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Contents

Editorial: Sir William Osler

rVan,tiiit (loliictein ill) 2110

Medicine, Meditation, and Osler’s AequanimitasRio/turd S. Weeder MD, TICS 201

Esophageal Cancer Surgery: Lessons from 1,200 ResectionsSimon Law MS and John Wdng MD 203

Chvluria due to Lymphatic Filariasis: Case Report and Review.Iulia F Lint MD. MPH and Susan L. Fraser MD 206

Severe Hemorrhagic Complication of Talc Pleurodesis for Idiopathic Pleural EffusionBra,te/on Ihrota MSJ1. Mit/tel/c 5’!. .Vç’uven MSil: Shigerr irimajiri Ml).Jr lint_/u 1 C hot 11511 and finn hi Fo/0esh lID 208

Residents’ Case Series: Insulin-Secreting Cystosarcoma Phyllodes of the Breast:A Case Report and Literature ReviewMarc Herr MD, Mat/new H. Chung MD, Christina Be/nap MD,and Donald A. Person MD 211

Medical School Hotline: JAIISOM’s Post-Graduate Evaluation:The Intern and Residency Program DirectorMar/cite Lint/berg PhD and Rio/turd Kasuva Ml). MSEd 214

Cancer Research Center Hotline: Reducing Cancer Disparities for and withNative HawaiiansLana Site!. Ka’opua P/il) 216

Hawaii Medical Journal, Instructions to Authors 218

Classified Notices 221

WeathervaneRut ce/I F Stodd MD 222

Cover art by Dietrich Varez. “solcano, Hawaii. All rightsreserved h\ the artist.

Hula lila

Red feathered birds were highlb prized in old Hawaii.

‘t gg

Editorial

i4 ir WiHiam Osler has been dead over 80 years. He authoredmore than 1 600 medical philosophic ii educational andhistoric essays and hooks, which live on and will continue

to he published for centuries serving future physicians.“The Principles and Practice of Medicine” published in 1892

contains a thousand pages of clrss ic descriptions of diseases from

Acute Gastritis to Syphilis and Tuberculosis. The signs and s mptoms are still the same today. The treatments, fortunately, havechanged. hut this textbook should be in every physician’s lihrar. Itis a ailable in the Classics of Medicine Lihrar\ edition. “Desienedftr the Use of Practitioners and Students of Medicine.’”

William Osler was born in 1849 in Ontario. the son of a minister.He attended Toronto Medical School, transferred to McGill School

of Medicine graduating in 1872 . After spending a year in the medical clinics of London. Berlin and Vienna. he came to the US,, then

became Professor of Medicine at the University of Pennsylvaniain Philadelphia, and in 1889 rose to Chair of the New Departmentof Medicine at Johns Hopkins Hospital and Medical School.

Thus a new era of American medicine began:

• Riorous admission requirements to medical schools were

e stab Ii shed.• Applicants \‘ crc required to eraduate in i four ear College

Program. with tno ears of pre-med including hioioO\.

chemistry & ph siolog• French or German language skills were necessary.

After seeing the new requirements for medical schools. William

Osler moved to Oxford. as the Regius Chair of Medicine. He died

in [)ecemher 1919 of Bronchopneumonia and emphysema. “Heserved three nations, all of which took him for their own: a feiiunlikely to he repeated ioda\.”

The Amertean College of Physicians. lie:idquai’iered ui Phila

delphia (where Osler came to the US in I . recently published

thr ( )uotablx_ Oski xnL t d th \C P s ill st p xpul u h roks Th

Quotable Osler should be adiaeent to your eop\ of the Principleson your primary librar shelf,

Sir William Osler

Richard S. Weeder. M.D.. FACS \ rote “Medicine. Meditationarid which he presented at the Straub Clinic

& Hospital Medical Staff on April 30. 2004. Dr. ‘ceder reh2rs tO

Sir \Villiam’s “Aequanimitas. with Other Addresses to Medical

Students. Nurses and Practitioners of Medicine first pi’esented to

the Graduating Medical School Class of 1889 at the [niversity atPennsylvania. Between 1932 and 1953. this has been presented to

more than 150.000 graduating medical students,

Is it not time that we revisit the words of wisdom. experience and

philosophy of Sir William Osler again and pass them on to future

physicians’?

References1 Osler Wilharn, The Princioles and Practice otMedcne 0. App:etan & Co New Yo,r 18922 Oser. WThiam The Pr ncples and P’acnce of Meccne. The Classcs of Meocse L.brar

Gruohor Eo.1ons. Ltd P0 Box 79108. Rirosogham Aiaoama 35223. 19783 Sdverman MO Ed The Quotable Qatar. The Amescan Cohege of Phvscans. Pn[adeona, 2303

XXIOster. Whiam. Aecuanmias. wih other Addresses to Medical Studesrs. Nurses ass Pracyoners ofMedicwe. Phi’aoelph:a. P Bakistos: 190.4

HAWA:: er:.:200

Norman Goldstein MDEditor, Hawaii Medical Journal

(rn/rn Air b/ti:, ni r/ ii tIliwn Us/xx’ .‘ ‘ i/n Prim/plcs we! l’irh A rn

ii,,. lost publisher! in l.S02, Re.i.’zthlishrnl hr tb,( !ri.rsi,’s hJxr,li,’ri/ L1/l,lii in /0.7’S.

Medicine, Meditation, and Osler’sAequanimitas

AuttorDepartment of Surgery

Straub Cfnlo and HospItalHonolulu, HI 96813

3385 Ka 5’.

Abstract1° this erao1neaOcnaot!C changing med/ca/practice.it seems sell to reflect on the past .stanaa rd-bearers of

ourprofession, our present state of mtnd and moraleand develop non emottona; tecnn/ques and valuessuited to our challenges.

I hesitate to talk to felloss physicians about thephilosophy of medicine as 1 am neither a philosophernor a paragon. The things I will sa will be moreconfession than counsel. And with this audience. Iam addressing a eroup of colleagues \ ho I respect asone of the best hospital staffs I have ever known. Thatsaid. I plan to share some thoughts about medicine andits future that have found their \\ a into the butterflynet I hold up to the o, inds of change to furnish ideasfor niv jottings.

We are at a difficult time. The golden age of medicineis probabl\ behind us. and ma already have started tofade in the days of Osler. who is one of the subjects ofthis talk. The burdens of malpractice suits, of managedmedical care. of excess competition. of decreasingpay. of increasing bureaucracy and heavy-handedoversight were not faced by Osler. And, indeed, theyscarcely dimmed nm liithcr’ optimistic smile fifty yearslater, in mid century. But the are now fully upon us,increasing in weight, and suffocating the joy that haspreviously suffused our ciorious profession.

Again personally, I have not been immune to thisnegative shift, I too have been increasingly depressedby the transition from self-motivation to outside controlby the unworthy, the materialistic, and the il I-informed.It has been so disheartening for me that, on two occasions, I fled the storms of practice for the calmerwaters of teaching and writing. M\ sanity required it.Again, I am no paragon, a’ [lass ed as any. Yet perhapsmy struggles can inform our struggles, my historycan smooth your path.

I find my personal standards slipping. The otherthree surgeons in my tami I’. ss ould he disappointedwhen I sal. or even wish, that a troublesome patientssould no ass a. I jokingl tell ms nurse. “I’d like tothink of her as \ our patient. when faced with such anirritant. But. truth he told, the ss innine over of such acrusts client can he a personal triumph of v’ratitvingdimension’., and a lcs’.on in our os’ n imperfections.

So how do we deal with all this. Hoss do we developthe unperturbabilitv and equaninlit\ Sir William Oslerso much valued in the seasoned ph sieianD Let meset the stage by quoting from his famous address tothe graduating medical school class of I 889 at TheUniversity of Pennsylvania.

Ifl 1/ic /1I’St/)//t(’tr’. Iii tiic /ihl.Sl/Uiii (Ii’ .Slli’iiI’O 1 no qua!—irs’ takes rank with iinpertio’bsthiiiiv... !nipi’riurhabiliivmed/Is (‘00/nt’S/s ci,id pi’escn(’e o/ iiiiiid inider all ‘ift’if ill—

00/Ut’S. calmness snnu/ .stom’in. i’lcaoie.s S of judgnient inillOillir’Jlt.S 0/Vale jiei’il. jmnniohiljtv. iimlpas.sil’e/i(’ss Inih secoiid picee. i/it’l’c is a miiemitai cqiill’ti/t 111 tO i/its

hoc/i/v endoii’ineiit. li/lu/I u.s /inpoi’taiit Iii our

:_‘l’iIlllls’e as unpei’turhabthtv. . .0/ 1 a/i/i eqilamlunhrv /5

the des/table1itiiitide, Hon di//icul,’ to ,lihliii, set 11011nece iscii’v ii 571(1/’ 0 (1.5 lii Ito/nit’.’

.8 di stressinC/c’(lll,/’(’ iii i/it’ h/,’ oh i,/i son arc 1/) ‘lii

ii’ eiitei: a featln’i ‘iAn/I iii /11(11 lund/v 11/1/ ‘17 i/ic fl/ill’

spirits nob/i.e von aiud mu/he their eqlianmiitv. is tile

unc’ertai,itv ivhi, ‘h pc/tn ills lit/i a/I ‘nI to our Science (111(1

art, hutito tile 1115 hopes atid/c,ii’s is’his/i make u.s tiieii,In seeking absolute truth sic ui/il ,it the unattainable,and tnt/st he con/cl/i 77/i/i /Iiii/iil /l/’o/ien porTions....isogrossed late atid SoOll iii jli’O/c.s siomial cal’es. .1/erring

atid spending, you trial so mi’ //‘,tste your pois ers i/la!you alas’ f/nil, too late, I/il/I /icsn’!s’uisen away, that

there is no place in s’our /talir s/i/s ken souls for thosegentler influences which m,iku’ li/c north, living”

There is much more quotable here, hut let us takeonly this one inspiration, store it away, to revisit in afew moments.

I’d like to make one more quote, not exactly aboutequanimity, hut about the attitude we might assumewhen faced with personal anguish and uncertainty.I was fortunate in college to ha\ c a religion professor who later became a close friend. His name was

Malcolm Diamond, and he was one of the professorswhose lecture halls svere always filled. One day, whenwe were having lunch together. I asked him, among allthe scriptures he knew by heart. ‘s hat passage gavehim most comfort when facing a cri’.is, He answeredme, not from the ‘l3rah. the Koran, the Bible, or theBaees ad Gita. hut from “Lord Jim,’’ by Joseph Conrad. The passage is from the middle of the text, and isrepeated ss ith slistht variation a tess pages late,’. Steinis talkine to Marloss. and both are in a philosophicframe of mmd.

Richard .3. V/Dec/er LID,LAPS

201

“A man that is born falls into a dream like a man who/it/Is into thesea. If he tries to climb out, as inexperienced people endeavor to do,he drowns-—-nicht wahr...No! I tell von! The way is to the destructiveelement submit yourself; and with the exertions n/your hands and feetin the water make the deep, deep sea keep you up.’

The point of Conrad’s metaphor, then, is to have an attitude thatdoes not run away from problems, but rather enters them. v orks onthem with knowledge, intelligence and courage. But let us now turnfrom an attitudinal point of view to a more physiological, anatomic,and practical approach to the mind and spirit.

Much has been learned about the mind in the past 100 years andits links to the endocrine and even the immune system. HerbertBenson at Harvard has proven the benefits of meditation in controlling. not only catecholamines and blood pressure. hut brain ayesthemselves. Religion, or at least some religious practices, has thusbecome a legitimate bed-fellow of science. Einstein remarked that“Religion without Science is blind, but Science ithout Religionis lame.” The practice of meditation has been mimicked by otherstress-relieving techniques: the great Frank Leahu would frequentlystep back from the operating table, sit down with ghwed handsbefore him. and meditate when faced with a surgical conundrum. Imyself used to turn away and splash my hands in the scrub-bucketin times of surgical uncertainty, so much so that my scrub nurseswould occasionally grace my bucket with a sterile rubber ducky

Scientitic investigation has shown that meditation, beside beinga practice going back thousands of years and followed in nearly allknown religions, can give more rest than sleep itself. And we find it

provides sharper focus of the intellect and greater control over thatpesky monkey -mind that bends our attention to elephants whenwe want to think of something else: that mental noise that repeatsparental put-downs on endless tapes of the super-ego. It seems theolder we get, the more our thoughts turn to past and future. Andthe more we need the living-in- the- moment which meditationprovides. The newest proponent of this idea is Eckhart Tolle inhis best selling, “The Power of Now”. Now is the only momentover which we have absolute control. The past has already slippedfrom our grasp, and is, for most of us, about eighty percent regret;the future becomes increasingly uncertain as we age, also abouteighty percent anxiety. Joy is possible only in the NOW. Tolle haswesternized this eastern wisdom represented by Thich Nat Hahnand Eknath Easwaren: Jon Kabat Zinn has put ii into practice. AsJerry Jampolsky says, forgiveness is the greatest healer of all. Andhe quotes a patient: “forgiveness is giving up all hope for a betterpast.” Now, once again, is the operative moment, the only one wecan control, for better or worse.

This is not to assert that meditation can be practiced only by sitting quietly, eyes closed, in the lotus position with running v atergurgling at your side, No, as the sage tells it, meditation can alsohe in chopping wood and carrying yater. Or in making tea. Or inpaddling a boat. Or in delighting in a glorioLis sunseL Or on hearingcaptivating music. Orin watching the glistening. mai’ching ayes. Ores en in tracing the fine trajectory of a golf ball destined for an eagleputt. I used to calm when entering the operating room. knowing Ihad a completely absorbing task in front of mc and no possihilit 01

being disturbed hile doing it. And as you goIters might agree. if

ou start to think of past or future on the golf course, you ye hlo nthe game.

So meditation, meditation of all sizes, varieties, origins, can bea superb stress-reliever, taking us miles from the petty and not-so-petty demands of our profession. I commend it to you.

And yet, we badly need more than stress-relief. In this time ofrapid change and near-chaos, we also need standards, values, andmotives that will stand up to this time and make possible a future withan ethos not superficially based on six-month accountant’s figures.Our Western civilization has been shaken, not only by contact witha non—compliant middle East, but also by a challenging Rising Sunand a materialistic television—based life style. Our parochialism isGreek. or Latin. to our new neighbors and new kinsmen from aroundthe world. So where is the moral Pole star that is True North froman ethical position on the globe’?

1 reconsider the values of my own Judco-Christian tradition. Theretain some validity for me, but I find them wanting as expressionsof clear vision and “purity of heart.” to usc Kierkegaard’s phrase. Ifwe take the Ten Commandments, fhr example. and study them forrelevance, we find most of them wanting. On a day by day basis.I’m not usually found coveting my neighbor’s wife. At least notin my advancing age. wisdom, and satisfaction with my own marriage. Nor am I tempted to kill or steal — it’s not fashionable .A sfar as honoring my father and mother. they’ve been dead for halfmy lifetime now. Or the golden rule, “do unto others.” There aremany times when I think ill of myself, when I put myself down.Should I do that also to my neighbor’? Or how about self hate to thepoint of suicide. Is that justification for ki 1mg the other’? MartinBuber stated truth here, with his “I and Thou.” NC). I find westerncivilization and philosophy lacking in what I choose to label “useful imperatives,” or moral guides that are helpful day by day in ourrelations with family. friends, patients and colleagues.

The Buddha has provided four such “useful imperatives.” Theyare known collectively as “The Four Sublime or Excellent States.”And they are as follows:

Loving kindness

Shared Joy

Shared Sorrow

Equanimity

\nd hL’l’c o c ri,’\ ‘it Oslr” ide:iI I don t kno\\ to itat C\tCni Sit

\\ ilham \\ N .i indent at Li’tcrn PhiIooph. hut it secnt he san the mie p.ah \\ ith LL’C.u’d to the other three inipeidti\ e’. I

uekindnL” j certjinR an ittitiid’ Inch an humimst iindersLInLI.

,iiid ..iti eitiI,t,e. ,t’ are Sh,u’ed .lu, iicloicinv m the hnppinc’ a

illic. t”. .u:d Shawd Sona\\. at’ enpath. I connucnd thsi.’ C\Cc.IiCiii

“tat ‘s to \ on ‘ pet’saIi ii en is Inch t.’anilot he nisnnk rstaau.

:u’It:tL :‘pi’ekc. at LiulteLi I hc arc trul Suhlintc. iltoecthe: vat’

tl ii ii i’ ii nit. ucthci in the t ‘nt’ irt ccnlur\ piaci ice ‘I

Iil.’,itilt.iiiiil.

References -

— .2’ ...‘. .D. “ — , I,’’ ‘J’-.’.,’,’’’ Lt 9’ ‘ —

.2

202

Esophageal Cancer Surgery: Lessonsfrom 1,200 Resections

UDArCJ

Authors:Division of Esophageal

SurgeryDepartment of SurgeryUniversity of Hong KongMedical CentreQueen Mary HospitalHong Kong (S.L., JW

Corre.spondence to:John Wong PhDDepartment of SurgeryUniversity of Hong KongMedical CentreQueen Mary Ho.spitaiHong KongTel: (852) 2855 4610Fax: (8t2( 2855 1897Email: jwong@hkohk

This paper was presented at the 26t5 Congress of thePan-Pacific Surgical Meeting

IntroductionTwo decades ago, cancer of the esophagus in theEast and in the West was a squamous cell cancer ofthe intrathoracic esophagus, situated predominantlyin the middle third. Today, in the East, this remainslargely unchanged. In the West, however, the diseasehas become a Barrett’s adenocarcinoma of the distalesophagus, as a consequence of gastroesophageal refluxand dysplasia occurring in specialized intestinal metaplastic epithelium.L2Indeed, this condition is epidemicin the West and has, like obesity, become a major healthissue. Furthermore, while the epidemiology in theEast has remained unchanged, in the West, Barrett’scancer primarily affects the professional middle-ageCaucasian, unlike the older blue-collar worker in thepast who habituates cigarettes and alcohol. As awareness increases in the West, the disease is diagnosedat an increasingly early stage and treatment institutedin a more timely manner. In the East, diagnosis stillrelies on the symptoni of dysphagia which usuallyindicates advanced disease. Treatment is therefore inmany instances palliative,

A combination of both the type of patients and thenature of the disease renders the option of treatment tobe fundamentally different, which then has an impacton the risks and results of the chosen therapy. By andlarge, treatment in the East for squamous cell carcinoma still mandates a thoracotomy, while in the West,the procedure has increasingly become a transhiatalapproach. While it is expected that the mortality andmorbidity rates should be lower in the West, this hasnot been shown to he so and the mortality rate remainsat around 10-I 2%.30 In the East, no data comparable tothe Veterans Affairs database is available but a surveyof 13 hospitals in Hong Kong also revealed a hospitalmortality rate of about l0%, Thus esophagectomy isstill one of the highest risk procedures whether in theEast or West.

Causes of Hospital MortalityTwo decades ago, the mortality rate for esophagealcancer worldwide was around 30%,’ Like other cen

ters with an interest in dealing with this condition, weembarked on a systematic approach to reduce this highrate. The first step was to collect reliable prospective,almost real-time data on all aspects of the patientepisodes in hospital, including both operative andnon-operative treatment, From this, starting in 1982we could identify precisely what were the incidencesofeach cause of death. At around that time, the hospitalmortality rate was 20%.

Medical CausesThe major causes were categorized as medical, surgical and malignant cachexia. The most common cause(45%) was pulmonary, which was not surprising giventhe average age of the patients (65 years), a malepreponderance of 5: 1, their smoking habits and mostof whom underwent a transthoracic resection (72%).Identifying relevant predictive factors for pulmonarycomplications was important to improve outcome.7Ourstrategy to reduce this single most important complication was to: (1) enlist a good anesthetist, (2) implementepidural analgesia and patient-controlled analgesia,9(3) use a smaller thoracotomy, (4) insert a small (18Fr) vacuum suction chest drain,9 (5) practise earlyextubation in the operating room, (6) perform regularpostoperative bronchoscopic sputum clearance,Lo (7)ambulate the patient from the first postoperative day,(8) maintain fluid restriction and albumin level, (9)perform a tracheostomy early to aid sputum suctionwhen the coughing effort was inadequate, and (10)institute vigorous chest physiotherapy. Although evenwith all these and other supportive measures pulmonarycomplications were not eliminated, the incidence waslowered and, more importantly, the seriousness hadbeen mitigated through early intervention. This is atheme that is relevant in the management of all othercomplications of esophagectomy. Cardiac complications (12%) were mostly atrial arrhythmia, and theavailability of effective drugs made for rapid restoration of sinus rhythm.0

Surgical CausesAs for surgical complications, technical aspects aremost important in preventing this occurrence ,Anastomotic leak was and remains a complication that strikes

John Wong MD

HAWALL MEOLCAL JOURNAL. VOL. 63. JULY 2.004

203

fear in the heart of all esophageal surgeons, and has the same effecton us as anyone else. By examining the problem objectively andinstituting solutions supported by randomized controlled trials, wehave reduced leak rate that was in excess of 25% to now around2% that are clinically in nature, and another 1% radiologically.4Changes in technique were made from a hand-sewn two layers ofinterrupted suture (before 1982), to the circular stapler, and in thelast 8 years to a single-layercontinuous suture using a4/0 absorbablesuture. H What is equally important is our willingness, indeed ourobsession, to re-explore a patient, even through a re-thoracotomy,when the patient is not progressing well and no other cause is obvious, or when there is the slightest suspicion of a leak. As all surgeonsare aware, how well the anastomosis was constructed technically atoperation usually forewarn the risk of an anastomotic leak,

Other surgical complications are not common if care to detailis exercised at the operation. Postoperative bleeding, gangrene ofconduit, chylothorax, bowel herniation into the chest, gastric outletobstruction,78and others should be recognized early and treated.

Progressive MalignancyDeath from progressing malignancy after a prolonged stay in hospital following a successful operation is a situation specific to thesocial environment in [long Kong and to our hospital. Previously,because alternative treatments were ineffective and associated withconsiderable risks, we were prepared to resect (orto bypass using theKirschner operation)’920 even in the face of very advanced diseaseand operative risks. Although the majority ofpatients recovered fromthese procedures and were ambulant and eating normally, they werenot discharged from the convalescent hospital to which they weretransferred because of social problems such as poor family support,living in the upper floors or roofs of buildings without elevators andsharing cooking and toilet facilities, and emotionally, physicallyand financially unable to cope by themselves. We have thereforealways used hospital mortality rate as the end point of success of anoperation and not the 30-day mortality rate, To include deaths as adirect result of a technical complication of the operative procedure,as had been used in the past by those who wished to present goodresults, does not reflect the true burden carried by patients after anesophagectomy. As with the holistic view of a surgeon’s mission, wehold that success is only achieved when a patient can be dischargedto his previous environment to enjoy what has been possible priorto the illness that sought our help, and, in the case of esophagealcancer, this is the ability to eat. We recognize social circumstancesas a cause of hospital mortality may not be a universal problem, butat least it is a consistently measurable end point.

Over the years, using the approach outlined, the hospital mortality rate has decreased from about 20% to 1%. From 1996 till 1999,we had no deaths for 169 consecutive resectkns. Since then, therewere three — the first was an elderly female patient who recoveredfully from the operation and died from a myocardial infarction asshe was transferred to a medical ward on day 38. The second wasa gentleman who had undergone prior resection for his head andneck cancer. A successful esophagectomy was performed but hedied from fulminant recurrence of the head and neck cancer onday 56. The third patient died from SARS-like illness on day 17postoperatively.

Changes in ManagementDuring the period of improvement, there have also been advancesin technology and drugs which are more effective and safer thanpreviously. This allowed us to better select patients ftr appropriatetreatment. Examples of such advances include the self-expandingmetallic stents,2’improved radiation techniques, and effective chemotherapy and combinations of them.

Thus there has been a reduction of the proportion of patients whounderwent resection from about 70% to 55%. and, in particular,introduction of chemoradiation has made this possible.22 On theother hand, the referral pattern to our hospital has now includedmore patients with more advanced disease. Coincidentally, it wasnoteworthy that the mortality rate was halved at a time when ourresection rate was at its’ peak in the early 1 990s. Therefore, the virtualelimination of postoperative death cannot he attributed to patientselection alone, but is more likely due to the practice that had beenadopted cited earlier.

Benefits of Reducing MortalityWhat are the benefits of improving the operative results? First andforemost is that survival is prolonged. In our cohort of patients, thereduction in mortality from 20% to 1% has increased median survivalfrom 8.6 months to 17.9 months and 5-year survival rate from 18.5%to24,5%. However, some of the gain may be in part due to the effectiveness of chemotherapy and radiotherapy because even whenhospital deaths were excluded from calculation of survival, thereremains a significant improvement in survival in recent years.22

Second, as deaths usually follow complications, and these aremanaged aggressively, there are the savings from reducing thenumber of these ill patients who are usually in the ICU. Patientswith anastomotic leak. forexample, would require repeated episodesof imaging, a variety of radiological and operative procedures.ventilatory support, parenteral nutrition, third or fourth generationantibiotics, and an immense amount of attention by surgeons. nursesand allied health personnel.

Third, the surgical community benefits because of the aura ofgood if not excellent results which encourages referral for operativetreatment. Most would agree that a successful operation still offersthe best palliation in terms of quality of swallowing and the widestvariety of food that can be consumed. Cure is now also a distinctpossibility. The need for further treatment in hospital to relievedysphagia from persistence or recurrence of the primary tumor, suchas from radiation stricture, is virtually eliminated. An uneventfulsurgical resection still offers the best chance of long-term survival,and is the most cost-effective.

Fourth, the argument that non-operative treatment offers less riskof death and complications cannot be sustained if resection mortalityand morbidity rates can be achieved at the same if not lower levelsthan, say, chemoradiation. This is now a verifiable claim.

Fifth, the morale and confidence of patients and relatives are liftedknowing they are being managed by a team with an excellent trackrecord. This in turn puts the responsibility on the surgical team toperform even better to ensure that trust has not been misplaced.

Sixth and finally, the impact of superior results are not lost to theadministration when formulating policy or distributing resources.It is hard to ignore or argue against success.

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ConclusionIn conclusion, improvements are possible and achievable. However,progress is slow and so requires persistence. Improvements are alsoincremental and therefore there is no single remedy that changesoutcome overnight. Advancement comes from a team and not justthe operating surgeon, as the assistants, residents and house staffs allcontribute to the minuteto-minute and day-to-day care these patientsneed. Progress also occurs through input from other disciplines,particularly anesthesiologists (epidural analgesia), intensive carespecialists and nurses whose diligence helps detect complicationsearlier. Improvements are not more costly, and in fact the reductionof complications derives major cost savings. Improvements are alsoinevitable because in the current environment of surgical practicethose who do not or cannot produce acceptable if not superiorresults will not be tolerated by their peers, the administration, orthe community.

To achieve improvement take vigilance, commitment and longhours, It will also require honest auditing, nourished by studies suchas randomized controlled trials to advance knowledge. Finally, toreach the level of excellence aspired requires the will and determination to succeed.

References1 Devesa SS. Blot WJ, Fraumeni-JF J. Changing patterns in the inctdence of esophageal and gastric

carcinoma in the United States. Cancer 1998; 83(t0i:2049-2053.2. Lagergren J. Bergstrom R, Lindgren A, Nyren 0. Symptomatic gastroesophageal reflux ass risk tactor

tor esophageal adenocarcinoma. N EngI J Med 1999:340(1 t (:825-8313. Birkmeyer JD, Siewers AE. Finlayson E\ Stukel TA, Lucas FL, Batista I et al. Hospital volume and

surgical mortality in the United States. N EngI J Med 2002: 3481t5i:t 1 281 137.4. Bailey SH. Bull DA. Harpole DH, Rentz JJ, Neumayer LA. Pappas TN et al. Outcomes after esopha’

gectomy: a ten-year prospective cohort, Ann Thorac Surg 2003:75(1 ):2t7’222.5. Hospital Authority Hong Kong. Clinical audit on esophagectomy and hepatectomy in Hong Kong.

2002.6. Earlam R. Cunha-Melo JR. Oesophageal squamous cell carcinoma: I A critical review of surgery. Br

J Surg 1980:67:381-390.7. Law S. Wong K, Kwok K, Chu K, Wong J. Predictive factors for postoperative pulmonary complications

and mortality after esophagectomy for cancer. Ann Surg. In press.8. Tsui 5L, Chan CS, Chan ASH, Wong SJ, Lam CS. Jones RDM. Postoperative analgesiaforoesophageal

surgery: A comparison of three analgesic regimens. Anaesth Intens Care 1991: 19:329-337.9. Lau H, LawS, Wong J. Prospective evaluation of vacuum pleural drainage after thoracotomy a patients

with esophageal carcinoma. Arch Surg 1997: 132(7):749’752,10. Whooley BP LawS, Murthy SC, Alesandrou A, Wong J. Analysis of reduced death and complication

rates after esophageal resection. Ann Surg 2001: 233(3):338’344.11. Murthy SC, LawS, Whooley BP Alexandrou A, Chu KM, Wong J. Atrial fibrillation after esophagectomy

isa marker for postoperative morbidity and mortahty. J Thorac Cardiovasc Surg 2003: t26(4(:1 162-1167.

12. Law SY. Fok M, Wong J. Risk analysis in resection of squamous cell carcmoma of the esophagus.World J Surg 1994: 18(3(:339’346.

13. Lorentz T Fok M. Wong J. Arrastomohc leakage after resection and bypass for esophageal cancer:lessons learned from the past. World J Surg t989; 13(4i:472-477.

14, Whooley BP LawS, Alexandrou A, Murthy SC, Wong J. Critical appraisal of the significance of intrathoracic anastomotic leakage after esopoagectomy tor cancer. Am J Surg 2001: 181 (3(:198’203.

15. LawS, Fok M, Chu KM. Wong J. Comparison of hand’sewn and stapled esophagogastric anastomosisafter esophageal resection for cancer: a prospective randomized controlled trial. Ann Surg 1997;226(2(:169-173,

16. LawS, Wong 1. Esophagogastrectomy for carcinoma of the esophagus and cardis, and the esophageala as or-os Ir Baker RJ Dec e eoitrs Mca urn t Su oert PA bpp ncott Wd6ams & 69 lPns2001:813-827.

17. Fok M, Cheng SW. Wong J. Pyloroplastv versus no drainage in gastric replacement of the esophagus.Am J Sum 1991: 162(5l:447-452.

18, LawS, Ch,eung MC. Fok M.. Chu KM, Wong J. Pyloropiasty and pyloromyotomy in gastric replacementottheesophagus afteresophsgectomy:s randomizedcontroiledtriai.JAm CotSurg 1997: 184i6.i:630-636.

it. Ong GB. The Kirschner operation--a forgotten procedure. Br J Surg 1973; 60(3(:221 -227.20. Whooley BD LawS, Murthy SC. Alevandrou A, Chu KM. Wong J.The Kirschner operation in unresect

able ea.opf.ageal cancer: current ap.plicstion. Arch Surg 2002; 137(11 (:1226-1232.21. Law S. Tung PH, Chu KM. Wong 1. Self-expanding metallic stunts for pailiatio•n of recurrent malignant

esophageal obstruction after subtotal esophagectomy for cancer. G.astrointeat Endosc 1999:50(3(:427-436.

22. Law S. Kw’ong DL, Kwok KE Wong KH, Chu 69$, Sh,am IS et al, Improvement in treatment resultsand long-term survival of patients with esophageal cancer: impact of chemoradiation and change intreatment strategy. Ann Surg 20.03: 238(3(:339-348,

Editor’s Note:This paper was presented at the 26th Congress of the Pan-PacificSurgicalAssociation, February 14-16, 2004, in Honolulu. The C’ongress, chaired by Torn Kosasa Ml) was outstanding. Look forwardto the next Pan-Pacific Congress — world class researchers andpracticers of the surgical specialties will again return to Hawaii inJanuary 14-16. 2006.

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HAWAH MEiO:CAL JOURNAi,,, VOL 63. JULY 2004

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Chyluria due to Lymphatic Filariasis:Case Report and Review

AuthorsTtipler Army Medical Center

Department of MedicineHonolulu, Hawaii 96859 (JTL,SLF)

Correspondence to:Julia I Lim MD, MPHTripler Army Medical CenterDepartment of Medicine1 Jarrett White RoadHonolulu, Hawaii 96859Fax: (808) 4331555Email: (ulia_lim@ameddarmy.mil

IntroductionChyluria involves passage of chyle in the urinary system and results in a milky-appearance ofthe urine. Themost common etiology worldwide is filarial infectionfrom one of three filarial worms to include Wuehereria

bancrofti, Bragia rnalayi. or Brugia timori. Recentfigures estimate that worldwide, greater than 120 million people are infected, and the majority are due toinfections from W bancrofti.2 W bancrofti is endemicto SoutheastAsia and India, many Pacific islands, subSaharan Africa, and certain parts of Latin America.In endemic areas, up to 10% of the population maybe infected, and up to 10% of those individuals candevelop chyluria.3

Case ReportA 52 year-old man from American Samoa with a pastmedical history significant for diabetes mellitus andhyperlipidemia presented with complaints of milk-colored urine (Figure 1). He described a history ofhematuria and milky-appearing urine with mucusclots that had worsened over the past 3-4 years. Hedenied any alcohol use or liver disease, and deniedany scrotal edema, prior trauma, or constitutionalcomplaints. His physical exam revealed bilaterallower extremity non-pitting edema. Urinalysis revealed proteinuria, hematuria, and glucosuria but noevidence of infection .A urine triglyceride level was1092 mg/dL. PPD, urine culture and urine acid-fastbacillus testing were negative. Acomplete bloodcountdemonstrated mild eosinophilia, and by serologic testing, was positive for filarial IgG antibody, but negativefor filarial antigen. Peripheral blood smears werenegative fbr microfilariae. Computed tomography ofhis abdomen and pelvis demonstrated only bilateralsimple renal cysts, and nuclear lymphoscintigraphy

revealed delayed lymph flow and dilated lymphaticchannels surrounding the left kidney suggestinglymphatic obstruction. He underwent cystoscopyand bilateral retrograde pyelograms, and was foundto have chyluria lateralizing to the left ureteral orificeand severe lymph fistula formation involving the leftkidney. He underwent laparoscopic nephrolysis ofmultiple dilated lymph vessels and left ureteral stentplacement. He also was treated with a short courseof ivermectin and for a few months had temporaryresolution of his chyluria.

DiscussionOther than filariasis, there are other infectious andnon-infectious causes ofchyluria that include tuberculosis, fungal infections, Hansen’s disease, malignancy(genitourinary, gastrointestinal, thoracic duct orthyroidtumors), trauma, pregnancy, hydrocele, and inguinalhernia. There are case reports ofchyluria being causedby a thoracic aortic aneurysm and following cardiaccatheterization.4’5

In filariasis, the filariae are transmitted through amosquito bite, with multiple mosquito species servingas possible vectors for transmission. The mosquitotransmits third stage larvae which are deposited intothe skin. The larvae travel to the lymphatic system anddevelop into adult worms usually by nine months,2Theadult worms live in the lymphatics where they mateand produce microfilariae (first stage larvae) whichare intermittently showered into the bloodstream.5Through another mosquito bite, these microfilariaeare uptaken, and over a period of 10-14 days theydevelop into second and then third stage larvae. Themosquito then bites another human and the life cycleis completed.2 The adult worms live an average offive years, and it is the dying worms rather than themicrofilariae which are responsible for most symptoms,as they incite an inflammatory’ reaction which resultsin lymphatic damage and obstruction.2 Patients mayhave recurrent episodes of lymphadenitis with feverand malaise, and repeated attacks lead to chronicmanifestations ofhydrocele, lymphedema, elephantiasis, and chyluria.5 Due to the lymphatic obstruction.dilation of these vessels occurs, as well as backflowof chyle and fistula formation to the urinary tract.4’5In severe cases, chy luria can cause hypoproteinemia,

AbstractChyluria involves excretion of chyle into the urine, andworldwide is most commonly caused by lymphaticfilariasis. With filarial infection, irreversible lymphaticdamage can occui and chyluria isa late complication.We present a patient with chyluria from filariasis whounderwent laparoscopic nephrolysis with short-termsuccess, We also review the literature and discussThe pathogenesis, diagnosis, and managementstrategies available,

Susan L. Fraser MD

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nutritional deficiencies, iron deficiency anemia, weight loss, andabnormalities of the immune system.4’°’6

The initial evaluation of chyluria involves urinalysis and urineculture to evaluate for possible infection.4 Naked eye examinationof the urine after it stands ftr a few hours may reveal a film of fat.Further analysis includes Sudan stain to confirm the presence offat droplets. lipid electrophoresis to evaluate for chylomicrons, ormeasurement of cholesterol and triglyceride levels in the urine.47Ultrasound and lymphoscmtigraphy are useful in demonstratingevidence of abnormal lymphatic drainage, and are less invasiveand have less potential complications than lymphangiographv.Ss

If filariasis is suspected. eosinophilia is a nonspecific finding andperipheral blood smears should be obtained to evaluate for microfilariae .AntifIlarial antihod tests are available. butcannotdistinguishbetween active or prior infections, and also cannot differentiatebetween the tYpe of tilarial inlections. Circulating filarial antigentests are considered the gold standard to diagnose infections from

W hancrofti.Various strategies are available to manage chyluria. Conserva

tive measures include bed rest, abdominal binders that increaseintra-abdominal pressure to prevent further chvle leakage. anddietary modifications to include a high protein diet. and low fatdiets supplemented with medium chain triglycerides.’ Mediumchain triglycerides are transported from the gut directly to the liverthrough the pc i-tal system and bypass the lmphatic Instillation ofsilvernitrate into the renal pelvis can induce chemical lvmphangitisand tistula fibrosis nitiall in 5fl—8O’ of patients, hut relapses in23—5OC of patients occurred ss ithin two years.” Lvrnphannioxenour anastomoses also has e a limited success rate, postoperativechsluria secondar\ to incomplete fistula closure may persist in5O_6OC of patienls. The most effective and long-term treatmentoption involves nephrol si5. or surgical stripping of lymphaticconnections to the kidnes. which have been performed using opensurgical or laparoscopic techniques. There is an overall success rate of 98% with nephrolysis. hut the relapse rate approached25% after tsvo years of follow—up due to new tistula formation or

incomplete l sis. lncludingthiscase. nineteencasesoflaparoscopicnephrolvsis have been reported in the literature with recurrence ofchvluria in three of the total Jitients.5’” Nephrectomv and renalautotransplantatiun have also been described in patients who havefailed the above approaches.

ConclusionThere are numerous etiologies of ehvluria and also a variet\ ofmanagement strategies. In Hawaii. with the high likelihood of seeing patients from Ii anal endemic regions. it is important to have abasic understanding in how to evaluate and manage patients withsimilar piC5CiltLlt1oit5.

The rico’s v’s.scd in this article are those of the authors and donot reflect the o//o’ial policy orposmon of the Departnzent f theArmy, Department at’ De/imse, or the U.S. government.

References1.. World Health Organization. L.ymphahc FilarlaVs:The Disease and Its Control, WHO Technical Report

Series, 1992,821:1-5.2. Leder K and Weller P Ep:demiology: Pathogenesis and Clinical Features of Lymphatic Filariasis,

Available at: bpJ/w, tad cm. Accessed 1 May 2004.3. Zhang X. ed. Comparison of Open Surgery Versus Retroperitoneoscopic Approach to Chyluria. The

Journal of Urology. March 2003,189:991 -93.4. Palaclo A, ed. Parasitic Chyiur:a. Southern Medical Association. January 2003,96)1):110-1 1.5. Psi M and Yueh T. Lymphoscinography in Chyluria, Chylopentoneum. and Chylothorax. The Journal

of Nuclear Medicine July 1998 39(7)1292-96.6. Hemal A and Gupta N Retroperitoneoscopic Lymphatic Management of Intractable Chyluria. The

Journal of Urology. June 2002,16061:2473-76.7. Cortvriend J ed. Non-Parawt:c Chyluria: A Case Report and Review at the Literature, Ada Urologicai

Belgica. 1998.66i31:rl.158. LederKandWelier P D:agnosa.treatmentasd preventionot lymphaticfilariasis. Availableat http:/:www.

uptodate.com Accessed 1 May 2004.9. Chiu A. Cnen M and Chang L Laparoscopic Nephrolysls for Chyluria: Case Report of Long-Term

Success Journal of Endourology August 1995.9i41:319-22.10. Punekar S ed Surgical Disconnection of Lymphorenal Communication tor Chyluria:A 15-Year Experi

ence British Journal of Urology December 1997.8016:858.11 Gomella L. ed. Eatrapentoneal Laparoscop:c Nephrolyo:sfor theTreatment of Chyluria. British Journal

of Urology 1998.8r ,320-2r

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Until There’s A Cure

There’s The

American Diabetes

Association

Severe Hemorrhagic Complication ofTalc Pleurodesis for Idiopathic PleuralEffusion

Authors:Unwersity of Hawaii, John A.

Burns School of Medicine (B.K.HM.M,N., J.C.)Kuakini Medical Center Family

Practice Residency Program (S. I.Associate Professor. Univerwty

of Hawaii. John A. Burns Schoo(of Med/one (J,T)

Ccrrespondence to:Jinichi Tokesru MD1451 5. King St.. #209Honolulu, HI 96814

AbstractTalc isa commonir usea sc erosviQ aeon I forpleurodes/s However there have been recent reports of a

numoer of con)o/icateons associateo u7tt3trre use ct

talc. A/though t/crc iS significant data regarding therespiratory complications associated with talc, reportsofbleeding come//cations are extremely rare. We present the case of a 78 year-old man who was treatedwith ta/c pleurodesis for recurrent pleural effusion andsubsequently developed a massive hemothorax, arare complication.

IntroductionManagement of idiopathic pleural effusion is a controversial topic. The effusion may resole spontaneouslv or be treated with pleurodesis. Talc pleurodesisis a commonly employed technique for the treatmentof spontaneous pneumothorax and recurrent pleuraleffusion. The use of talc as an agent for pleurodesisis ascribed to Bethune, who used it in preparation forlung lobectomy in 1935.’ Due to impurities associatedwith earlier preparations of talc, tetracycline was theagent of choice in the United States until the 1980’swhen its production was discontinued for commercialreasons. As tighter quality control was placed on the

production of talc. its popularity increased making ittheagent of choice ft)r chemical pleurodesii. Preferencefor talc as a sclerosing agent is based upon its cost.availability, ease of use. and effectiveness in creatingpleural adhesions.” Regardless of its high degree ofeffectiveness, talc is not the perfect sclerosmg agentfor pleuroclesis. Its use is associated with a numberof complications. We present a case of hemothoraxfollowing tale pleurodesis in an elderly male treatedfor idiopathic, recurrent pleural effusion,

Case ReportA78 year-old Japanese-American man w itha30-pack-year history of smoking, asbestos exposure, coronaryartery disease with two coronary arter bypass graftsCABGv h\ pertension. diabetes and intermittent

swelling of his lower extremities was stable in hisusual state of health until the day of admission, whenhe presented to his primary care ph sician for recularcheckup. Upon examination, his ital signs were

within normal limits. 1-Ic was noted to ha e cracklesand diminished breath sounds over his right lungfield as well as bilateral pitting edema extending upto his knees. Chest x-ray (CXR) revealed right-sidedpleural effusion filling half of the lung field, and thepatient was subsequently admitted. Laboratory studies revealed: hemoglobin 10.3 g/dL. hematoerit 30%,platelet 136,000/mm3,sodium 126 mEq/L,total protein5.5 g/dL, and albumin 5.0 g/dL. Cardiac enzymesand urinalysis were hcth \vithin normal limits. Furo—semide was started on admission. and pitting edemasubsequently resolved. Echocardiograni showednormal ejection fraction and left ventricular wall mo—(ion. Follow up CXR was performed on the secondhospital day and showed no improvement in pleuraleffusion (Fig U. On the third hospital day one liter ofyellow, turbid fluid was removed by thoracentesis andanalysis revealed: pH 7.5 13. RBC 33731mm’. WBC110/mm3with 81 % neutrophils and 10% lymphocytes,glucose ill mg/dl. LDH 105 U/L, protein 3.3 g/dl.pretein fluid/serum ratio of 0.56, with the presence ofhistiocytes, mesothelial cells, and lymphocytes. Gramstain and culture of the fluid were negative.

On hospital day 5. CXR revealed reaccumulationof effusion and aspirin was discontinued. On hospitalday 7. his PTT. PT. and INR were 38 sec. 12.3 sec.and 1 .2 respectively. The patient underwent ideoassisted thoracoscop (VATS) that revealed diffuse.fibrotic, whitish plaques in his parietal pleura. and asmall posterior pleural mass. Biopsy of the pleuralplaques and the mass showed numerous hvperplasticmesothelial cells admixed with fibrin Malignancy wasnot identified. Twelve grams of talc was insuffiatedthroughout the pleural surfaces to produce pleurodesis. The morning after the procedure, the patient wasnoted to have a temperature of 100.7 “F, blood pressureof 90/40, and altered mental status. Arterial bloodgas revealed: pH 7.395. P0. 60 mmHg, PCO, 42.6mmFlg, HCO: 2ft4 mmoliL.. BE 2. and SaO, S6.6Hon 2L oxYgen. Hemoglobin dropped to 8.5 g dL. butreturned to baseline of It) g, dL after transfusion offour unit.s of packed red blood cells. Chest tube wasleft in place for three da s and a total of 500 ml of

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sanguineous fluid was collected. On day 7 CBC revealed white cell count of 11 .000 with 57ff segmentedneutrophils and 32ff hands Afterremoval of the chesttube the patient was noted to have diminished breathsounds on the right and recurrence of effusion \cas

suspeetedthus aCTscan was performed and revealeda massive heterogeneous effusion in his right thorax.suepestive of eit.her a hematom.a or ernpvema 1 H.71 On %pitai day l 7, right th.oraeotomv s.h owed

lied and sea.rred parletal. uleura and d ffuse he in

un3tme ice ml leura. Donna the proeedurc_ ‘-U ii

ml ut elotted blood ras e-vaeuated trout the pleuralisa wotent develo ad acute respitsiars Li! lute

and reautred mechanical eutilationin tile lC LI Chest s-mu revealed reaeeurnulattott of

I ntrathoraete and subcutaneous het nan una’-f total of I 300 ml of sauzuineous fluid sva’ drainedCrouch tOe chest tube. and several units of packadred blood cells fresh Cozen lasitia. and latelet

0 eta- transtused. On hospital Civ Sl the patient Is as

tninsterre—d to a skilled riursinc faeilitr %r rehahlita—

DiscussionChemical pleurodesis involves the niroduetion of aelerosine agent into the pleural space inducing fusion

ot the visceral and parietal pleura to prevent recurrence of pneumothorax or pleural effusion. Currently,tale is the agent of choice for producing pleurodesisn the [nited States. Tale is thought to produce

pleural adhesions by stimulating a local inflammatory response. causing mesothehal cell injur andtibroblastic proliferation, and decreasing Ii hrinol\ ticactivity.5-6Several studies have found tale’s abilit\to produce adhesion to he equal or superior to otherselerosants.ss Although talc is believed to he one

of the safest, cheapest, and most effective agents for

promoting pleural adhesion, there are a number ofreported complications.

Minor complications such as taehycardia (33%),5

fever (2.8-24% %tm0L0 and dyspnea (7-1 2%)° havebeen observed. Hypoxia and hypotension have alsobeen reported with eases ranging between 101 2%.and 1-12% respectively,°-°-5Other major complications that have been reported inc lode prolongeddrainage (4%)J airleaks (0.1-2.4%).”5re-expansionpulmonary edema (2.2 - I 2.3%),012 empyema (I .2

and acute respiratory distress syndromeI 3( 9%)Our patient had similar complications including

lever. hpoxia. and hypotension. He also des elopedhemorrhagic pleuritis, which has not been extenivelrdiscussed in the literature We conducted a Medlincliterature search, limited to English language andfound unIv three reports of bleeding complicationsassoeiatedw ith talc pleurodesis. One retrospeetis estudy showed that of 85 ptitieilts undergoing talcpleurodesis. unIv one des eloped postoperative bleed-

ing, Another study by Cardillo et al reported that I out of 69(1 patients developedhemorrhagic complications.0The third study reported that 2 out of 614 patientsdeveloped postoperative bleeding.° None of these three studies discussed thebleeding complication in detail.

The exact cause of the hemorrhagic pleuritis in our patient is unknown. We belies e that this patient’s coagulation profile, asbestos exposure. and pleural biopsydid not directly contribute to his post—operative bleeding. (‘oagulopathv was not amajor concern in this patient since he did not develop postoperatis e bleeding ss ithhis pres ious CABG surgeries. The patient had no histor of ss arfarin use, his PTand INR were within normal limits, and aspirin ss as discontinued tss o dar s priorto surgers. Exposure to asbestos may have contributed to this patient’s pleuraleffusion. Ilowever. it does not seem to he solel responsible for the hemorrhagicpleuritis. Diffuse, fibrotic. whitish plaques consistent with pres ious asbestosexposure ss crc noted on the parietal pleura during VATS. Hos es er at the time ofthoraeotomv on hospital das 17. bleeding was observed from the iseeral pleura.and not the parietal pleura. In addition, Aelons el al did not observe hemorrhagic

209

complications in three patients with asbestosis injury who underwent talc pleurodesisi7 Since the bleeding in this patient came from the visceral pleura, the biopsy,which was performed on the parietal pleura, did not contribute to this patient’sbleeding complication. The safety of video-assisted thoracoscopic pleural biopsyis supported by the study by Allen et al, which demonstrated no postoperativebleeding complications in 6 patients who underwent the procedure)3

Possible causes of hemorrhagic complications are the talc itself, the methodof talc application, and the amount of talc used. Although one animal studydemonstrated that intrapleural talc administration does not cause hemothorax.several other studies suggest that talc could cause damage predisposing a patientto hemorrhagic complications.S Studies in rabbits and rats have shown that talcdistributes systemically after intrapleural administration. In another study. anautopsy of a patient who died from acute respiratory distress syndrome showedtalc particles deposited in ipsilateral and contralateral lung. brain, liver, kidney.heart, spleen. and skeletal muscle) Thus. talc particles could hae entered thecirculation and caused damage to the vascular endothelium resulting in bleedingcomplications.

Talc delivered b insufflation may contribute to hemorrhagic pleuritis. Ourpatient and two other reported cases developed postoperative bleeding after talcinsufflation. The method of talc delivers is unknown in anothercase mentionedby Allen et al. In contrast, an animal study comparing anatomic and histopatho—logic results of four different methods ofpleurodesis including thoracoscopic talcinsuftiation. talc slurry abrasion, focal gauze abrasion b limited thoracotoms. andmechanical abrasion by thorascopv. observed no hemorrhagic complications.’Hosever. the studs ‘ sample site of 10 may have been too small to observe anybleeding complications.

Lastly, the amountof talc used may pla a role in the developmentofthe bleeding

complication. Our patient had 12 grams of talc insufflated to achiee pleurodesis.

Hoxever. postoperative bleedings have been reported at different doses. Bleedingcomplications s crc reported in Milanez et al’s study, which used only 2 grams oftalc, The study by (‘ardillo who reported one case of postoperative bleeding used5 grams of talc. 5 The amount of talc used is unknown in the study conducted bxAllen et al. who reported one case of postoperative bleeding. Rehse et al used It>grams of talc slurry and they (lid not observe any postoperative bleeding.’° Sincethe occurrence of bleeding complications varies with different doses of talc, it

is unclear s’. hethcr the I 2 grams of talc used for thispatient is dircctl responsible for the dc clopmcnt of

he morrh aoi c pie a riti s,

Conclusion1_sing tale as a se lerosine a.enr Pr pleuiodcsis is

comntonh accepted practice In thts case i cport.

cai —old man w ho nnderss cnt thora rscopiL Lilt

plcun dcsis dc eloped massic . ol cdin. P istopt. i atis c bleeding is a rare eornplt ‘ttiofl itt 11 1 irodcsis

\lthoueh the exact mcchanisn I ‘tWo L this patientinassib e hcmorrhaee rem tins nkno so th tiolosis most likels malt f to i’ It ma h th t ilritself the methodottal ‘ippli ‘ot s. n andt m antalL used. Our patient s oWes c p0 a and by htlpiolonged PT INR rc p oh’ bly of I 5 import’ nc\Ithoueh talc cfheac and ommon comphea ion

are ss cli do un nt ‘d it is import tnt to onsider poopei atib bI edin as a possible c. r compli ationFurther studies at needed to better understand thesafety and complications oi talc pleurod si

ReferencesBrrtbune N Fl poudr g n is’ qu for the d hb d opIe ira ad to pr limin o lob ctomy 3 T o S r 1

2 Cot H RussackV Cfv Y Ko OP R C tIe P Pede S iC Kaoei H CAcompar con of thoracos opic talc 5 uffl ton rry rd chant b,a on

pleurodesis Ch t 19 11112j 4 24483 Zimn’erP HtIlM C - yK Hare yE LowD P ospecttverandomtz dtriaio

sljrry vs bless yci in p1 erode sf0 ymptomatt mahgnant pleur ftc toChest 1997 11212t 430 434Ong K Indumathi V RagI r m J Ong V A compa ative rudy of pleurod auringtalcslurryanobleomycini them n g m ntofm lignan SI ur I if tonsRespirology 2000 599-103

5 Van den Heueel Talc-induced inflammation in the pleural cavity Eur Reapir1998 2 419-1423

6 Antony V Kamal M Godbey S Frank W Loddenkemp r P Talc aidrcedpleurodesis role of basic fibroblast growth factor lbFOFt ‘ Re Ps j ‘‘

0 40°S— Whillow C Cra R Brady K Hetz S Thoracco. rrc0 5’c a lb rr nocyr inc

talc in the porcine modrl Surg’cai Erocr:os ‘00w‘ ‘05’ 1050

8 Lignt RW Disea es of the oleura t5eu cf ‘ac ci. o-tr Curm’i Op norPulmonary tiedic ne 2000 nO. c55 258

9 Brant A Eaton T Sw-toss ccrnpicafionc wit r c “ o w.roe Re pirotuo2u0’ S’tl 185

‘C Rehne C Aye R F’orence M Renoi ato’1 falre o ‘swig talc pleurodecs AJSurgery 1999 177 5’ 437 440V 511313 Rcb F Astoui P Boutin C Tnoraco cop c :a poudraoe ocurodesTa iaa9t ‘fcsons a reciew of 36C case C”er’ ‘05 ‘ ‘ 38 ‘fiGS

2 M a”ez oe CenSor J ‘1w-gas F de Campos Wer oe E Ca doco P Tis re LJ’ene F Lig” R Tho’Gco coos ‘J. oodrrge 15-car oe C’20fl t’03 801 836A en i.IS Ds’ha”roc C ecr 3M t a Vdec A ..‘c Ti - rr a -

‘ocecu”s 10w p1-,” E’o”c”c’ Mayo C’ “to “‘r-” “a ‘5.0w —. 4 ‘5’

4 K”’LPc It—C” Pe’Or, “O”r

“04

cC Facc cc FC,s’- .-c 1 ‘Cc’” P - A Cliar:’ ti c”a ““‘ccoc’ . swc 5-c’: c c- -

—.

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M Residents’ Case Series

Insulin-Secreting Cystosarcoma Phyllodes of the Breast:A Case Report and Literature Review

Marc Herr MD, Mathew H. Chung MD, Christina Belnap MDand Donald A. Person MD

IntroductionTumorhypoglycemia is most commonly associated with insulinomassecondary to insulin production by the islet-cell tumor. Insulinomas are the most common pancreatic endocrine neoplasms. withan incidence of one case per million per year. They are rarelyectopic, with almost 100% ofdocumented tumors occurring withinthe pancreas. The majority occur sporadically (> 90%) and aresolitary.3 Lesions occurring in the setting of multiple endocrineneoplasia (MEN) type I syndrome constitute approximately 5% ofcases and may be multicentric within the pancreas.2

Almost all affected patients have symptoms due to hypoglycemiaand adhere to Whipple’s triad consists of: (I) symptomatic hypoglycemia induced by fasting, (2) glucose levels less than 50 mg/dL.and (3) relief of symptoms with administration of glucose.4Thesecriteria are fundamental forestablishing the diagnosis ofinsulinoma;however, they may also be used to indicate that presenting symptoms, in general, are caused by severe hypoglycemia.1In additionto insulinomas, symptoms may arise from non-islet-cell tumors.Doege reported the first case in 1930 when he described a patientwith a large fibrosarcoma and hypoglycemia. Since that time, anumber of similar cases have been described in the literature.5Thesetumors are generally large, slow-growing, mesenchymal tumors(e.g. sarcomas, fibromas, mesotheliomas, orhemangiopericytomas)located in the retroperitoneum or thorax.6Theunderlying mechanismof hypoglycemia appears to be the production of peptides with insulin-like structure and bioactivity that exerts an effect on the insulinreceptor.1

We describe a unique patient who presented with hypoglycemiaand a rapidly enlarging breast mass. Surgical resection revealeda cystosarcoma phyllodes tumor with insulin-secreting epithelialcells, We believe this to be the first reported case of a breast masscausing severe non-islet-cell tumor hypoglycemia.

Case ReportA 33-year-old. nulliparous. Marshallese female presented to MajuroHospital in March, 2000 with complaints of generalized weakness.At that time, she was found to be profoundly hypoglycemic. Thehypoglycemia responded only to infusion of D111, with occasionalneed for D51 boluses, She had no history of diabetes mellitus anddenied taking any medications. Initial evaluation also revealedmassive enlargement of the left breast. She denied having any painor constitutional symptoms. The patient’s mother reported havingnoticed the enlargement only 3 weeks earlier; however, sufficientdetails regarding the breast enlargement were difficult to obtainsecondary to the patient’s mental derangement and the mother’spoor history. Apart from her mental illness, the patient had no

significant past medical history. She had always been short andsmall, hut otherwise developed normally until the age of 27 whenher mental status deteriorated abruptly. She stopped taking careof her personal hygiene. often showing no interest in eating or herown safety. Her sister had visited the Marshall Island within thepast year and had not noticed any breast enlargement at that time.Menarche was at age 15 and she reported regular monthly cycles..There was no family history of breast or ovarian cancers.

The patient was air evacuated to Tripler Army Medical Center,where she was promptly taken to Emergency Room for deteriorationof her mental status. She was severely obtunded with questionableairway compromise. On arrival, her serum glucose level was 55mg/dL. Following an infusion of D, her glucose levels remainedlow at 24 mg/dL. Additional glucose replacement finally succeededin normalizing her levels with subsequent improvement ofher mentalstatus. During her hospitalization, normal glucose levels could notbe sustained with regular meals; therefore, she was started on a D10infusion, which was titrated to maintain euglycemia.

On physical examination, the left breast was massively enlarged(Figure 1). There was a firm, freely mobile, non-tender mass involving all four quadrants of the breast. The overlying skin was shinywith mild hyperemia and visible, dilated veins. No discharge wasnoted from either breast. Examination of the right breast revealedtwo discrete, firm, mobile 1 cm nodules in the upper outer quadrant.No axillary, supraclavicular, or infraclavicular lymphadenopathywas noted, Examination of her skin revealed extremely small handsand feet with multiple old scars on her lower extremities bilaterallyand lesions on her upper extremities in various states of healing.Remainder of the physical examination was unremarkable.

The patient’s laboratory work-up was significant for: normal liverfunction tests and pancreatic enzymes, a glucose of 25 mg/dL andinsulin level of 39 izU/mL while fasting, C-peptide = 0.4 ng/mL,Insulin-like Growth Factor (IGF)-I 59 ng/mL, Insulin-like GrowthFactor (IGF)-II = 330 ng/mL, a random cortisol level of 8.8 ig/dL,and a TSH = 1.62 ulU/mL.

Mammography showed diffuse enlargement of the left breast.A core needle biopsy demonstrated that the mass was consistentwith fibroadenoma vs. cystosarcoma phyllodes tumor. Abdominalultrasound revealed a normal liver, gallbladder, and pancreas. CTscan of the abdomen/pelvis, including her pancreas, did not showany abnormalities.

She was taken for simple mastectomy on 15 May 2000. A firm,irregular, lobulated mass measuring 18 x 16.5 x Il .5cm was excised.Each lobule had a papillary appearance surrounded by a thick fibrousrim with prominent vascular channels. The cut surfaces exudeda scant amount of gelatinous to highly viscous clear fluid as well

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as multiple areas of cho’olatc bros n. distorted sacs. Pathologicexamination clas sitied the inas’ as a massive. lois —grade phx ilodestumor. Sections shon ed the tumor to he composed of broad leaf—likeprocesses ith spindled. mildix cellular stroma without cytologic

atvpia and univ rare mitotic tigures. Immunohistochemical stains

liar insulin ‘tere focail\ positi\ e in the epithelial cells (Figure 21.Immunostains for CK1)03 and smooth muscle actin were also evaluated and revealed a mosaic pattern of staining in the hvperplasticepithelium within the tumor.

The patient did well postoperatively with resolution of her hypoglycemia. She u as discharged on post-operative day 3. She hashad no evidence of hvpoulycemia to date, on follow-up.

DiscussionWe report a patient ss ith a laree. well—differentiated cystosarcomaphvllodes tumor st ho presented with a history sieni licant for weakness. altered menial latus in the tasted state, and symptolns consistent

ss dli Vhipplc’ triad The difteicntial diaenosis liar such a patiemL 01 ci c ,d a n id 1 h ,lx il I

patient as on no medications, ‘ionnil C-ocptide levels

factitious hs oeivecmd, Thus. ssc faa ucd on thee the hkel culi it

The nialorita ofiosulinomux am less than 7. cm, benign, and. w .1 it.arv,”Thc are almost cxcioi intrapancreatic, with approximated

tI tumors being located in the body and tail of the pane reas.to the left of the supurior mesenteric arteryd This distributi.on seemsto correspond to the normal distribution of insui.i..n cells with.i.n thepancreas. Howes en up to ten percent of i.n.suhnomas are• malignant.and thus, ntetastatic Metastases are found most commonly in the.surrou.nding ‘mpti nodes a.nd liver. Furthermttre, muiti.centric. lesions are found in the meonitv of pat.ient.s with MEN I syndrome.Radiological studie.s in our patient failed to detect any suspiciousmasses in the pancreas; therefore, we suspec.ted. her breast mass toIc tb. primary source of h..er symptom

Ectopic insulinomas are exceptionally rare. A retrospective studyby the Mayo Clinic examined the institution’s sixty-yearexperiencewith insulinoms from 1927 to I 9867 This investigation describedonly one ecu pie tumor in a cohort of 194 patientsd Although thespecific location of this trunor was not discussed, the surgical procedures for all patients in the study were intraahdominal, suggestingits development st ithin the abdomen, No ectopic insulinomas werereported in additional studies that encompassed over three decadesof clinical experience. A Medline literature review from theyears 1902 to 2003 found no record of an insulinoma presenting as

a breast mass.Ci.)re biopsies of the patient’s breast mass indicated that it was

I ikelv a c stosarcoma phvl lodes. an uncommon fibroepithelial neo—plasm of the breast that accounts for 0.3-0.9fa of all breast cancersin females. Although similar in structure to a fibroadenoma, thetumor may be distinguished histologically by large leaf—like projections of stronla with increased strornal cellularity. -‘The biologicalbehavior of these tumors is highlr variable, and the criteria fordifferentiating between malignant and benign neoplasms remainpoorl delined. Surgery is the primary mode of treatment .Althoughradical mastectom\ tt as performed in the past. more conservative approaches are noss recommended. Currently, the choice is

made between ts ide local excision with I cm margins vs. simplemastectom\ without a\illarv clearance.’1 While recurrences are

not unc( mnion with these lesions, a number of recent studies haveshott n that wide local excision with negative margins yields local

control rates ot approximatel\ 99(‘ Due to the laree size of the

tumor in our patent. we elected to perform a simple mastec tom\.

Pathologic ret en ret caled a cr stosarcoma phvliodes tumor n ithinsulin-secreting epithelial cells. The absence of islet-cells suggested

that this mass, although insulin—secreting, was not of pancreatic

origin, and thus St as not an ectopic insulinoma.Although non-islet-cell tumor hypoglycemia (NICTH) has been

reported in several neoplasms of mesodermal and epithelial origin.

to our knots ledge. there have been no cases of NICTH in patientswith cystosarcoma phllodes. The tumors tend to he large and

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welhdifferentiated, as in our patient. However, patients with NICTHgenerally demonstrate low or unmeasureable levels ol serum insulinduring hypoglycemic episodes. Recent studies have explained thisparadox by suggesting that peptides with an insulin-like structure,especially insulindike growth factor (lGFhll and an incompletelyprocessed IGFII propeptide (“big” IGF-ll), may he responsible.In contrast to this typical presentation of MUTE-I, our patient wasfound to have elevated insulin levels as well as decreased levels ofIGF—l and IGF—II. Histological evaluation of the tumordemonstratedinsulin-secreting cells.

Medical treatment thr insulinomas and NICTH-causing lesionsis generally either palliative or used only while awaiting surgicalexcision of the lesionle Surgical therapy is typically curative andcontinued hypoglycemia following tumor resection is suspiciousfor the presence of multicentric lesions or metastases. Surgeryis also the mainstay of treatment for patients with cystosarcomaphyllodes. Our case is interesting in that etiology of our patient’shypoglycemia was an insulin-secreting cystosarcoma phyllodes.Furthermore, histological and laboratory evaluation revealed thatthe lesion was neither a true ectopic insulinoma, nor was it typicalof a NICTH-causing tumor. Despite these unique characteristics,definitive treatment was straightforward. Simple mastectomy ofthe affected breast provided complete resection of neoplastic tissuein addition to resolution of the patient’s hypoglycemia. In the end,this case serves to illustrate another rare, but plausible, culprit inthe differential of tumor—induced hypoglycemia.

This article contains the opinions of the authors only and does notrepresent the opInIons oft/ic United States Department of Defenseor the United States Army.

ReferencesTietge 1j,J,E, SchOfi C, Ocran KW, et aL Hepatoma with Severe Non-Islet Cci Tumor Hypoglycem[a.The American Journal of Gastroenterology 93(6): 9971000, 1998.

2. Bieligk 5, Jaffe SM. Islet Cell Tumors of the Pancreas. Surgical Clinics of North America 75(5): 1 025-40, 1995.

3. Dolan JR Norton JA. Occult Insulinoma, British Journal of Surgery 87: 385-7, 2000.4. Grant CS. tfsulinoma, Surgical Oncology Clinics of North America 714): 819-44, 1998.5. Daughaday WH, Emanuele MA, Brooks MH, ef al. Synthesis and Secretion of Insulin-Like Growth

Factor Il by a Leiomyosarcoma with Associated Hypoglycemia, The New England Journal of Medicine31 9(22): 1434-40. 1988.

6. Auelrod L, Ron D. Insulin-Like Growth Factor II and the Riddle of Tumor-Induced Hypoglycemia. TheNew England Journal of Medicine 319(22): 1477-9, 1988.

7. Richards ML, Gauger PG. Thompson NW, et al, Pitfalls in the Surgmal Treatment of Insulinoma,Surgery 132(6): t040-9, 2002.

8. Howard TJ, Stabile BE. Zinner MJ, et al, Anatomic Oistribution of Pancreatic Endocrine Tumors. TheAmerican Journal of Surgery 159: 258-64, 1990.

9. Service FJ, McMahon MM, O’Brien PC, Ballard DJ. Functioning Insulinoma — Incidence, Recurrence,and Long-Term Survival of Patients: A fioYears Study. Mayo Clinic Proceedings 66: 711-9, 1991.

10. Jordan, PH. A Personal Experience with Pancreatic and Duodenal Neuroendocrine Tumors, Journalof the Amerrcan College of Surgeons 189(5): 470-82. t999.

11, Menegauv F Schmitt G, et al, Panc.reatic Insulinomas, The American Journal of Surgery 165:243-8,1993.

12. Pandey M, Mathew A, Kattoor J, et al. Malignant Phyllodes Tumor, The Breast Journal 7)6): 411 -6,2001.

13. Chancy AW, Poliack A, Mcneese MD, et ai. Primary Treatment of Cystosarcoma Phyllodes of theBreast, Cancer 89(7): 150211 2000.

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AMERICAN ACADEMY OF DERMATOLOGY

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Medical School Hotline

JABSOM’s Post-Graduate Evaiuation:The Intern and Residency Program Director

Marlene Lindberg PhD and Richard Kasuya MD, MSEd

BackgroundThe University of Hawaii John A. Burns School of Medicine (JABSOM) launched the first phase of a comprehensive new programevaluation system in 2001 A key component of the system is aseries of surveys administered to students at the end of each courseand clerkship during their four years of medical school. In 2002,the school added two new surveys to the series, the Intern Survey,which is sent to graduates near the end of their intern year. and theResidency Program Director Survey, sent simultaneously to directorsof residency programs in which .[ABSOM graduates are completingtheir intemships. JABSOM also sends surveys to alumni six yearsafter graduation, at which time most are expected to have completedtheir post-graduate training. The surveys provide valuable feedbackthat helps guide ongoing curricular decisions.

Intern and Residency Program Director SurveysIn the two years that the surveys have been administered, the returnrate has been 67% for interns and 83% for residency program directors,’’ Approximately half of the graduates who replied to the InternSurvey in 2002 and 2003 are in Hawaii residency programs and halfin mainland programs. Currently, JABSOM graduates are locatedacross the U.S., some in highly competitive residency programsincluding Stanford, UCLA, Northwestern, Mayo Graduate Schoolof Medicine, University of Chicago, Harvard, Yale, Georgetown.and Columbia Presbyterian.

Graduates are asked to take a moment to reflect on their internyear and then rate their medical school preparation for internshipon 22 items, using a four-point Likert Scale. The items tap specificskills that fail into four broad categories (1) life-long learning, (2)patient management, (3) oral and written communication, and (4)professional and ethical behavior. A few examples of survey itemsthat address each of the categories follow, Items that focus on lifelong learning include (a) appraising medical literature and applyingit to the care of patients. (b) evaluating own knowledge, skills andperformance, and (c) conducting independent, self-directed study.

Examples of patient management items include (a) formulatingproblem lists and differential diagnoses, (b) developing and carrying out comprehensive management plans, (c) applying clinicalreasoning and problem-solving, and (d) understanding importantadvances in the clinical and biological sciences. Examples of oraland written communication skills include (a) communicating effectively with colleagues and other health professionals, (h) teachingmedical students and other healthcare providers, and (c) teachingpatients and their families. Examples of professional and ethicalbehavior include (a) communicating compassionately with patientsand families, and (h) considering the effects of health care costs onpatients and providers.

In addition to completing the ratings, graduates are asked to provide narrative feedback to a set of questions addressing what theymost and least valued about their JAB SOM learning experiencesand what topics they wish had been more and less emphasized inmedical school. Their written responses add detail and richness tothe quantitative data.

The Intern SurveyThe findings of the intern survey have been favorable, with ratings.averaged overthe two years, ranging from 3.0, “adequately prepared,”to 3.8, just slightly below the 4.0 rating of “well prepared” on allbut one item. Graduates gave the lowest rating (2.6) to the item thataddressed preparation to consider the effects of health care costs onpatients and providers.

In response to the question, “What do you most value about yourJABSOM learning experience,” the resounding response was “problem-based learning.” Many graduates also added “early exposureto patients.” Sample responses in the graduates’ own words are:’

“Mv JABSOM learning experiences were great. I learned how toanalyze information critically and the curriculum gave inc the toolsto be a life-long learner”

“P131. and self-directed Iearning...Exposure to patients from thebeginning of medical school... Teamwork, camaraderie, and anenvironment that is conducive to learning.”

“Whole person thinking and evaluation of patients and illnesses,’putting all pieces together in a fifg picture.”

“I. Flexibility. 2. Compassionate care. 3. Taught me to approachpatient problem from a multi—dimensional approach.

“How to attackproblems systematical/v. Open atmosphere to discussproblems. How to be a good teacher

‘Independent learning and dissecting HCP cases ...getting to seepatients and MDs in l and 21 years, too.

“I’ve realized that at .J.4BSOrVI we had a lot more opportunity fuìrhands on learning than I see the students here getting.

“The confidence we gain from patient contact for fpjty years.

“Ifrel that I got an excellent education @ JABSOM. Ifrel well,or even hette, prepared fur clinical medicine as compared to my

HAWA% MEDCAL JOURNAL, VOL 63, JUlY2004

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mainland trained colleagues @ my level of training.”

“...Now after 12 months, I feel very strongly that I was well prepared, andproblem based learning was the best tool to do that bothclinically and academically.

“...Atflrst I was skeptical about PBL. Now I realize that it works andI am having fun in my internship year. I’ve worked with residentsfrom such programs as Yale, Harvard and Boston — Jam adequatelyprepared (if not more) as compared to my counterparts.”

“Ididn ‘t realize how muchproblein-hased learning helped with beinga good intern. I knew that I would he bringing something di’erentto my program but didn ‘tfrel confident in my knowledge. thinking 1had a lot of gaps in my knowledge. Its amazing what I was able topull out ofmy head.As lam completing my internship year I cannotbelieve how much (ff a heads up JABSOM gave me. Things that Idid at the beginning of the year my classmates are just starting todo. For example, citing the literature and teaching our students tobreak down a case and ask ‘What are the learning issues involved?’It:c difficult ftr me to think I’m setting the standard for people inmy internship class because 1 was just an average student at JABSOM.. Even when taking Step 3, 1 kept all my JABSOM materials,the PBL cases! freud over the learning issues we had madefor eachother to studs’! I had very little time to study but passed by flippingthrough year 1 and year 2 materials. Thank you.”

“PBL— self directed, lifelong learning, which is exactly whatphysicians do everyday.”

“That it was stressed not to memorize but to think through situations.The practice of looking up literature to help care fr my patients.The practice of teachmg others/communicating what I learned. Allof these things got me named intern of the year in my program.”

As effective as JABSOM graduates believe their school was inpreparing them for residency, their feedback suggested two additions to the curriculum, one of which was to provide more basicscience lectures and the other to better prepare students to considerthe effects of health care costs on both patients and providers.

The Residency Program Director SurveyItems on the Residency Program Director Survey are essentiallythe same as those on the Intern Survey, but written from a teacher’sperspective. Using a live — point Likert Scale, program directorsare asked to evaluate the performance of JABSOM graduates incomparison to others in their intern class. Directors also are askedto comment on graduates’ strengths and weaknesses.

The Residency Program Director Survey findings also have beenfavorable. Averaged over two years, directors’ ratings of JABSOMgraduates at the end of their intern year ranged from 3.8 to 4,3, Arating of 4.0 on the five - point scale = “above average.”45

In response to the question, “What do you believe are this intern’sstrengths,” residency program directors most frequently describedJABSOM graduates as hardworking, intelligent, knowledgeable,competent, collegial, committed, compassionate, caring, enthusiastic learners, and professional team players. Also noted were theirinteipersonal skills and patient rapport.

In response to the question, “What do you believe are thisintern’s weaknesses,” many directors said they saw no weaknessesin JABSOM graduates. Those who did see weaknesses most oftendescribed them as (a) a lack of confidence or (b) a lack of “basicknowledge.”

Acting on the survey feedbackAlthough the preponderance of feedback given to us by interns andtheir residency program directors has been positive, the JABSOMCurriculum Committee has chosen to act upon the two mostprominentsuggestions offered by graduates: to increase instruction in the basicsciences and health care costs. A Basic Science Foundations serieswas implemented in the fall of 2003 in years I and 2 of the curriculum and the Unit Chairs Committee is currently developing a planto place discussion of health care costs in appropriate courses.

ConclusionThe survey results suggest that JAB SOM students are well preparedfor postgraduate residency training. The school values the feedbackof its graduates and those who oversee their postgraduate residencytraining, and uses this information to monitor, reaffirm, and improvethe quality of the educational experience it provides.

ReferencesKasuya, R, Arakaki L, Lindberg M, & Sakai D. The role of program evaluation in medical education atthe John A. Burns School of Medicine. HMJ. 2003:62:254-256

2. Intern survey: Report of findings. Internal document of the University of Hawaii, John A. Burns Schoolot Medicine. 2002.

3. Intern survey: Report of findings. Internal document of the University of Hawaii, John A. Burns Schoolof Medicine. 2003.

4. Residency Program Director Survey: Report of findings. Infernaldocument of the University ofHawaii, John A. Burns School ofMedicine of Medicine, 2002.

5. Residence Program Director Survey: Report of findings. Internaldocument of the University ofHawah. John A. Burns School ofMedicine. 2003.

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215

Ib Cancer Research Center Hotline

Reducing Cancer Disparities for and withNative Hawailans

Lana Sue I. Ka’opua PhD

OverviewAdvances in cancer care, prevention education, and the relativelywidespread availability of routine screening for many types ofcancer are credited with the unprecedented decline in overall age—adjusted cancer mortality rates of recent years. ‘- Hov ever, not allsegments of the U.S. population have benetited from these advancesand disparities or differences in cancer incidence, prevalence, andmortality. are experienced h certain ethnic/racial and medicallyunderserved groups. Native Hawaiians. whose ancestors settledthe Hawaiian Archipelago prior to 1778. are among those groupsmost heavily burdened by unequal suffering and death from can—cer.’ This update briefly details current incidence and mortalityrates experienced by Native Hawaiians. identities considerations fordeveloping interventions, and highlights efforts of the Preventionand Control Program of the Cancer Research Center of Hawai’iand its community partners to improve cancer outcomes with andfor Native Hawaiians.

Native Hawaiians and the Cancer BurdenResidents of the State of Hawaii enjoy some of the best healthindicators in the U.S., including the longest life span and the lowest cancer mortality rate of any other state (161 .6 per I 00.000 tothe national average of 206.0 per 100.000).’ Yet against this generally salutary backdrop exist less than favorable cancer outcomesfor 1-Iawai’i’s indigenous people. In national comparisons, NativeHawaiian men rank second highest in overall cancer mortality rates(African Americans are first) and Native Hawaiian women are tiedwith their African American counterparts for the second highestmortality rates (Alaska Natives are first).2

Native Hawaiians. including those of full and part-Hawaiianancestry, comprise 19.8% of Hawai’i’s population and are thesecond largest ethnic group. In comparison to other major ethnicgroups (Caucasians, Japanese, Filipino. Chinese) in the state. Native Hawaiians experience the highest overall cancer incidence andage-adjusted mortality rates, as well as one of the highest incidencerates of cancers diagnosed in late stages.

Three malignancies—breast (female), colon and rectum. and lungand bronchus—contribute substantially to the Nati e Hawaiiancancer burden.’ Native Hawaiian men have the highest incidencerates for lung and bronchus cancer and Native 1-Ia aiian womenhave the highest incidence and mortality rates for breast cancer.Native Ha aiian men and women ha e the highest mortality ratesfor lung and bronchus cancer, as ‘ eli as cancer of the colon.

Considerations in Reducing DisparitiesCancer disparities are often reported by ethrnc categories ithvthnicits enei ills usLd is a piox for sO. ioL(.onomiL st itLis ( SFS

and/orcultural norms and mores.4The relationship ofethnicity. SES.culture. and health outcomes may be a meaningful one for furtheringthe understanding of cancer disparities and developing strategiesto reduce the cancer burden among Native Hawaiians. Moreover.Native Hawaiians share a distinct cultural tradition, a unique historyof socioeconomic and political disadvantage, patterns of low healthservices and preventive screening utilization, and some of the poorest health indicators in the state. as well as in the nation.5As such.there is a need to better understand how these cultural. historical,and demographic variables affect cancer prevention. etiology, andtreatment. Thus, the challenge of reducing cancer disparities amongNative Hawaiians is a complex one. a/bell, critical and urgent tothe nation’s overall health. The National Cancer Institute (2004)25

affirms its commitment to reduce the burden of cancer among allsegments of the population and identities the need for research intwo related areas: First, to increase theoretical and conceptual understanding of the ways in which social position. economic status.health services delivery, and cultural beliefs and practices influencecurrent disparities; Second, to develop. implement. and integrateeffective interventions aimed at prevention and control of cancersthat contribute to the disproportionate burden of suffering and deathborne by ethnic minorities and the medically underserved,

At the CancerResearch Centerof Hawaii (CRCH), University ofHawai i, we are dedicated to understanding the fundamental causesof disparities experienced by Native Hawaiians and other diversepeoples living in the state. The CRCH Prevention and Control Program brings a multi-disciplinary group of scientists and heaithcareprofessionals together to collaborate in understanding the multipleand complex factors influencing disparities. Such understandingserves as a basis for the development and testing of interventions toprevent cancer and improve control of disease once it is diagnosed.In the CRCH Prevention and Control Program otir overall aims andactivities include:

• Decreasing cancer incidence and avoiding excess mortalitythrough interventions that encourage routine use of early detection screening, promote behaviors to reduce cancer risk, andfacilitate access to participation in clinical drug trials.

• Improving patient outcomes through the de elopment at dice—tive disease management and comprehensi\ e clinical care.

• Enhancing the qualit of. life experienced by cancer patients,survivors, and their significant others through effective supportive care services that are culturally acceptable and communitv -relevant.

216

Collaboration in Research for and with NativeHawaliansNational and state initiatives emphasize the important role thatcommunities have in eliminating disparities.-5Application ofCommunity-Based Participatory Research (CBPR) principles7intointervention research seems especially relevant for Native Hawaiians because of their reluctance to he research “subjects” or “guineapigs” Nati e Hass aiians have not always benefited from past researchconducted in their communities and in some instances, have evenbeen harmed: such experiences have fostered caution and distrustof research: As indigenous Hawaiian communities and groups havegrown in organizational strength and capacity. they have advocatedfor i-c—mediation of the historic power imbalance in conventionallyconducted research and have insisted upon meaningful collaborationcharacterized by respect forcommunity expertise. shared leadership.and tangible benefits to communit residents: namely those valuesassociated with CBPR,57

Research partnerships involving members ofaffectedcornmunities,as well as health care professionals and university-based researchersmay have a profound impact on the development and implementationof effective interventions. The positive potential of such a partnership was exemplified in the landmark Wai’anae Cancer ResearchProject,u a live-year study funded by the National Cancer Instituteto test a culturally tailored, community-based intervention aimedat promoting adherence to routine screening guidelines and medical follow-up to suspicious and abnormal screening results. Studyfindings strongly suggest that this intervention derived from NativeHawaiian social mores and informed by community residents acrossall phases of the intervention, offered the prospect ot reduced breastandcervieal cancermortalityforNative Ha aiian women living in asocioeeonomicallv disadvantaged, vet culturally rich communit.

Current efforts ofthe CRCH Prevention and Control Program buildon knowledge gained from this study and on the positive relationshipsforged through collaborative work with the Wai’anae communityand other Native Has aiian community—based health organizations.As a direct result. se are engaged in active collaborations withimi Hale ——the Native Hawaiian C’ancer Awareness Research andTraining Network funded by the National Cancer Institute’s SpecialPopulations Network— and other community-based organizationsserving predominantly Native Hawaiian groups. Examples of ourcollaboration for and with Native Hawaiian communities are many5°and include:

• Descriptive studies of knowledge. attitudes, and practices(KAPs) associated with cancer treatment trials among oncologists and among physicians serving predominantly NativeHawaiian patient populations, and Native l-lawaiian survivors’perceptions of harriers and support to treatment seeking.

• Technical assistance and ongoing scientilic support to assessneeds, further strategic plannine. and den elop a community—based research infrastructure (i.e.. imi I lale aimed at improving cancer outcomes among Natin e Hawaiians.

• Mentorship to advance the scientific careers of a cadre of Native Hawaiian researchers currently engaged in pilot mterven—tion studies to increase colorcctal and breast cancer screening.

to enhance patient skills in accessing treatment-related information, and to enhance social support and coping with cancerdiagnosis and treatment among patients and families. Notably.these studies integrate salient l-lawaiian values and practicesand actively involve Native Ha\vaiian organizations and socialnetworks.

ConclusionsReducing the cancer burden through prevention and control inter—entions for and with Native Hans aiians is a priority for the CRCH

Prevention and Control Program. While current research to reduce theunequal suffering anddeath experienced by Hann ai’i ‘s native peopleis in a relatively early stage of development, a critical foundationis being laid for future intern entions that may effectively addressdifferences in cancer outcomes. To advance this work, continuingcollaboration between CRCH and its community partners is essential. In the journey to discover effective means for addressingdisparities among Native Ha aiians. we areoptimally, guided by thetraditional native wisdom: “Ho ‘okohj ka ‘ilau like ana” or “Wieldthe paddles together— work together” [1Oj.

For more information on the Cancer Research Center of Hawaiplease visit our website at www.crch.org.

ReferencesArrerican Canc r Society H wai Pacihc Inc Hawai cancer fa ts and tigure 200 004 Author

Honoluiu HI 2003

2 Miller BA Kolone LN B rn I in L et aI Eds Racal ethnic patterns of cancer in the United Staten

1988-’ 992 NIH Pub No 96410 National Cancer Institute Bethesda MD 1996

National Cancer lnst:,.:e “

nation c nvestmeni r

_______________________________________________________

research A olar ano D.dOe1proposal for hear 2005 A,.rorntIS plan canceraovdisoarc.es3rt!2004

4 Williams DR & Collins C USocroecor’omic and ruci dif

ferences in heaith Patter” andespluratiorm Anrual Revw ofSociolosy 21 3us-385 ‘can

Form M Brau” KL T.,,

In proung Nativu Hama — rca.,

throjah communit-bas d partiuoato’y caearch Californi nJo,’nalo’Heal Promotion Aloha Laboratorie Inc

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HAWAIi MEDICAL JOURNAL. ‘O•. 02. .J1JL( 2004

217

Hawaii Medical Journal (Guidelines for Submission)

ManuscriptsSubmit scientific articles, essays, letters and other manuscripts toHawaii Medical Journal, 1 360 South Beretania Street, Suite 200,Honolulu. Hawaii 96814.

Manuscripts are reviewed by the editor, the peer review panel.and other experts in the particular specialties. Please be aware thatyour article will be edited to comply with the AMA style, correctedfor grammar, and recommendations could be made by the peerreviewer.

Please submit five copies on 8-1/2 x II paper. It is recommended the article be submitted on a floppy disk or CD withthe manuscript. Please indicate what software you are using(Micosoft \\‘ord or Word Perfect). Submit only articles thathave not been submitted elsewhere.

• Use Times font in 10 point size.

• Please do not underline and do not use full caps.

• Use double spaces between lines. Do not use 1-1/2 spacing.

• Number pages consecutively beginning with the title page.

• Graphs. tables and figures must he sized by the author.up to 7-1/2 inches in width. Please make graphs separatefrom text.

A cover should contain the name of the author with whom HMJwill correspond. include an address, phone number, fax numberand pager if needed, along with a statement that the manuscripthas been seen and approved by all authors.

Title and Authors’ NamesPlease keep the title short, specific and catchy if possible. If thetitle submitted is too long, it will be edited. List first name, middleinitial and last name of each author with highest academic degrees:name of department and institution to which the work should heattributed: name and address of authorto whom requests forrepriniswill be addressed, or statement that reprints are not available: thesource of support in the firm of grants. equipment. drugs. or allof these.

Abstract (see Synopsis-Abstract)The second page of the manuscript should include an abstract nolonger than 60 words that highlights for the reader the essence ofthe authors’ work. It should focus on facts rather than descriptionsand should emphasize the importance of the findings and briefly listthe approach used for gathering data and the conclusions drawn.

Style[se JAMA style or consult the AMA Ma,mcil of Style. Use theobjective case, such as “the team determined” or “the study in‘olved. not I or v e. and as otd medical jargon. Use generic drugnames unless citing a brand name relevant to your finding’s. Do notusc abbreviations in the title and limit their use in the text.

TextHMJ recommends that articles be divided into sections with headings:

Introduction.—The purpose of the article and rationale kir thestudy. Do not review the subject extensively.

Methods. — Describe the patients or experimental animals clearly.Identify the methods, apparatus, and procedures in sufficient detailto allow other physicians to reproduce the results.

Results.—Present the results in logical sequence in the tables,illustrations, and tables. Do not repeat all of the data in the text.summarize important observations.

Discussion. -—Emphasize the new and important aspects of the studyand conclusions taken from them. Do not repeat data in Resultssection. State iiess hypotheses when warranted, but clearl labelthem as such. Recommendations may be included.

Illustrations, Tables, Graphs and FiguresTables and graphs must be prepared in Mircosoft Word or Excel.Numerical data should accompany graphs.

Each figure or illustration should have a label pasted on the backindicating the figure number, name of authors, and the top of thefigure. Do not write on the back, or scratch or mar them with paper-clips.

Illustrations must be clear, distinct, and unmounted. Please limitthe number of illustrations.

Figures should be done on a computer or professionally drawnand photographed.

Type legends for illustrations starting on a separate page witharabic numbers corresponding to the illustrations. When symbols.arrows, numbers or letters are used to identify parts of the illustration, identify and explain each one clearly in the legend. Explaininternal scale and identify method of shining in the photographs.

ReferencesAll references must be cited in the text and should he arranged inthe order in which they are cited—not alphabetically. Please usethe JAMA style for the references:

1 Jones J. Necoflzng Candda esophaets JAMA. 1982.2442190-21912 Style L. Bloctiernsry 2nd ed San Frarrscc Calf WH Freemar Co ‘o15d9.5Q5 lNn CA3 “ nd 1h at IFS 0 — -, ar nat “p

‘1 5’8 UflIted States. n Se:by P ed. inenzaVnus. taccnes. and Strategy Orlando, F a Acaden.c.Ptess Inc. 96 29n308

AcknowledgmentsAcknowledge only persons who have made substantial contributionsto the study. .-\itl(.)rs are responsible forobtaining written permissionfrom everyone acknowledged by name; readers might believe thoseacknowledged are endorsing the study and conclusions.

ReprintsAuthors may order article reprints for a fee; however, a copy ofthe Journal will be sent to each author from which photo-copiesmay be made,

Synopsis-AbstractIn thsage ofeleclronicdataretrieval. a elI—sr ritten synopsis-abstracthas become increasingly important in directing readers to articlesof potential clinical and research value. The synopsis—abstract sum—manzes the main points of an article: (I) the purpose of the study.(2) the basic proccdurcs folloss ed. 3 the main findings, and 4)

the principal conclusions. Expressions such as “X is described,”“Y is discussed,” “Z is also reviewed” should he avoided in favorof a concise (limited to 135 or 150 words in AMA’s journals)statement, A few specific guidelines to consider in preparing asynopsis-abstract follow:

• Do not begin the abstract with repetition of the title.

• Omit P values,

• Cite no references.

• Avoid abbreviations.

• Use the salt or ester of a drug: at first mention.

References to WebsitesI. Roth AE. Report on the design and testing of an applicantproposing matching algorithm, and comparison ith the existingNMRP algorithm Idesign review of the National Resident MatchingProgram home page]. December 6, 1996. Available at:.hitp//wwv.

itedu/aJTQth/phse,1htrni. Accessed August I. 1997.

2. Ameican Medical Association-Medical Swdent Section. American Medical Association-Medical Student Section resolutions forthe 1995 interim meeting f Texas Medical Association Web site].Available at: igfp//ww.bcm.tmc.edu!ama-mssii95res.htm#11.Accessed August 1. 1997.

• If an isotope is mentioned, when first used spell out the nameof the element and then, on line, give the isotope number.

• Avoid the use of trademarks or manufacturers’ names unlessthey are essential to the study.

• Include major terms in the abstract, since the abstract can betext searched in many data retrieval systems. This will enablethe article to be retrieved when relevant.

References to BooksComplete Data.—A complete reference to a book includes (1)authors’ surnames and initials: (2) surname and initials of editoror translator, or both. if any: (3) title of book and subtitle. if any:(4) number of editions after the first: (5) place of publication: (6)name of publisher; (7) year of publication: (8) volume number, ifthere is more than one volume; and (9) page numbers, if specificpages are cited.

I .Stryer L. Biochemistry. 2nd ed. San Francisco, Calif: WH Freeman Co; 1981:559-596.

2,Kavet J. Trends in the utilization of influenza vaccine: an examination of the implementation of public policy in the UnitedStates. In: Selby P. ed. Influenza: Virus, Vaccines, and Strategy.Orlando. Fla: Academic Press mc; 1976:297-308.

Figure Sample

For assistance with tables, figures. charts, and graphs you maycontact Drake Chinen, HMj Editorial Assistant, at (808) 536-7702 or (808) 383-6627.

Table Sample

Table 1.—Age Structure of the Study PopulationEbeye CHC

Age Study Popula- % Ebeye Census %tion

30-39 302 43% 1227 45.5%

40-49 206 30% 843 31.2%

50-59 110 16% 391 14.5%

60-74 52 7.5% 193 7.2%

75 22 3.1% 40 1.5%

Total 692 2694

Comparison ot age structure of study population with age structure at residents of Ebeyeas recorded in 1999 Census.

100Female

80 Male

60

I:

__ __ _

Filipino Hawaiian Caucasian Total

Figure 1.— Incidence of Invasive Colorectal Cancer. Hawaii 1996-2000 (Age-adjusted to the US 2000 Population]

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DEPARTMENT OF VETERANS AFFAIRS HONOLULU — has an opening for a FULL-TIME BOARDCERTIF lED INTERNIST to provide inpatient medicalcare to veterans hospitalized at Tripier Army MedicalCenter. individual must demonstrate excellent clinical skills and have extensive experience in the fieldof hospital medicine. Responsibilities include directpatient care on the inpatient medical service, medicalconsultation on surgical and psychiatric services, andactive participation as a faculty member in the Triplerinternal medicine residency training program. VA andTAMC are affiliated with the University of Hawaii JohnA. Burns School of Medicine. Academic credentialsshould supportaclinical faculty appointment. Individualmust possess a full and unrestricted license in any state.Contact Human Resources Management Service at808-433-0196, for an application package. Fax CV to808-433-0391. attention Amy Duarte. Candidates aresubject to physical examination and drug testing. AnEqual Ooportun:ty Empioyer.

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Politicians Are Like Diapers. They Should Be Changed Regularly And For The Same Reason.The Democratic leadership in the Legislature was obviously greased withdollars andheav lobbying to fullill the wishes ot theoptometrv practitionersin this state. Allowing irtuallv no chance for amendments, and very littleopportunity for medical testimony, both the House and Senate pushed a‘,erv dangerous bill into law. WiseI. the Governor vetoed the bill, but thislegislature is ohviousl determined to embarrass the Republican governorand simply overrode the veto. The concept of politicians defining scope ofpractice for various professionals is an alarming one. There is no logic in acrazy-quilt group of elected people deciding how, what and if pharmacists,nurses, chiropractors. naturopaths. psychologists and optometrists shouldhe permitted to practice medicine. Why not use common sense, and trustsuch issues to medical school deans and the Board of Medical Examiners?But wait! That ssould mean a loss of campaign money.

$430 Million In Penalties And Pfizer Didn’t Even Blink.In the last five years. Plizer has pocketed a cool $9 billion revenue on

Neurontin alone. The Food and Drug Administration approved the drugfor epilepsy and herpes zoster, but once approved, doctors can prescribea drug however they see fit. Presently, doctors prescribe the drug for anarray of unproved conditions, including migraine, pain, and mental illness.In fact, 90% of Neurontin scrips are for off-label uses. Company salesreps and medical personnel have misrepresented the use with a distortedpicture of effectiveness, as in migraine where a study showed it had nomore effect than a placebo. Now the hammer has come down, and Pfizerwill pay about $430 million in lines; $240 million for criminal activities,$152 million for civil fines, and $38 million to state consumer-protectiondivisions. Pfizer also had to sign a “corporate integrity” (now, there’s anoxymoron!) document that allows for monitoring of marketing plans. Ofcourse, with Neurontin earnings in the multi-billions, Pfizer is feeling nopain, and anyway the company is busy threatening Canadian pharmaciesfor selling drugs to Americans. What nice people!!

Practice Healthy, Safe Eating. Always Use Condiments.At the Johns Hopkins Bloomherg School of Public Health five nations werestudied trying to determine the effectiveness of health care. They wereAustralia. Canada, England. New Zealand and the U.S.A. England had thelowest suicide rate. hut the worst survis al rate after breast cancer diagnosis.Canada had the best five-year survival after kidney andlivertransplants,butwas at the bottom in 30-day survival after a heart attack. The U.S. scoredat the top in live—year survival following breast—cancer surgery, tied withCanada for lowest smoking rate, had the lowest incidence of measles, andthe best record for cervical cancer screening. Australia had the best rate 01breast cancer screening. but the worst survival rate for childhood leukemia.New Zealand got the best score for colorectal cancer screening. but hadthe highest suicide rate. especially among young people. AMA PresidentDonald Palmisano noted that some factors were not accounted for. such asdifference in patient populations. and waiting times for procedures.

I Love Mankind. It’s Just People That I Hate.Frightening statistics in population i’e\ cal that the sorld’s human populationpassed the one billion mark in I Kfl4. B 1927. homo sapiens had doubledto 2 billion, and h l%t) sse passed 3 billion, and hs 1974 it was 3 billion.and I 9K7 the number came to 5 billion. B I 099,

,billion humans were

rubbing elboss s. In less than 4() ears, earth’s population had doubled!Since I ran this item just bye cars ago. 4(K) million souls have been addedto the office buildings. airports. suburb..freevas. Starhucks, inner-cities.condos. Wal—Mans. des ators. ball parks and bathrooms, Is it surprising thatyou can’t bud a pai’kin place’.’ Does anyone see a problem here?

Why Yes. You Did Hear Me Say Oops In The Operating Room.It is not a ness approach. but the practice of admitting medical mistakes topatients is gaining credibility as a mechanism to reduce the cost of medicalliability. At John Hopkins Hospital an 18 month old child died because offailure to treat severe deh dration. The family was enraged and ready for a

blood bath, hut within days the Hopkins Children’s Center director came tothe family, apologized, and accepted full responsihilit for the fatal mistake.‘l’he result was that the family did not sue, and settled for an unknow namount. much of which was donated to the hospital to spend on improvingpatient safety. Noss. Johns Hopkins hospital and the Dana-Farber CancerInstitute in Boston are among some promment medical facilities whichencourage their doctors to own up to errors and make appropriate apology.At Vanderbilt Unisersity students and residents take mandatory coursesin cominunicatnig errors and making apologies. Oregon and Coloradohave passed lass s stating that an apology cannot be used against a doctorin court. Possibly the model demonstrationn was reported in the Annalsof Internal Medicine in 1999 where the Veterans Hospital in Lexington.Kentucky. after some major losses, established a policy to discuss medicalerrors promptl and completely. The result was a signilicant reduction inerror-related payouts. JCAHO now requires disclosure of serious medicalerrors, hut so far has not recommended any apology. Insurance carriersand trial attorneys remain skeptical.

Liberty Is Doing As You Please, But With Control Over TheOther Fellow.Plodding through the legal labyrinth is a class action suit brought on behalfof approximately 200,000 resident physicians, claiming that the NationalResident Matching Program violates antitrust laws. The restraint-of-tradelawsuit was filed two years ago, and now a U.S. District Court judge hasdismissed the American Medical Association and the American HospitalAssociation. The suit alleges that the remainingdefendants preventcompetition for services, artificially depress wages below competitive levels, andconspire to make rules that accredit and govern residency programs. TheNRMP. the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education remain as defendants. If thesuit is resolved in favor of the residents, house staff hiring will become afire drill.

“So I Lied, And You Trusted Me. Send Me A Check.”In Texas. a teen age girl went to a physician requesting an abortion. She hadno ID Texas requires parental consent for underage abortion), so she wassent away. She returned with a non -government issued ID cai’d. includingsocial security number, and (late of birth stating that she was 1 sears 01(1.The pregnanc svas terminated, hut the card was fraudulent. Now, severalyears later and married with two children, the woman and herfatherhroughta lasvsuit stating that the father wasn’t given opportunity “to counsel hisdaughter and to offer her his guidance and love. “‘The judge chose notto dismiss the complaint. so ajlir\ heard the suit. They awarded no money.and found the girl 9ft( at fault and the doctor 10%. Counsel for the phs-si—cian stated. “Fhis was a l’rivolous lawsuit, You cannot commit fraud andthen come to court and sue the people \ou deceived.

ADDENDA+ A chain saw produces as much ozone pollution as a car going 201

mph.+ A Purdue I.’nisersitv communications professor has warned that

many Americans will sufl’er “cognitive and emotional disruptions”Irorn the loss of ‘para-social relationships” now that Friends is goingoff the air.

•:• Police in Elko. \es ada. arrested a man for burglary after matchinghis DNA to the ellow snow left at the crime scene. Police claim theperpetrator rclicscd himself on the root—top 0) a restaurant that hadbeen burglarized. The “cs idence” produced enough DNA to link theman to the scene.

+ Wal-mart has more emplo ees than the U.S. military.+ A day without sunshine is like night.

Aloha and keep the faith —rts

Contenrs ii i/mis m’imlmonn da not neces.s’arily reflect the opinion or p0.5/lion oJ theHawaii Ophrlmoinmr’itmcal Societt and the Hawaii Medical As,socmation, Editorialcomment is ori,’th’ i/mat a the writer,

222

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