences in one or more exposure tactors:

it also compares exposed to unexposed persons to identify associa

tions ss ith disease. The application of epidemiologic principles

demon strated the role of smoking iii lung cancer. con ‘nar\ heart

disease, chronic ubstruc tis e pulmonary disease. cerebrovascular

di cease, peripheral arterial occlu’.is e disease, and many other nega

tive health outcomes. Perhaps this is a classic example of the

importance of epidemiology.With the recognition of new pathogenic agents and “emerging”

infecnou diseases such as III V!AIDS. Ehola hemorrhagic fever.

Legionnaire’s Disease, Lyme Disease. Hantas irus Pulmonar Syndrome related to Sin ‘somhrc Virus, \Vest ile encephalitis in the

L .S., and Bos ne Spongiforni Eneephalopath\, the importance ofinfectious disease epidemiology has been underscored. The popu

larity of Laurie Garrett’s crningpigue and Richard Preston’s

The Hot Zone4 clearly demonstrate the layman’s fascination with

infectious diseases and the epidemiolocic Drocess.

The “epidcmioloeic’’ perspective has lead to the development ot

unique niethodologic approaches. ss Inch has e been successfull

applied t ‘delineate etiologic tactors in newly identified svndi’omes,

such as Toxic shock syndrome. Re c’s Syndrome, Eosinophilia

myalgia syndrome. and AIDS.

In clinical practice. even the busiest clinician ma interact with

only a finite number of’patients: in contrast, as the population is the

“patient” for the epidemiologist, there is a much wider potential

influence. A clear example is that of the eradication of smallpox.

Through intensive surveillance, im mu n i tation. and eontai nment

programs. sinallpo\. an endemic illness with an estimated global

i neidem’ e of It)— 15 million in 1967. was officially declared ‘‘eradi

cated’’ b\ the World Health Organi,ation in 195(3. The eradication

of polioinyelitis is now a goal being activeh pursued by the

international epidemiologic community.

Until the 1 970s irtuallv all epidemiologists ss crc phsicians,

studying the distribution of arious diseases. Today, hosses er.

epioemiologv is a separate and unique I ield of studs , “Being either

a physician or a statistician, or even both snnultaneouslv. is neither

a necessary nor sufficientqualifieation tor being an epidemiologist.

What is necessary is an understanding of the principles of epidemio

logic research and the experience to apply them.”

Epidemiology training options for physicians:

The training of ph sicians in epidemiology I’olloss different tracts:

the US. Centers for Disease Control and Prevention t CDC ) otters

a unique “applied” training esperience: the Epideirnc Intelligence

Service E1S). Admission into the EIS is highly competitive. EIS

Officers participate in a two sear on—the-ioh training program that

focuses on mastering applied epidemiologic skills such as conduct

ing outbreak investigations and public health surveillance activities.

Although the greatest pi’oportion of EIS trained phsicians sta\ with

the CDC after completing their training. man\ go on to careers as

epidemiologists or public health physicians within local or state

departments of health, or other federal. or international agencies.

Others go into academic medicine or public health. and many go intoprivate or hospital—based practices.

Physicians who desire more “classical” academic training in

epidemiology may pursue an MPH or MS degree in epidemiology.

The MPH degree is seen as a pLiblie health “prot’essional”degree and

as such involves learning epidemiologic concepts within the broader

public health context, Additional requirements include course work

in the related fields ot’ biostatistics. ens ironmental health sciences.

health services administration, and social/behavioral science’. The

MS degree is more of an a’ ademic or i’esearch degi’ee. and focuses

more on mastery ot epidemiologic aiid hiostati sI cal methods.

Preventive medicine i’esidencv traming is anotheroption for post

graduate training in epidemiology and public health, The residency

training program is three years in length. The first year includes

completion of one ear of clinical training in a primar care

specialt\ : the second \ ear includes completion of an MPH decree:

aiid the final year is dedicated to a supers ised preventive medicine/

public health pracncum.5A number of academic institutions otter joint MD/MPH degree

programs. These programs are geared towards pi’eparing physicians

for a career in public health. The program usuallm takes fi e ‘ears

to complete. ss ith the insertion of a 1 2 month MPH cunTiculum

between ihe second and thud year of medical school.

Sled ca I students plannine a career in acadein ic med ici mc u’ a

i’esearch institution ttia consider pursunig a dual .\lD/Ph[) degree.

These programs generally require sev en years to complete. with

three years of research intensive PhI) training placed between the

102

second and third \ ear of niedical schoolChnical research training pri grams are also available s thin

selected schools of medicine. In these progranis. epidemiologicresearch methods are introduced and applied to the clinical setlineas opposed to the \Victer population-based Ii cu s of public health

Stephen HulL sIksignmeçjmgjiRcse nLh emph isi/esthc \ dueof epidemiology to the physician engaged in clinical research.

But one neednt he a ph\ sician researcher to benefit from anunderstanding ot epidemiolooie concepts: the ability to criticallyread the medical literature is dependent to a large extent ipon anappreciation and understanding ofepidemioheic principles [)a\ idS ik t s CliniL ill- p nuoh nnslJ ‘LOt thL tin of Lpide nnologs to the practie mg phx sician. In addition. The British medicaljournal The Laucgi has recenll\ embarked upon an II seek seriesI commencing 5 Jan uarv 20t C to address the application of epidemiology to clinical practice and the critical re\iew of publishedmanuscripts

Epidemiology training at the University of Hawaii:The John A. Burns School of Medicine (JABSOM) currentl\ oIlersboth the MPH and MS degrees m epidemiolog through the Department of Public Health Sciences and Epidemnioloev Altliouih —Iiicredit hours are normally required for conipletion. students s ithextensive background in their specialization and/or research methods i such as practicing ph\ siciails or current fellows ma graduate

ith 30—S—i credits. Physicians and fellows may be able to completethe MPH degree program in one calendar ear. while most studentscomplete the MPH in 16-20 months, The MS degree generally takesmore time to complete due to the written thesis requirement.

.\lthough an Accreditation Council for (raduaie Medical Education 1 ACUME ace recitied prevenlis e medicine residenc trainingpmgrani is currentl unavailable at Jr\BSOM. thei-e is interest indeelopnig a new pronram in the future as the l.Jni\ ersii\ of Hawaiirebuilds its acadenuc piogram in public health.

JABSOM isin the planningprocess of dc\elopmgioint MD/MPHand MD/PhD progranis for select medical student to pursue concurrent, advanced academic training in epidemiology, The MD/MPHprogram would take at least five ears to complete. while the MDJPhD procram would take at least ses en years to complete. Anepidein iol ogical l\ -based master’ s degree and cent ficate program inclinical research is also in ihe piannine stages.

Epideimnology has a \ ital role in graduate medical education. ltsuccessful applications are necessar\ or qualit clinical researchand the critical appraisal 01 published research ilanuscripis. Although ills not necessar\ for all ph sicians to become epidemiologists. in order to attain “scientific literacy’’, it is ahsolutcl essentialthat all physicians familiarize themsels es with epidemiologic methods and principles.

References

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,. Cancer ResearchCenter Hotline

The Role of NCI-Oesignated Cancer Centersin the Nation’s Fight Against Cancer

Sharon Shigemasa RN, MS,Public Information Officer and

Carl-Wilhelm Vogel MD, PhD, Director,Cancer Research Center of Hawaii

I here are nunierous cancer research centers in the IJ.S., hut onI (()

ha\ e the distinction of heinc National Cancer Institute (NIdesignated cancer centers. The Universit of Hasai ‘i’s Cancer

Research Center is among this elite ernup. It is also the only \CI—

designated cancer center in [iawai’i and the Pacific basin. NCI—

designated cancer centers can he found in 31 states and the Districtof Columbia. with some states boasting several designated cancer

centers and 19 states that have none, When there are so many cancer

research centers across the nation, what is it that distinguishes an

\Cl-designated cancer center from the others and what is the

significance of having this designation’?The National Cancer Act of 1971 established the Cancer Centers

Branch C’CB ol the NCI. B ca e broad charge to the cancer centers

that included research, excellence in patient care, training and

edncation. demonstration of technologies .and cancer control. The

initial model lor a cancer center was based on several ni the older.

fi’ee—standinc institutions such as Roswell Park. Memorial Sloan—

Kettering. Mi). Anderson. and Fox Chase.

The Cancer Centers Branch classifies centers as either “basic,”

“clinical, or”comprehensive: In order to receive recognition as an

NCI-designated comprehensive cancer center. a center must have

reasonable depth and breadth of research activities in each 01’ threemajor areas: basic: clinical: and prevention, control, behavioral andpopulation-based research AND exhibit a strong body of interactiveic search that bridges these scientific areas. The center is also

encouraged to initiate and conduct early phase. ninovative clinicaltna Is and to participate in the NCI ‘ s cooperative group network b

pro idnie leadership and accruing patients to trials. Additionally.

the center must pros ide outreach, education and information on

cancer to the conlnlunit\ it serves.

A clinical eancereenterconducts reasonable research actis ties in

ci meal oncotog\. with or ss ithour research that includes basic and:

or prevention and control and population scie nce.A center ma\

compete successfull\ mr a Cancer Center Support Grant with

clinical programs only. However, when other areas of research arcpresent, they should he integrated collahoratively with the clinical

re’earch, A clinical cancer center is also encouraged to conductcarir phase. innovatis e clinical trials and to participate in the NC!’

c sperative eroups.the term cancer center. fiwnierly knoss n as a basic cancer center,

is cnrrcntl usc’d in refei’ence to a cancer center has mc a scientitie

accinla other than that ot a comprehensis e orclinical caneercenter

Such a center niav has c a narrow research iocns such as in basic

scic nec. population science. epidcnlioloe\. diagnosis. iniinuilolog\

or other ai’eas. i’his type of cancer center is activel\ involved in the

ti’anslation process through collahoratis e arrangements ‘.s ith other

institutions, including coinprehensis e and clinical cancer centers

and/or industrr Today the NCI supports 4ficomprehensis e centers,

I 2 clinical centers including the Cancer Research Center of Hawai ‘i.

and eight cancer centers,In spite of the great institutional s ariety among the NCI-desig—

nated cancer centers, the one common denominator of all successful

centers is excellence in research, Successful cancer centers have

scientifically strong research bases. oi’ganized into collahorarive

pronrams focused on cancer. From these programs ness ideas are

generated and nlultidisciplmnar\ research is fostered. I’he founda

tion of suppoi’t t’or the research base is ins estmgator—mnmtiated grant’

from the National I list tutes of I- leal t Ii and ither funding sources that

tise rigorous peer reviess in their es aluation and funding pro’s’

Currently the Cancer Research Centerot Hawai ‘m brings S25 million

ann nallv in to the state throuch ass aids of comracts and grants,

primarily funded h\ the National Cancer Institute v hich also hap

pens to represent the second largest i’esearch funding sonrce for the

entire University of Hawai’i, Of this amount. 90% of the Cancer

Center’s extramural funding is from peer-reviewed awards.

In addition to excellence in research, a successful center is

organized and operated in ways that maximize the potential of its

i’esearch base and can serve to strengthen the institution through the

productivity and success of its individual programs, There are si \

essential om’ganizational and administratis e characteristics of suc

cessful ‘enters:

• A clearly defined scientific focus on cancer research that is

reflected in examination of the center’s gm’ants and contm’acts, by

the structure of its programs objectives, and hs the natum’e of

collaborations between l’undantental m’esearchers arid others inter

ested in applications of its research findings.

• A strong commitment of the parent institution to the cancer

center through: I) recognition of the cancer center as a formalorganizational component and provision of sufficient resources

and space to insure organizational stability and f’ulfillment of its

objectives: 2 assignment of comparable organizational status of

the cancer center to other organ i/at i onal units ot st mm lar i mpoi’—

tance within the institution: and 3 provision of asstirailce ot its

commitment to continuing support f the cancer center in the

event of a change in dii’ectorship and ha ing in place a ssell—

defined plan for this occurrence.

• Arrangement of the center fir the conduct of research and the

evaluation and planning of center actiities to promote (mintactivities and collaborations and interactions within and among its

programmatic elements.

* Facilities dedicated to the center’s shared resources, to the

conduct of research and to administrative activities thai are

appropriate and adequate for the center’s needs.

• A highly qualilied center director s\ ho is a distinguished scientist and administrator with leadership experience and authority

appropm’iate to managing a complex orgamnzation.

104

• A hkh degree of coordmation. interaction and collaboration

among cancer center members that enhances the product i tvand qualit\ of cancer research in the center.

The Nat tonal Cancer \ct n fused the necessar\ dol iar and authority into the \Cl to make the “conquest of cancer a nationalcrusade” The NCI invested v i sely in cancer research by engagingand organizing the efforts of many brilliant scientists from universities, cancer centers, and hospitals not only in the U.S. but also fromall over the orld. The National Cancer Act and more than 30 earsexperience and billions of dollars of public in estment in cancerresearch, produced an o er hclining record ot scientific discos civ.established a nation ide nets ork of cancer centers, trained cancerexperts. and des eloped procrams in commLinil\ outreach and cancerprevention.

The nation’s ins estment in cancer research has resulted in tangible dividends. Since 1991 there has been a notable decline in U.S.death rates in certain cancers. and today there are more than eightmillion cancer survivors. Although the biology of the more than 100types of cancers has proven more complex than imagined in 1971and effecti s c treatments fur the many cancer’ have remained clii—sic, moi’e than 3t) ears of cancer research has e given ph\ siciansbetter inf’onnation and tools to deal with cancer. This has resLiltednot only in better survis al but an improsed qualit of’ life forindividuals ss it h cancer.

There is much more to be learned and accomplished in cancerresearch, Therefore, the cancer centers program remains a significant component of the nation s cancerresearchinvestment and one that needs and deservescontinued public support. The stability andcentralized support by the Cancer Center Supp rt Grant alto ss s an institution to conduct ass ide array ot investigations i ito the etiolog\and treatment of’ cancer. With today’s turbulent healthcareenvii’onment. cancer center support is especiaii\ critical ni ensuring that cutting edge research he allowed to fluorish, Thisis also a time ss hen the scope ofcancer researchhas been expanded to include studies of asvmptomatic individuals for whom genetic susceptibility and early detection can play a kerole in risk reduction, and clinical investigations will require an cs en broader arra\ ofresearchers and access to a greater numberresearch participants.

Fierce competition exists among cancer recearch centers in the U.S. to attain NCI desig-nation due to die limited availability of funds,Therefore, once stich designation is achieved.it is imperative that designated cancer centersmaintain their research focus and expand theircollaborative recearchefforts, ss bile at the sametune continue toconduct high quality research.

‘I he -concept t the cancer centers proeramthat evolved us er 30 \ea rs aco has resulted ina highly successful ini’rastructni’e within which\Ci-deisnatcd cancer center’ has e become

centers of’ excellence. Because of the major success of the cancercenters program. other \ Ill institutes are considering adoption ofthe same model to create similar pi’ograms for other disease entities.

Has inc all of’ its programs organiied and housed in a single

p1 sical structure is a niajor benefit to successful cancer centers as

this ens ironment facilitates and encoui’ages the conduct of translational i’csearch. This is an area that will receive increased fundingin the t’uture to ensure and enhance greater strides in medicalresearch. The Cancer Research Center of Hawai’i ens isions beingable to conduct translational research in its future plans. In order todo this the Center. ss hich long outgm’ess its current facilit. hopes tomos e its entire operations into a snigle f’aci1it one da. \s hether ii

be at the planned F- nis erit of Hawam ‘ i Health and \\ ellness site inKakaako or elsewhere m I lonolulu.

.-\s mentioned earlier, the Cancer Research Center of I lass ai’mcuri’entl classified as a clinical cancer center. 1—lowes er. onr futuregoal is for the Center to become a conipi’ehensive cancer center byadding an outpatient clinical component which is currently lacking.Addition of a clinical component would enable the Cancer ResearchCenter to he classified as a comprehensive cancer center, fullycapable of conducting Phase I and II clinical trials arid to nltimatel\henef’it the cancei’ patients of Hawai’i, F—or more information aboutthe Cancer Reseai’ch Center of Has ai ‘i. s isit our ss ebsite atsswss .crch.org or visit the N(’l webs ite at wsvss ,nci,nih,gov’cancercenters! to learn more about the cancer centem’s program.

Visit our website at’ www hhsc.org

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105

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News and Notes Henry N. Yokoyama MD

POTPOURRIHave you heard about the new sushi bar down town that caters exclusiuelsto lawyers? It’s called jUll! Legal Facts.

“Souse sot to help mc Doe, the Irishman said. “It’s inc ear. ‘There’ssontethin in there.

‘‘1_ct has e a It tok. \Vhs . ms goodness, it’s true ...Yi ‘u e cot nioneslodged up in there.

The doctor pn ceeded to pull ut a S 1 00 hi II. “Vs’oss,” he said “And thereis sti I more. Out caine a few more hundreds, then some hl)ies and some tensFinally the doctor said. “Well, that seems to be it.”

“How mitch was there all told?”‘‘One thousand, ttine hundred and ninety dollars,”

S s t..s th it d hr I tht s ud ihr It tshm in I kncss I ss i it t Iceling tssrand.”

A ntan contes into the ER and sells, ‘‘SIs ss tIe’s going to base her habs inthe cahg’’ I crabbed us stulf. rushed out to the cab. litted the lads’s dressand began to take off her underss ear, Suddenl I noticed that there w crcses eral cabs and I was in the wrong one,

i)r. Mark MacDonald, San Antonio, iT

At the beginning of ins shift, I placed astethoscope on an elderls and slightlsdeal female patieitt ‘s anterior chest ss all. ‘‘Big breaths.’’ I instructed. ‘‘i es.they used to be.” sighed the patient.

f)r Ri,’har,l flirt,,’ s,.S,’afjIc, 11 -1

1 \S as perfortning a complete physical, including the visital acuity test, Iplaced the patient twenty feet from the chart and began with, “Cover yourright eye with your hand,” He read the 20/20 line perfectly.” Now your left,”Agaiit a flawless read. “Now both,” I requested. There v,as silence,,, Hecouldnt even read the large F on the top line. I turned and discovered hehad done exactly ss bat I had asked: hesv as standing there ss tb both es e’cosered. I was laugbmg too hard to finish the exaiti.

I),’. .tlanIn’u’ ‘irs, II os’I,c.s’r,W,’1

A Family Affair‘The well dressed business man in the consultation room had abnormal

liver function tests, As I pi’ogressed through the his,.t()r, I was getting noclues to the cause.

He denied excessive alcohol intake: had no risk factors for iral hepatitis:55 as on no medications and had no ss inpton’is. ‘I’h in king he nay have o ‘incgenetic disease such as hems ,chrsmatosis, I l:iu nched into his 1:11mm Is histot’s

(),Are sour tat her and mother ,i live?\, Mother is. Dad is dead.,,

Q. What did our father die ,‘f’.’A, Oh, of natural causes...Q. ‘That doesn’t help me mitch. What disease did he die ol?A. Well, actually my mother shot him.Q \nd you consider that a nut ural cause’.’A. With a slight n rv grin, Es ervone ss ft ‘ knew then’, considered itnatur,il ... lan’t rensember if’ I eser t’ound ,i cause for his ,ibn,’rmal tests..

ii /t5’ “(‘11,5 s/ [Jig’ Rr\’ l’,j ‘y l’!aim’,

I ),iri nc a patient’ two week t, ‘Ilow-up appol ntn lent ss it h his carnliolo 1st.

he iut’ormed me. his doctor, that he was has ins, trouble ss ith one Of hismedications. “Which one: I asked, “The patcl’t. The nurse told inc to puton a new one every six hours and I’m running out of places to put it”. 1 hadhim quickly undress and discos ered what I hoped I wouldn’t see.. Yes, the

man had 05cr l’ifty’ patches on his body Now the instructions include:“remove the old patch before applying a new one.

1),’. Rebecca St. (‘lair, Norjdlk. V4

Vs bile acquainting ins sell’ ssimh a ness elderly l tent, I asked, ‘‘Doss bitebase ,‘ti been bedridden .‘‘‘ Slier a look of complete cont its on sheansss’ere,l. “Vs by. not tsr about tssents ears, ss’hen ins husband was alive.”

I,),’. Src,’,’,i S’,’,,,is,’n, (‘,‘,‘i’a/li.s. OR

I svas caring for a woman from Kentucky’ and asked, “So boss’s yourbreakfast this morning?””lt’s very’ good, except for the Kentucky IcIly, Ican’t seem to get used to the taste,” the patient replied. I then asked o seethe jells and the sson’iant pi’oduced a toil packet labeled “KY Jells.’’

1),’. Leo,i,i,’,I Kr,e,i,/ort D,’r,’ ‘ii. .111

A nurse ss’as on duty in the Emergencs Room, ss’hen a vouns’ ss’otttail ss.’ithpurple hair sts led into a punk rocker \Iohass k. sporting a sanets ol tattoos,and wearing strange clothing entered. It us as quiekls determined that thepatient bad acute appendicitis and suas scheduled for immediate surgery.Wheit she was completely disrobed on the operating table, the staff noticedthat her pubic hair had been dyed gi’eeit and above it there was a tattoo thatread, “Keep off the grass.” once the surgery was completed, the surgeonsvrote a short tote on the patient’s dressing ss’hich said, “Sorry’, had to ittosvthe lass it.

Medical Tid BitsKidne_,ygjj,s: About 10’ of Americans have had kidney stones and toldto cut doss’n on calcium. Italian researchers report that a diet low in salt andvery low in protein (approximately four ox/day) with normal intake ofcalcium is better for pres enting the problem. Researchers found that lowcalciutm diets may actually’ promote kidney stones.

SSRI’s and Therapy: .IAM.\ reports that hetsveen I 957 and I 997, thettuniher at’ Americans being tt’eated br depression tripled front I .5 ti ill ionto 6.3 mill on ss bile those taking ant depressants has doubled it he vastmafonts on SSRI’s. I.itttng depression ss tb lesser stile eI’fects :tnd less riskofoverdose. ‘I’he downside is that a lot of people aren’t getting face—to—facetherapy.. Over the sante period, JAMA reports that patients in therapydropped frotn 71 ci to 60.2rk.

ODoit Vitamin B: Labels sum most \‘itatnin B bottles rel’lect boss muchVitanun B are in the pills. hut in more than i12 of the brands tested, ti’te,mi’tonttt of \ i tamin B exceeded the stated amotmnt , The ssorse ol lender msNI AC I \ i more thami 35ine day causes ski it f’ltisb inc ,s,md liver damage

cold War: \ drug called l’i ECONARl I.. may he appros ed by FDA at terthisyear’s cold and hut season. the drug cults the duration of symptoms by’ oneda by attacking the cold s’irtts and destroytng its ability to reproduce.

Aspu’m .—\lerm: folks sn Issus dose aspirin to pi’csenm a se’ond nean:’,ttackthink’ notlung about takiits additiontal anti—tn’l’lann,natories. e.se. buipi’otenwhich interferes ss ith aspi ri it’s ability is’ protect the heart, 2* leitol. ‘Ii arm,,ind \io\.\ do not mesS su ith aspIriit. 1

I ft., Cmv it \4ultts tt mm Deh,mtL Thu. \ss I’ ha1 md lout n ml of Mdmctnt.reports that the benefits of mnttltivitamnmmts is still far front certain, bun thedollars speitt on themn timas’ be a good ins estmnent.

107

Folate: (‘)ne if the B itamilis ) prevents neural tube defects in emhrr us

and with B 2 and B decreases tIe rehlt ekace f coronary stenosis a her

angio1kiivHeahh folks who take 40)11 of \ itamm I. dady for at least two \ears

are less likely to develop heart disease.Important caveat: It’s easy to take too much RETINIL, preahrmed

\ itamin A 1mm supplements hieh nereases the risk of htp fractures and

birth dct?cts, tMultivifannns are no substitute fir exei’eim and a balanced

dtet per t hristine (Tirman

BEST PATIENTSFisesurgeons arediscussine is hmakesthe best ‘atientoti the peraimg

a hI eThe t’irsr scrme,.n sa\ s. ‘I like to see accountaiim sit nir operating table.

because si hen von open them up. ever thing inside is numbered.”The second responds. “Yeah, hut von should try electricians Everything

inside them is color coded.”The tlni’d smreeon sa\s, ‘?so. I rcall think librarians are the best.

eservehing niside theni is in alphabetical order.”

I he fourth surgeon clii n tes in “You know, I like construci i ii workers,

those guys always understand when you have a few parts left os cr at the end

and when the job takes longer than you scud if is ould.But the fifth sursten shut them all up when he obsersed, ‘A ou’re all

0 iS ne.Politicians are the easiest to operate in. ‘[here’ no cuts, no heart, and no

spine, and the head and their helund arc interchangeable”

POTPOURRITwo atoms wei e walking dow ii the sidewalk when they accidentally

bun iped in cad i her.“I’m really sorry I” the first atom exclaimed, “Are you all right

“Actuallr, no,” the second atom replies. “1 lost an electron,”

“Oh. no I” “Are you sure?”“I ni positiue

A study in the Washington Post says women have better verbal skills than

men.,.‘‘I tust want to sa to the autlirs of that studr .. . Duh

€0011 U Bi’uut. “Jets, Vi/i! \ /‘R

All in the FamilySeveral \ ears ago. I was taking the initial histor\ from a rural farmer.., This

piddle aced man had a Isnc’standnig ltiston, o( asihitia and rhinitis,

‘l’he patient oh’f’ered his opinion: “You know Rrc.” he said.” Thevsar that

this here allergies are inherited. hut heck. I know a lot oh people who gotthem that ain’t related to mel”

Spotty KnowledgeOh ‘un universities adopting the new curriculum of L’ditit’ig medical

students nvolx ed with patients at an earlier stage in their education.

teaching first ye.ar ttudents .a.n be p u.i.te a humerous expenencc.One such student. Alan. was recently interview trig a oung Sc moan w hi le

I ‘hse rved icaihr“\Vha t seems tsr be the pi’obls’n: today’,’’ Alan asked,,.‘\Vell. I’,e hyems laS pg a lot it spottn ocerllte pvt week “ said the

patient.“I. see,” Alan replied. “And whe.re are the spots.?”

Di’, 1)50w’! L.o’kic’!. f ‘s’:. i’s’

St1,’sj ‘. .irssrssr’ 2u1,i2

in matters a.rthrime.tic al, down under it’s “mat.h.s,” hut in (‘Anad.a it’s“math.” “l’hi.s care ris.’e to an interestinc situation i.n Fute.rgencv when an

piesetitesi ‘,sttlt lie ‘(T tn,ti rl’te’,ct> tad lust tier

me tory lie precesf ne a ‘ek.\t’tcr’ srine lnpltim’\ I mifm,srk’cf tipon a tOtS;’ ttlditt,ti assessment, [he pin

I adv was, howe s er, all at sea is lien it caine ho serial sevens,

Feeling sorr\ for her embarrassment, I contineitted. “I guess von cc ei’ent

cery good at “ittaths” when you cc etc young’,’‘[here a as a pause. iheit both partners cli imed ni together, “( )h, to, a e’ nc

not Catholics, cc crc Protestants.’J) 7 AiiI,r’o, Ooisirjo

“Stiw’/t’v”

Bativ,Ny,: Infants on wy bean form rita gross up as healtlir as those on

standard cow derived f?irmula. Soy’s high Icc ci of photoestrogen (a hichacm like female sex hornmones could al’f?’et development. hum experts say

breast milk is still the best’

Oral *\0 iser: A stLidy’ no estigat hg FIR transmission from oral sex showed

iero cases., Unprotected oral sex with infected parfners is sathr than analSr vaginal sex is ith condon: protected oral sex is cet’taittlv tl’ie safest 4

LpWiienoyp.i’Ic,grtet)sion: Abut one—half’ tf the estimated 42 million

Americans s.virh hypertension are unaware ther have a conditioti. (704 had

seen a doctor thi’ee times the past year and 00.! have iimstu’ancc’.

I.une Cancer: ,\study of’hiaih’anitlliotipeirple in I hO cities shiasthai lineterm expi tsure to soot particles from coal burnt ng plants and diesel etigi nesraises the risk of lung cancer 204! (comparable to living with a smoker>.

Solution: Get out of toss n and tv air filters

The PSA ControversyPossible causes of dec cited PSA’s: limfection; inf’lammatiort; long bike

rides; enlarged prostate: PROSTATE (‘ANCER,Roult tie PSA st tidies: Two trials ate ondersi av to determine whether

i’outitie PSA tests sace hi’ses. Bitt the results will not be in tsr another hive

on ten eam’s.

(‘ontrovei’sial Issues Regarding Prostate Catmccr:a. Not all prostate cancers ate equal lv deadlI, .\1 at men if they lix e long enough. des clip pritstate cancer.

c. —\tud most itmen do tot die from their p151st ate cancer.ii. ff14’ to I 54 oh’ prostate cancers are x’er\ benign and 1ff”, to t, 5’ al’”

verc aggressive. t is hard to predict what wiIl happen to thte middle701!,

e. Most men xx ho get prostati’ cancer don’t die from it. Sn cc hy’ get

tested .‘ Good priest on. t Per I ME n iedical reporter: (‘tat’u stine

(a mImi

Rs?iimfiil: Researchers report that adult stem cells don’t just generate bloodcells: they also develop into sktn. liver, and ntreslinal tissuues’—w hieh

suggests that the body hi;us a st;ishi of mlii ensal repair cells capable 5f heirtu

i spatched to whiem’ec er they arc needed.

l.)tht’tih irOns: (An mmigrcdic’nm imi m’nany’ oser the c,iintcr drugs) in theldcriy Di, .Iosph Ac stint amid eollc’:ucm,mes ,ut ‘talc Scfmo.ol ‘f Medicimtc

it resmicated ->20 h spite I patients. aces “ussr, rider and sh i set ivened Dl Pill: N -

IIYDR.\\IIN’E mmicreascd the likelihood it deliriritt’s ho ‘EO”, caitsimmy

s\ mptonts like gstrhlemf speech and contusion.

The AM AdvantageCet’ta it c.t mid en ,hmps sec’mn to s r irk hem en amid h,ts e tess en side e ‘Gets a Iten

taken in mIte mont rig. N ‘si a study suggests tlt;st dtaly sis patietsis treated mt

the titormung, live looper.Re’se.archers: am Emory U’n”.versity in Atlanta trac.ked the we> fare. of 242.

;‘atiCnts ,uecd (itt .tti ,sldem whir were ‘ndt aI\sjs a

I’ytmietmts cciii’ acme treated bet’s ‘me I I AM suns ives,f steer hr mttoi’etlm’,ut

a rears thaim thus5’ ott Slim at’tcrn’’,tt schedule.,

108

Nendina Hearts..Scient isis fr on \ew York \ led cal Ci illege e\amt ned hearts trom eittht men cc ho had been

transplanted hearts fiVom cc omen donors and found that the temale hearts contained male cell’.Piero Au c ersa, heart researcher and c auth ur of the studx ca led thent “ri intl e stein eel Is.” hopes

the prinntive cells can he niohili,ed to lix heart problems. [‘I tdntasy is that then ‘II generate all thecell lineages that von have in the heart. TI ultitnate moil is to eet the heart to heal itself,V

POTPOURRIltccasa stmtling hot day anda man tainted in the middle ofa husn intersection ...‘‘l’rttieeluicklvpiled

up in all di recliotis rmd a wom;m rushed over to help hi in. ‘\s she knelt down to 1w ,sen his collar, aman emerged from the crowd, pushed her aside and said. “It’s all right honey. “1’ cc had a course inbrst aid,”

The woman stood up and watched as he took the ill man’s pulse and prepared to adnnnister artificialrespiration.

At this point, she tapped him on the shoulder and said, “When von get to the point about callirtg thedoctor, l’n already here”

Kern ,avet, cc as I ccli nut ill and cc ent to ee Dr. West V He began to ask all the Lisual LlltestiOiis.svtnptoins. duration .and the like—-u hen Kern suddettln cLit hi iii off, ‘‘1-1ev. lo ik, I’ in a vet.’’ shedeclat’ed V “I don’t need to ask inn patients these kinds ot rtnestions. I can tell cc hat’s cc tong lust bylooking at thetmi—whs cant non’.”’

‘l’he d lcti r VI itodded iii response. h ioked Kern up and di cc ii, and wrote out a prescriptionV I Ichattded it to her md said, “There n on are, \occ, of course, if that doesn’t work, cc e’ II hat e to Vi mi

uocc n.

The doctor took Dan into the room and said, “Dan, I hacc some good news and some had news,”

“Oh. no Cii ye me the good nests, I guess,” Dan replied.“They’re going to name a disease after you,”

A college phn tics professor was explaining a particularin cotnplieated concept to his class when aprwmed student interrupted him, ,

Classified NoticesTo place a classified notice:

HMA members—Please send a signed and typewritten ad to the HMA office. As a benefit of membership, HMA members may place a compfmentary onetime class:tied ad m HMJ as space s available,

Nonmembers.—Please call 536-7702 for a non-member form. Rates are Si .50 a word with a minimumof 20 words or $30. Nof commissionable. Paymentmust accompany written order.

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Physician Wanted“i.iipoi’osi’o/iu’ Dono , (‘onllniux/ founj). /0(1

6. U-ted Netwcr O’nsr S/ar-no am Ce s D’ T’mm anlahcr. Bn’euu n’ Sea Pevc..’css m’s Se’, nec Ann’, :a:un. An-a,Repc-n ot the. U.S .Scinnhlic Registry ot Oranspiartaton Pen. dents ann’ the Orcan Procurement

and Trnnsciantat:c’n Neicuork-TranspiantData Rockv’le MD US DeartmenI of HealS ass Hirran Services, 2001

a M rIgor en, PA — roved c piem r us 1r r C m- o 5er’ormm” as c 5 I I’ ectomy Tr yr ut Pro e dnqu2001:33:1 19.8-’. 110.

IC,, Kuo, PC. Lasaroscopic donor nephrectomy increases the supply of living donui kidneys. Transplantation. 2002. 62:2211-2213.11. Shafizadeh. S. Laparoscopic donor nephrectomy: impact on an established renal transplant program. Am Surg. 2000:66:1132-I 135.12. Hawasli, A. Lyparoscopic versus conventional live donor nephrectomy: Experience in a commumty transplant program. Am Surg.

2001:67:342-345.

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PRIMARY CARE PHYSICIAN— Position Available.Half-time. Universiy Health Services. UH Manoa, Contact Dr.Lily Ning. 1710 East West Rd.. Honolulu. HI96822. 808) 956-8965.

KAUAI. HAWAII— Seeking a BC/BE General Hematologist/Oncologist interested in consultative practice.Kauai Medical Clinic is a 65-physician multispecialtymedical group affiliated with Wilcox Memorial Hospitaland Hawaii Pacific Health, Our opportunity offers excellent qualify of life in a safe. beautIful, family oriented,rural community. Competitive salary benefits and relocatIon package. Send fax CVtc:M, Keyes-Salk. Kaua:tleoica Clinic 7 C.2D VjHo H Su t E —

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109

The Weathervane Russell T. Stodd MD

Childhood Begins With Mother Goose. Second ChildhoodWith Father Time.A Canadian study conducted by Mounir Bashour Ml). FRC.SC., found

a relationship between pbs steal integument and the risk ot corneal epithelialdlt.ts tolDss tn rUt ictiS sur,wr\ Spctftc il Is p utants older thin i

di) had a six-had greater risk of detects, and5ignificant skin wrinkledpanents were nine times a likely to have eorncal epithelial erosions afterlaser urcer Lightls pta menied patients sa crc irnics as ltkel to has a

;hictns. and just has inc blue or green eves sre]dcd t .) greater rLk, So.

,eeordurc ra Dr. Baslour. aoune hiak p,utcnt undercurne rctractt\ a

>urcer\ have lotte rtsk 1 e’rncal erosions. bile ‘!dcr persons ith pale.orinkled skin sltould he cannoned about the nercased possibility f pst

sin cieai deldets.

The Television Ad Gives You The Headache It Is SupposedTo Cure.The Food and Drug Administrariti FDA ssant to re iew Os plia ott

pesenlltion drug ads coisna on TV. In liN the ,rannec made it easier br

pharn taceutical people to ue tire television tied intl I hr direct-to-pat Ciii

advertising of prescription drugs, arid the ads hrs e exploded across the

screen with annual consumer ad spending noss at 52.5 billion! The FDAintends to interview doctors for up to 15 minutes on the suhiect, and rewardthe physician with up to 5100 tVr his time. Certainly, it is worthwhile tore, iew this absurd polics sa hich encourages patients to he their own doctor.but the question is. whs pas Dr the input? Most Actors will he glad to tellthe FDA anytime, anvsc here. and with no more tnnsenti\ e than a phone call.

doctor wants his patcttt to it Sc drntgs beyond in hat the physictan deet r’necessary and eost-ctbcctnne. I he FD-\ should cntrtail the stupid ads, andtell the drue companies to cut drug rices comtaenrsnratelv.

Super Contract Or Super Con?In ni hat s e lainted be a super itltt( \:iiti in ill contract lens teehnoloey. 1 soft

ants mradeof fiutsn-siltcnnrte h drottel has hit rIte nttirrkci Dr cotlttnttous ii earup to 3ttdavs’’ The claintt is that the material allins borhb s’ tIlOre o\\een

traitsntission no the cornea than ordinary ‘ott lenses. in tin no bacteria buildup atid less proteiti depositiort. Supposedis. tile lcits could he offered as an

alterntattve to laser eye surgery with a better risk profile. and less einpettsc.Viell, es, the claims arc ltjlfilled in clinical trials, hut what about the tealsat rId ot poor hsgtene itlct c rrelcss h tbtts1 F s ttrcons itt. untlontlnlsaware of ugly corneal ulcers generated by fttolish patients Ltsing extendedwear contacts, so healths skepticism will no dottbt rrtle physicians’ ap

Pt nach.

A Thing Of Beauty Is A Job Forever.)ptithnltoologisis hate Inc used hotulinits to\trr br the treatment if c\c

n use Ic nibalatlca. ineludtna facial and esclnd spaonr. The drut iscfldcttncproducnng retnponars paralysis or rnusclc sseakness of nariable dtnrattt

at) decree. ?\ow. it] tile tncnttnc’ battle for ourhitni appeat’atlce. ei.nstttetot

‘ha stnrecons ate using Botox. hoastntlc of “reduein’ writtkles” ,ttnl- sttsthrrsa racial skntt” sa it npinc out the action ot ,irious tdeial muscles.Tc’.ar mittd that the action’ tctniporars and tire la5 aid ttttsclcs produce anaspessionless Parkinrstt’sdiseasc appeaia;rce. the nasa 5sisnsare lintnn up

tie ‘eta’ lu, is us ctlo\ ed ,iI tire prospect of nurntnc a utisa tintited tnarketa hoomim, costt]etie sate, It won’t do hr all man) af us already has a

enouyih saeging muscles.

It’s Not The Pace Of Life. It’s The Sudden Stop At The End.Pb,. V ire! n II its t V 1 s Iii sa rccntI e reported on tnlusetswnt hat kinjuries. The tlewe.r parks otter rides reaching C forces excee.dinsg thosecxnere.nce.d. by astronauts! The report. suggests that. there may be antittarcase in ltuuries invol “‘ head. nt.e.ck and has k trauma. Data is collected

tw ( nsurner Pr ktts S it t ( ommiss m A Ps( rid the risk t rputit it hats ii it t t tn t n tic tt tinti II sit. mh

a a p ‘s dlii too lost - ha5 an sa area i i xcd-si ma iran nanti parks. e.g Dtstcs1 I n cmii I I ,_,t lit t —‘ ,,, it

accident lest nria’. hr. th

Discretion Is The Better Part Of Indiscretion.\aardntne mt rIte ()tficc it Population Research at Princeton t nit ei’stt\

rn “s tint Sib) ‘b’ sainitcin baltic-en age” and —I) liii c had rn tints anncsl

t’nccttancs. Add tnottal sin ri as di ta show that mote than Sb do tin kit in

it tine rniornmnng-after till in hmcln ciii pi’eventm ,ilitiost .bttC ot those pn’ectiant

cies. In anefl’ort to attack the problem. the \nnerican Academy of( )bstetrics

and Gyriecologs t-\COG has mounted ann efhnrt itt influence their pinysi

cians. In a letter to their 40.01)0 members. ACOG is idling doctors to writeprescriptions to gn\ e to their patnents tnt advance for etllergencies.An“accident” on Friday’ night might not allow a woman to contact her doctor.

then get and fill a prescriptionni within the iitlle limits. The drug acts by

preventing itiiplantatinin, and is not ant ahortis e like the controversial drugRlJ-386, so the tn inidons of effectiveness 5 brief. ACOG also is oft’crinig asample letter in gin c tin pharmacisis to ciicimi’age 01cm to stock ilte drug.

Of All Creatures Hunted For Sport, Woman Is First.,\ sfljdv troth Ha riard Medical Schosnl ann) Massachusetts Getteral Hospitalis’as conducted tn a gr np of Ileterosexunal mcml. i’he men stemc presetlied

i iii pictures it tticnm mttd wunnncnl and rasp itt set t’ecorded. The sittds it ms

puhhislled itt ills’ ti nLmrtnal N5 it iso in hich shots ed that pictures nf hetnut bun I

unoinneni actis ated tile santne reward circuits iii the nten’s brains n’ bud.

plcm5mn1r tasie”. .111) cocaine ‘?t. Connrarils. thcs I’niunnd that the same males

reacted negatis dr no ptctures of atiraciis a mcmi, suggestinc tlnitt they snare

threatetied by good—looking gmnys. Otle of time sittdy’s anthors noted that thns

revelation was intO shocking. hut that the t’esponse is not conditional, andcotTipared it to the same futtetiorm fotntnd in lizards. Geez. I’)id some

foundation actually fund a study to find out that nlen can he hornty?

Now If You Don’t Mind, I Have Just One More Question I’dLike To Ask...In Florida,a ptnt tttanagenrnent physician nsas convicted of n’tanslaunghterbecauseofaderiih cansedbvOx Coniin. The jurs believedthe proseeuiiott’s

erston of the docti r’ pact tee. charging tllat tine doctor wrote prescript mittis

to ,mnmvotte sa mlltng in par or an ot’fmce n sit it tihout proper qumesmntilting. Ii

was clammed that lit’ pracitce bed to set anti deaths, ‘File physieianl an’ettesb

that he funilO)’ esi nmedical protocols amid his presert pttotls nil’ Oxr (_n mitt mn and

itiher patti ttiedtcat mitt’ were leetit mate. The dincior faces till ii t t ears nI

prisoti. and plans iu appeal. He ts sink mite of set arid doctors accused of

criminal charges nit die imlittla ettlent nib chri nine pait. ‘‘Its tm iv scars

aecnnrdimlg iii Ira Rick MD. director nit palliative care in Nlissonla. Ninmit

iana, At least inn in ttntre cases like ibm’ mine are on the docket, one 1

California amId tmtnsnnher in Florida. No question. a manslaughter conviction

and other criminal charges against ph) sictans for pait management, will

base a chilling efbCct on all doctors involved in caritig bitr patients with

chronic pain. Atld ott the flip side of the coint is the recent California case

where the doctor was foumid nlegligenti bor not prescribing enotigh patilmedication, So, in paint nlatlagernentt you cotmldhe damned forwhaieveryotn

If It Looks Like Chicken, Sound Like A Chicken, Smells LikeA Chicken, Is It A Peacock?‘File F estorm o’t gthlers itt I .onOott. EtlglLmtltl. had ann ‘‘art’ displas dottstst—

net n pile if itt II ttslttrtts s. beer bottles, soda cans, coffee cups att) csmildvts rappers. all umsed. inibi a price tag attached if 57.000, The gal let’s ann i tor

simst ad ump atid in isiniok the pile for parts trash. Sc hicil it appeared ii he, “‘\

soon as I clapped as as s’n it, I smiled because there wtns sO nitich ness

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Never make secondary

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To contact Kyni and to

get a binder on Straub

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call 522-4444.

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4

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