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HAWAII MEDICAL

JOURNAL (USPS 237-640)

Published monthly by the Hawaii Medical Association

Incorporated in I 856 under the Monarchy I 360 South Beretania. Suite 200 Honolulu. Hawaii 96814-1520

Phone( 808 )536-7702; Fax(808)528-2376

Editors Editor: Norman Goldstein MD

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

Editorial Board John Breinich MLS, Satoru lzutsu PhD,

Douglas G. Massey MD, Myron E. Shirasu MD, Frank L. Tabrah MD, Alfred D. Morris MD

Journal Staff Editorial Assistant: Drake Chinen

Officers Pres ident: Gerald McKenna MD

President-Elect: Calvin Wong MD Secretary: Ali Bairos MD

Treasurer: Paul DeMare MD Past President: Philip Hellreich MD

County Presidents Hawaii: Jo-Ann Sarubi MD

Honolulu: Neil Katz MD Maui: Joseph Kamaka MD

West Hawai i: Ali Bairos MD Kauai: Gardner Quartan MD

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The Journal cannot be held responsible for opinions expressed in papers. discussion, communications or advertisemenLs. The ad­vertisi ng policy oftheHawaii Medical Journal is governed by the rules of the Council on Drugs of the American Medical Associa­tion. The right is reserved to reject material submitted for editorial or advertising columns. The Hm.-aii Medical Journal (USPS 237640) is published monthl y by the Hawaii Medical Association OSSN 0017-8594). 1360 South Beretania Street. Second Floor. Honol ulu. Hawai i 96814.

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Nonmember subscriptions are $25. Copyright 2002 by the Hawaii Medical Association. Printed in the U.S.

Contents Editorial Nomwn Goldstein MD .............. .... ..... .. .................... ....... .... ................ ......... ............ 116

Letter to the Editor Beth A. Kost. RHIA ............................ .... .... ...... .. ..... ......................................... .. .. .. .. 117

Outcome of 5,000 Flexible Sigmoidoscopies done by Nurse Endoscopists for Colorectal Screening in Asymptomatic Patients Ankur Jain , John Falzarano MD, Amod Jain MD, Robert Decker MD, Gail Okubo RN, and Dat)'l Fujiwara MD ...... ............................................................ 118

Pain Assessment in Hawaii Nursing Homes Marya Levintova-Romero PhD and Carolyn Cook Gotay PhD ............ .. .. ... ....... ... .... .... 121

Medical School Hotline Kathryn L. Braun DrPH and Michael Cheang DrPH ............................................ .. .......... 125

Cancer Research Center Hotline James Tom CRA ..... .... ......... .. ........... ....... ................................ ... ....... ... .... ... ...... ...... 126

Classified Notices ....................... ..................................... .......................... ... .. ....... ..... ....... 129

Weathervane Russell T. Stodd MD ......................... .. .. .. ... .. .... .. .. ........ .. ... ... .. .... ................................... ...... 130

Cover art by Dietrich Varez, Volcano, Hawaii. All rights reserved by the artist.

Kalo

Taro was cultivated as the staple food of old Hawaii .

-HAW All MEDICAL JOURNAL. VOL 61. JUNE 2002 115

fa Editorial

Norman Goldstein MD Editor, Hawaii Medical Journal

Sick Buildings · Sick Patients

For several decades, I have read about sick building syndrome and

have heard that Hawaii is having problems in its high-rise buildings.

Hawaii has more than its share of environmental allergens, giving it

the reputation as an allergy capitol of the country. The combination

of high humidity and year round warm weather makes paradise the

ideal "petri dish" for fungi, molds, pollen, mites, and other allergens.

This problem became acutely personal when my wife and I

became sensitive to molds in our downtown condo with central air­

conditioning, prompting us to purchase a home. After living there

for 18 years, new air-conditioning improperly installed increased

humidity and a variety of molds suddenly proliferated, forcing us to

seek a well-ventilated and mold-free environment. This is an all too

frequent occurrence for families in Hawaii.

Despite regular servicing of a building 's air conditioning system,

the growth of mold can outpace the most meticulous methods of

control. Recently , CNN News interviewed Jeffrey May, the author

of My House is Killing Me! Writer May is an indoor environmental

specialist with vast experience in what has become a major world­

wide health problem. While allergists and pulmonologists are aware

of these problems, other medical specialists generally are not. This

book is suggested reading for practicing physicians, especially in

mold-provoking areas, and should be recommended to patients

suffering attendant respiratory distress.

Air pollution indoors can be ten times more prevalent than

outdoors in Los Angeles on a bad day, no matter where you live,

according to the American Formulating and Manufacturing Asso­

ciation. The Environmental Protection Agency estimates that indoor

air pollution kills more than I I ,000 people every year.

In the longest study of indoor and outdoor fungal concentrations,

Shelton et at studied I, 717 buildings and found there was no one

species of mold associated with illness in the occupants. In the three­

year study, the most common mold species, indoors and outdoors,

were Penicillium. Aspergillus. Cladosoorium, and non-sporulating

molds. Stachybotrys chartarum, the "toxic black mold," which

contains macrocytic trichothecenes, was found in 6% of the build­

ings studied and in I% of the outdoor air samples.

Unfortunately, even after molds are identified, control after an

outbreak may be difficult or impossible to eradicate. Sensitive

people may have to relocate to avoid these environments.

Hospitals are also potential breeding grounds for mold problems.

An article in Hospital Materiel Management Quarterly by Brownson

reports that some people become very seriously ill just by breathing

indoor air. This is a problem in all industrial buildings, and Brownson

suggests that hospital staff are at particular risk, and that hospital

managers should endeavor to make the air safer for staffs and

patients. A MedLine review of the "Sick Building Syndrome"

reveals that this is a worldwide problem with several texts on the

subject currently available. A special hospital in Japan is research­

ing this burgeoning environmental problem.

Continued on next page

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~ Letter to the Editor

Medical Records Privacy

Why are we going backwards on the subject of Privacy of Medical Records?

The proposed changes to the HIP AA privacy rule announced two weeks ago by the Department of Health and Human Services (HHS) loosen restrictions on providing care before obtaining consent and discussing patient care out loud with other clinicians.

Just as the MD credential obligates Medical Doctors to adhere to the tenets of the Hippocratic Oath, the credential of RHIA obligates Registered Health Information Administrators to tenaciously pro­tect the confidentiality of private medical information on behalf of patients at all times. Because there was never Federal regulation to protect this private health information, this has been a challenging task at best. Also, patients have not always been aware of how their medical information was being used and what they could do to direct that use.

Fortunately, the HHS along with the Office of Civil Rights have been strategically positioned by the HIP AA Privacy standards to improve this legacy while expediting patient care and payment to providers for that care. That was, until March 22, 2002.

Don't forget that as a country, we have invested somewhere between $10 and $15 billion dollars on healthcare information technology since 1996. Healthcare professionals have made the collection of patient data, the conversion of that data into useful information and access to that information infinitely simpler than anytime in the past. Our government had the foresight to know that with this massive investment, we needed a system to protect this easily accessible information in the spirit of ensuring the "zone of privacy" it seeks to provide its citizens through various laws regarding private information.

We should proceed cautiously in modifying the HIPAA privacy regulations. Recall the original intent of these privacy regulations with these examples from the Federal Register of December 28, 2000:

"Editorial," continuedfrom p. 116

Perhaps this is the time for our Medical School to plan an environmental medicine department in the proposed Kakaako facil­ity.

References 1. May, Jeffrey C. My House is Killing Me. John Hopkins Press. Baltimore, MD 2001. 2. American Formulating & Manufacturing Association, San Diego, CA 2001 (www.afmsafecoat.com). 3. Sheldon B et al. Profiles of airborne fungi in buildings and outdoor environments in the United States.

Applied and Environmental Microbiology 68(4), 1743-1753 April2002. 4. Brownson K. Hospital air is sick, Hospital Material Management Quarterly 22(2):1-8 2000 Nov. 5. Kitasato Kenkyusyo Byoin, Minato-Ku Tokyo.

• 35% of Fortune 500 companies look at an applicant's medical records prior to making hiring decisions

• A Health System posted records of thousands of patients on the Internet

• A Health Department employee took a disk with the names of 4,000 people who had tested positive for HIV

• A woman purchased a computer that still contained prescription records of pharmacy customers

• A banker who also sat on a county health board gained access to patients cancer records and called in their mortgages

Do we really need more evidence than this that we should not allow the other protections (e.g., civil monetary penalties, imprison­ment for using or selling protected health information for personal advantage, personal gain or malicious harm) provided in the HIP AA privacy regulations to be carved away until we find ourselves back at square one?

Administrative simplification was the original intent of the HIPAA regulations. Those of us responsible for running and operating healthcare organizations have questioned this as we have learned more about the arduousness of implementing various HIPAA pro­visions. It isn't going to be easy. As leaders, it's time for us to step up and figure out how best to implement these regulations, share the successful methods for doing so with our colleagues in the healthcare community and maintain the protections that we as citizens have been provided.

Beth A. Kost, RHIA Corporate Compliance Officer Vice President, Professional Services Precyse Solutions

Editor's Note: Beth Kost has worked in Health Information Management for more than I6 years. She has served as a Senior Consultant for Ernst & Young in its Health Care Consulting Practice in Washington D.C. Kostjoined Precyse in 1998. In 1999, she became Chief Operating Officer and in 2002 she joined the corporate team as Vice President of Professiona!Services, HIPAA and Corporate Compliance Of flcer. Kost is a graduate of Bowling Green State University.

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American Diabetes

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-HAWAII MEDICAL JOURNAL, VOL 61, JUNE 2002 117

Outcome of 5,000 Flexible Sigmoidoscopies done by Nurse

Endoscopists for Colorectal Screening in Asymptomatic Patients

Ankur Jain, John Falzarano MD, Amod Jain MD, Robert Decker MD, Gail Okubo RN,

and Daryl Fujiwara MD

Abstract Objectives: There have been several studies to date establishing

the efficacy of nurse endoscopists in colorectal screening. How­

ever, no such study has ever been conducted in Hawaii. Utilizing the

large sample size of our study, we hope to further support endos­

copy by nurses as both a safe and cost-effective means of screen­

ing for colon cancer. Methods: This is a retrospective study of the results of more than

5,000 flexible sigmoidoscopies done by nurse endoscopists in the

colorectal screening clinic at Kaiser Hospital in Honolulu, Hawaii,

between November 1995 and February 2001. These results were

separated into normal, non-neoplastic polyps, adenomas, and

cancer. Results: The rate of detection of polyps was 13.3% (non-neoplas­

tic and adenomas). Colon cancer was detected in 15 patients (.3%

detection rate), of which 8 were carcinoma in situ, 3 were Dukes A,

2 were Dukes 81/82, and 2 were Dukes C2. Clinically significant

lesions (ie. carcinoma, large adenomas, or atypical adenomas)

were found in 1. 8% of all patients. There were 8 carcincids, 11ipoma,

2 condylomas, and 3 leiomyomas detected. For patients who

underwent colonoscopy, no other significant lesions were found in

the areas examined by nurse endoscopists. There were no compli­

cations, i.e. perforation, bleeding, infection, and death, in any of the

patients. Conclusion: The results of our study emphasize the importance

of being screened for colorectal cancer. Nurse endoscopists can

safely and effectively perform screening flexible sigmoidoscopies.

By training more nurse endoscopists, we can increase the rate of

colorectal screening in a cost-effective manner.

Correspondence to: Amod Jain MD 3288 Moanalua Rd. Honolulu, HI 96819 Phone: (808) 432-8077 Fax: (808) 432-8201 E-mail: amodjain@pol.net

Purpose Over 150,000 cases of colorectal cancer are diagnosed in the United

States yearly. Over90% of these patients are over the age of 50. As

the United States population ages, over 50 million Americans will

be eligible for colorectal cancer screening. Although screening

flexible sigmoidoscopy is associated with a significant decrease in

colorectal cancer mortality, only 30% of eligible patients have

undergone sigmoidoscopy .1 The projected increase in a population

eligible for screening is expected to increase demand for this

procedure and may overwhelm currently available endoscopic re­

sources. Screening flexible sigmoidoscopy by nurse practitioners is

the most cost-effective method available currently to reduce colorectal

CA mortality. 2"4 The purpose of this study is to evaluate the outcome

of 5,000+ flexible sigmoidoscopies done at the Kaiser GI clinic

between November 1995 and February 2001.

Subjects and methods Patients were referred to the colorectal screening clinic if they met

the following criteria: between 50 and 7 5 years of age (or above the age of 7 5 without

any major medical conditions) free of GI symptoms no first degree relatives diagnosed with colorectal cancer below

the age of 60 not at high risk for developing colorectal CA:

_.no family history of familial adenomatous polyposis, juve

nile polyposis, or other hereditary polyposis conditions

_. no family history of hereditary non-polyposis colorectal

cancer _.no personal history of adenomatous polyps

_.no personal history of colorectal cancer

_.no inflammatory bowel disease

• tested negative for fecal occult blood

Registered GI nurses who worked in the GI department for at least

2 years assisting gastroenterologists with colonoscopies were eli­

gible for training in screening flexible sigmoidoscopy. They per­

formed a minimum of 50 supervised flexible sigmoidoscopies prior

to functioning independently. They were trained to perform biop­

sies of polyps less than 5mm in size, and consulted gastroenterolo­

gists for patients with polyps of larger size and/or multiple polyps.

-HAWAII MEDICAL JOURNAL, VOL 61, JUNE 2002

118

Initially, patients were recommended to have colonoscopy done for all adenomas. Later however, colonoscopy was limited to those adenomas greater than 9mm in size, smaller polyps with abnormal histology, e.g. atypia, and multiple small polyps found on sigmoido­scopy. The decision whether or not to proceed with colonoscopy for adenomas between 6 and 9mm size was left to the discretion of the gastroenterologists. This decision was based on the publication "Clinical practice guidelines for colorectal cancer screening".5 A similar screening strategy has been found to be the most efficient in terms of colonoscopies generated and cases of colorectal cancer detected.6

Results The rate of detection of polyps was I 3.3% (666/50 17), out of which 290 (5.8%) were non-neoplastic and 376 (7.5%) were adenomas (Table I). This is similar to published rates of detection by physicians performing flexible sigmoidoscopy.7

·8 Table 2 breaks down adenomas by size.

Colon cancer was detected in I 5 patients (.3% detection rate), out of which 8 were carcinoma in situ, 3 were Dukes A, 2 were Dukes B l/82, and 3 were Dukes C2. See Tables I and 3. Upon reviewing the literature, there has been no consistent rate of colon cancer detection by physicians.H

Lesions were found to be clinically significant, i.e. carcinoma, adenomas with atypia, or large adenomas, in I. 8% (9 I /50 I 7) of all patients.

There were 8 carcinoids, I lipoma, 2 condylomas, and 3 leiomyomas detected (Table 1).

For patients who underwent colonoscopy, no other significant lesions were found in the areas examined by nurse endoscopists.

There were no complications, i.e. perforation, bleeding, infection, and death, in any of the patients encountered. Upon reviewing the literature, flexible sigmoidoscopy by physicians carries a .004% risk of perforation.9 Colonoscopy is associated with a much higher rate of perforation, .19%, and a .019% risk of death.9

Discussion Nurse endoscopists in our clinic safely and effectively performed over 5,000 screening flexible sigmoidoscopies. They detected clinically significant lesions (carcinoma, adenomas with atypia, or large adenomas) in approximately I out of every 56 asymptomatic patients. In addition, there were no complications from any of these procedures.

Several studies have explored the role of nurses in screening sigmoidoscopy. Schoenfeld et. a!. 2 randomized patients to undergo screening flexible sigmoidoscopy by a nurse endoscopist or by a gastroenterologist. No differences in detection of adenomatous polyps or frequency of complications were found.

In the largest of these studies, Wallace et. al. 1 report the results of sigmoidoscopic screening by nurse practioner (NP) and physician assistant (PA) endoscopists and gastroenterologists at a large insti­tution. Polyps were detected in 23% of the examinations by physicians and in 27% of the examinations by NPs and PAs. After screening over 9,500 patients, the authors noted a l 0% incidence of adenomatous polyps and a .32% incidence of colorectal cancer. 10

These findings are similar to those of other large organizations that offer colon cancer screening using flexible sigmoidoscopy.

Because our study of colorectal screening by nurse endoscopists

was retrospective in nature, we could not directly compare our results with those of physician endoscopists. However, after under­going sigmoidoscopic screening by nurses, no significant lesions were found in the rectosigmoid area on follow-up colonoscopy.

Colonoscopy is the most sensitive method of screening for colorectal lesions. 11 However, it is not feasible at this time to perform colonoscopy as a tool for mass screening because of the limited availability of gastroenterologists, the high cost of colonoscopy, and the complications associated with this procedure.

Several studies have shown the utility of fecal occult blood screening in reducing the incidence of colorectal cancer. 12 Flexible sigmoidoscopy of guiac negative patients by nurse endoscopists has been shown to be the most cost-effective method of screening the general population for colorectal cancer. 13 In our opinion, this should become the primary large-scale screening tool for colorectal carcinoma in patients of average risk.

Conclusion Nurse endoscopists can safely and effectively perform screening flexible sigmoidoscopy. Given the large number of significant lesions detected by nurse endoscopists in our study, their role in performing flexible sigmoidoscopy should be expanded in order to keep up with the increasing demand for colorectal cancer screening in the U.S.

Acknowledgement We are grateful to the staff of the Kaiser GI department for helping us with this study.

Authors John Falzarano MD, gastroenterologist, Kaiser Hospital Amod Jain MD, gastroenterologist, Kaiser Hospital Robert Decker MD, gastroenterologist, Kaiser Hospital Daryl Fujiwara MD, gastroenterologist, Kaiser Hospital Gail Okubo RN, Supervisor of GI Department, Kaiser Hospital Ankur Jain, visiting 4'h year medical student, Northwestern Univer­sity

References 1. Wallace M, Kemp JA, Meyer F, et al. Screening for colorectal cancer with flexible sigmoidoscopy by

nonphysician endoscopists. American Journal of Medicine. 1999 Sep; 1 07(3): 214-8. 2. Schoenfeld P, Lipscomb S, CrookJ, et al. Accuracy of polyp detection by gastroenterologists and nurse

endoscopists during flexible sigmoidoscopy: a randomized trial. Gastroenterology. 1999 Aug; 117(2): 486-9.

3. Maule WF. Screening for colorectal cancer by nurse endoscopists. New England Jornal of Medicine. 1994 Jan 20; 330(3): 183-7.

4. Schoenfeld P, Cash B, Kita J, et al. Effectiveness and patient satisfaction with screening flexible sigmoidoscopy performed by registered nurses. Gastrointestinal Endoscopy. 1999 Feb; 49(2): 158-169.

5. Clinical practice guidelines for colorectal cancer screening. Clinical Practice Guidelines, Kaiser Permanente Northern California Region. September 1995.

6. Olynyk JK. Plate! I CF, Collett. JA. Fecal occult blood and flexible sigmoidoscopy screening for colo rectal cancer: Modeling the impact on colonoscopy requirements and cancer detection rates. Journal of Gastroenterology and Hepatology. 2001 April; 16(4): 389-392.

7. Gupta TP, Jaszewski R. Luk GD. Efficacy of screening flexible sigmoidoscopy for colorectal neoplasia in asymptomatic subjects. American Journal of Medicine. 1989 May; 86 (5): 547-50.

8. McCallum RW, Meyer CT, Marignani P, et al. Flexible sigmoidoscopy: diagnostic yield in 1015 patients. American Journal of Gastroenterology. 1984 June; 79(6): 433-7.

9. Anderson ML, Pasha TM, Leigh1on JA. Endoscopic perforation of the colon: lessons from a 1 0-year study. American Journal of Gastroenterology. 2000 Dec: 95: 3418-3422.

10. Horton K, Reffel A, Rosen K, Farraye FA. Training of nurse practitioners and physician assis1ants to perform screening flexible sigmoidoscopy. JAm Acad Nurse Pract. 2001 Oct: 13(10): 455-9.

11. Lieberman DA, Harford WV, Ahnen DJ, et al. One-time screening for colorectal cancer with combined fecal occult-blood testing and examination of the distal colon. New England Journal of Medicine. 2001 Aug 23: 345(8): 555-560.

12. Mandel JS, Church TR, Bond JH, et al. The effect of fecal occult blood screening on 1he incidence of colorectal cancer. New England Journal of Medicine. 2000 Nov 30; 343: 1603-7.

13. Frazier AL, Colditz GA, Fuchs CS, and Kuntz KM. Cost-effectiveness of screening for colorectal cancer in the general population. Journal of the American Medical Association. 2000: 284: 1954-61. -HAWAII MEDICAL JOURNAL, VOL 61. JUNE 2002

119

Table 1.- Total flexible sigmoidoscopies performed

Results Nov 1995· 1997 1998 1999 2000 Jan-Feb Total 1996 2001

Total 928 991 1018 1034 936 110 5017

Normal or no significant pathology 789 870 894 885 797 87 4322

Non-neoplastic polyps 62 46 47 67 58 10 290

Adenomas 73 71 69 75 75 13 376

Adenocarcinoma 1 3 6 3 2 0 15

Carcinoid 1 1 1 2 3 0 8

Lipoma 0 0 0 1 0 0

Condyloma accuminata 0 0 1 1 0 0 2

Leiomyoma 2 0 0 0 1 0 3

Table 2.- Breakdown of adenoma

Results Nov 1995- 1997 1998 1999 2000 Jan-Feb Total 1996 2001

Total 73 71 69 75 75 13 376

Adenoma <6mm 49 52 37 38 44 8 228

Adenoma 6-9mm 8 11 10 21 20 2 72

Adenoma >9mm or adenoma with atypia 16 8 22 16 11 3 76

Table 3.- Breakdown of adenocarcinoma

Results Nov 1995· 1997 1998 1999 2000 Jan-Feb Total 1996 2001

Total 1 3 6 3 2 0 15

Cain situ 0 1 4 2 1 0 8

Dukes A 1 0 1 1 0 0 3

Dukes 81/82 0 2 0 0 0 0 2

Dukes C2 0 0 1 0 1 0 2

-HAWAII MEDICAL JOURNAL, VOL 61, JUNE 2002

120

Pain Assessment in Hawaii Nursing Homes

Marya Levintova-Romero PhD and Carolyn Cook Gotay PhD

Abstract Nursing home personnel from adult long-term care facilities on Oahu were surveyed on their pain assessment practices with demented and non-verbal residents. Many reported having difficul­ties evaluating pain in these residents. Observation and standard­ized pain assessment scales were most frequently used pain assessment methods. Recommendations are made about how to improve pain assessment with demented and non-verbal patients.

Introduction The population of individuals over the age of 65 in Hawaii is growing at a rapid rate. It is estimated that this group of elderly will double by the year 2025. 1 However, extended life expectancy and increasing age are associated with likelihood of living with chronic and/or disabling conditions, many of which are associated with experiences of pain. The consequences of untreated pain can be dire, including depression, fatigue, decreased socialization, sleep and appetite changes, and increased physical disabilityY

Studies on the prevalence of pain among community and nursing home residents indicate ranges from 25% to 80%.45

·6· 21.7 A recent

Minimum Data Set (MDS)8 report by the American Medical Asso­ciation determined that 2.2 million of nursing home residents across the United States suffer from persistent pain.9 In Hawaii, in 1999 there were 5,268 nursing home residents, with nearly 38% reporting experiencing severe painY These ratings were collected through an analysis national repository of MDS data.

Assessment of pain among nursing home patients is crucial and is the initial step in treatment planning. Furthermore, research indi­cates that inappropriate pain assessment measures used for pain detection result in under-diagnosis and under-treatment of pain. I0-!2

In addition, reporting habits of the elderly, acceptance of these pain reports by the medical professionals and their reluctance to admin­ister analgesics to frail elderlyl 3 are additional factors in poor pain treatment. Patient communication, memory and/or emotional dis­abilities can also hinder pain assessments.

A number of studies evaluated appropriateness of various pain assessment tools to be used with non-verbal, confused, demented,

Correspondence to: Marya Levintova-Romero PhD Clinical Sciences Program Cancer Research Center of Hawaii University of Hawaii 1236 Lauhala St, Honolulu, HI 96813 Phone (808) 586-2975 Fax (808) 586-2984

Figure 1.- Pain Assessment Measures

Observational Assessment McGill Pain Questionnaire 20

Visual Analog Scale of Pain Intensity 21

Verbal Rating Scale of Pain Intensity 21

A Faces Scale of Pain Intensity 22

Rand COOP Chart 23

Memorial Pain Card Subscale 24

and cognitively impaired elderly. 11 ·14.1 5 These pain assessment

approaches can be divided into two categories: behavioral observa­tion and patient self-report. Behavioral observation methods in­clude, but are not limited to, observation of changes in behavior and functioning including sleep, appetite, physical activity, mobility, and facial/body language. A number of behavioral observation schedules have been developed. 14·16-19 Several patient self-report scales are also available, as seen in Figure I.

However, nurses and direct care personnel may not be aware of such assessment tools, and may rarely, poorly or inconsistently use them. 25 According to Coyne and colleagues, nursing and medical personnel are usually poorly trained in pain assessment, with most receiving 1-4 hours of pain management content during their cur­ricula.26

In this study we inquired regarding pain assessment practices among nursing home/direct patient care personnel on the island of Oahu, Hawaii. The respondents were all asked about their use of published and well-researched pain assessment measures. The measures (Figure I) selected included both observational and pa­tient self-report assessment tools. We did not provide specific descriptions and/or information regarding the assessment measures.

Methods A non-experimental design and a descriptive approach were used to examine pain assessment techniques among nursing homes and extended geriatric care facilities on the island of Oahu, Hawaii. A fourteen-item survey was mailed to 23 nursing homes/extended care facilities listed in the GTE Pages Directory for Oahu.

Participants 9 out of 23 nursing homes/extended care facilities responded to the survey. 78% of the facilities were located in Honolulu (n=7). Two facilities were located outside of Honolulu, one of the Windward side of Oahu, another on the North Shore. Numbers of beds in the facilities that participated ranged from 5 to 182 (Mean number of beds = 70). A total of 20 individual surveys were returned com-

-HAWAII MEDICAL JOURNAL VOL 61. JUNE 2002 121

pleted. Overall response rate was 39%, with an average of one

participant from each of the facilities (range of participants per

institution 1-5). 90% of the surveys were completed by females

(n=l8). 30% of the respondents had an Associate's Degree (n=6),

and 25% were Registered Nurses (n=5). Equal number of respon­

dents had a Master's in Nursing Degree (n=4) or a combination of

degrees (n=4). One participant was a Licensed Practice Nurse.

Instruments A 14-item survey was constructed that included both closed- and

open-ended questions. This survey was developed specifically for

this study. The survey included items on demographics, pain assess­

ment tools, frequency of pain assessment, whether report of pain is

recorded, and whether participants experienced difficulty in assess­

ing presence of pain and intensity among the non-verbal and

demented residents.

Statistics All of the variables were analyzed using descriptive statistics.

Results 100% of the participants reported that they treat pain and painful

conditions at their facility. We did not inquire about the age range

of the patient population; however, 100% of respondents reported

their facilities treat individuals over the age of 65. 60% of partici­

pants reported that they conduct pain assessments with every patient

they work with during their shift, and all of them reported that they

record their evaluations following each inquiry. However, only

40% reported that they conduct pain assessments on a schedule (i.e.,

at the same time of day), regardless of the presence or absence of

pain complaints from the patient. 70% of participants reported

consistency with pain assessment measure(s) (i.e., using same

assessment procedure(s) with the same patient). The most fre­

quently utilized approach used by 35% of respondents, was a

combination of behavioral observation, faces (i.e., a row of human

faces with the range of facial expressions) and verbal analog scales,

followed by the combination of behavioral observation, faces,

visual and verbal analog scales (30% ). 15% of participants reported

using both observation and verbal analog scales, 10% reported using

the McGill (a standardized pain questionnaire), and 5% reported

using a combination of behavioral observation, visual and verbal

analog scales. Other pain assessment methods reported included

observation of changes in mood, physical functioning (e.g., appe­

tite, sleep, movement), motor agitation, and facial grimacing.

Frequency of pain assessment during a single 8-hour shift varied

greatly: 35% of participants stated that they evaluate pain on an "as

needed" basis; 25% ask once during their shift; 25% ask twice; 5%

ask 3 times; 5% ask 4 times; and 5% ask 10 times.

75% of participants responded that they find it difficult to assess

presence of pain among patients with dementia. 65% indicated

having difficulties evaluating presence of pain among patients who

are non-verbal.

Discussion This study is the first one to document pain assessment practices in

nursing homes on the island of Oahu, Hawaii. Due to a small number

of participants and an incomplete response rate, it is difficult to make

definitive conclusions about the quantity and quality of pain assess­

ment practices. Furthermore, due to a limited number of facilities

with multiple participants, we are unable to report on any differences

in pain assessment methods by different personnel in the same

facility. Further research utilizing larger, more complete samples is

recommended. Such studies will provide information regarding

pain assessment and treatment practices in Hawaii to contribute to

future program planning. Although our findings are not conclusive, we did find that most

care personnel reported having difficulties evaluating pain in de­

mented and non-verbal elderly. This is a serious concern, since

many nursing home residents suffer from cognitive and other

conditions that affect their ability to communicate about their

concerns, including pain. A number of ways to improve pain assessment practices among

nursing home personnel can be suggested. Awareness about poten­

tial cultural differences in expression of pain and treatment seeking

behavior in a culturally diverse population of Hawaii is one of the

essential and necessary tools for successful clinical practice. 27·28

Learning about patient pain beliefs and myths about pain may assist

health professionals to discuss some of the barriers experienced by

patients and health practitioners about pain control. Professional

training and continuing education should provide information on

specific pain assessment tools and measures, teach about miscon­

ceptions on pain and aging, and provide hands-on experiences

assessing difficult patients. Many professionals in this study are

already using standardized pain assessment tools in their work,

indicating a good foundation for further strengthening pain assess­

ment skills. Improving multidisciplinary communication with

primary care physicians in order to provide comprehensive care to

nursing home residents is also very important.

Measures of patient self-report vary significantly by degree of

complexity, ranging from extensive questionnaires and/or interview

assessments, to brief visual, verbal and number rating scales. Many

nursing home residents experience communication, comprehen­

sion, and sensory problems 15, making it difficult for them to respond

to such assessment tools. Ferrell and colleagues 2 reported that one

out of five institutionalized patients they interviewed was unable to

respond to "Yes" or "No" questions, therefore being unable to report

presence and/or significance of their pain experience. Additionally,

those individuals who were able to respond regarding presence of

pain were unable to quantify their pain experience.2·29 Therefore

self-report measures need to be designed using simple cognitive

parameters that would enable nursing home residents to report and

to quantify their pain. Finally, care personnel need to be aware that not every pain

assessment tool will be appropriate for every patient. Verbal, visual

and/or faces scales may not be simple enough for demented and/or

non-verbal elderly. These assessment tools require abstract thought,

ability to recall previous experiences/events, comprehension, ver­

bal ability, and ability to recognize emotions in self/other all of

which are impaired in individuals with dementia and in some people

who are unable to respond verbally to questions and instructions.

Patient-administered and/or physician-, nurse-administered ques­

tionnaires generally are not appropriate to use with demented

patients. However, some non-verbal patients who are cognitively

intact may prefer to complete such measures, because it provides

-HAWAII MEDICAL JOURNAL. VOL 61. JUNE 2002

122

them with an opportunity to report their concerns about their pain experience.

Flexibility and incorporation of pain measurements into patients' daily routine are some of the ways to improve assessments and patient care. Because there is variability in patient pain behaviors, initial pain assessment should focus on regular observation of the patient in a number of daily activities. A measure frequently suggested in pain assessment literature is a brief observation sched­ule, developed by Simons and Malabar. 14 This scale includes patient demographic information, a pain assessment chart to record time, response and site of pain, and a list of 25 observable pain behaviors. Observable behaviors include verbal responses to pain, facial ex­pressions, body language, physiological changes, behavioral changes, feedback from others, and state of consciousness. This instrument represents a promising approach to use in nursing homes. Pain assessment with demented and non-verbal patients is a critical issue, particularly since the number of individuals over 65 is growing rapidly in the State of Hawaii. Further research, training, and use of multidisciplinary treatment approaches will provide significant improvements in quality of life, physical and emotional functioning among nursing home patients.

Authors Marya Levintova-Romero PhD and Carolyn Cook Gotay PhD Clinical Sciences Program Cancer Research Center of Hawaii University of Hawaii I 236 Lauhala St., Honolulu, HI 96813 Phone (808) 586-2975 Fax (808) 586-2984

References 1. Hawaii State Data Book, Department of Business, Economic Development and Tourism: State of

Hawaii; 1999. 2. Ferrell BA. Pain evaluation and management in the nursing home. Ann Intern Med 1995;123(9):681·

7. 3. Ferrell BA, Ferrell BR, Rivera L. Pain in cognitively impaired nursing home patients. J Pain Symptom

Manage 1995;10(8):591-8.

-

4. Fox PL. Raina P, Jadad AR. Prevalence and treatment of pain in older adults in nursing homes and other long-term care institutions: a systematic review. Cmaj 1999:160(3):329-33.

5. Weiner D. Peterson B. Keefe F. Evaluating persistent pain in long term care residents: what role for pain maps? Pain 1998;76(1·2):249-57.

6. Roy R, Thomas M. A survey of chronic pain in an elderly population. Canadian Family Physician 1986:32:513-16.

7. Weiner D, Peterson B. Keefe F. Chronic pain-associated behaviors in the nursing home: resident versus caregiver perceptions. Pain 1999:80(3):577-88.

8. Won A, Morris JN. Nonemaker S, Lipsitz L. A foundation for excellence in long-term care: The Minimum Data Set Annals of Long-Term Care 1999;7:92-97.

9. Teno JM. Weitz enS. Welle T, Mor V. Persistent Pain in Nursing Home Residents. JAMA 2001 ;285:2081. 1 0. Bernabei R, Gambassi G, Lapane K. Landi F, Gatson is C, Dunlop R. et al. Management of pain in elderly

patients with cancer. SAGE Study Group. Systematic Assessment of Geriatric Drug Use via Epidemi­ology. Jama 1998;279(23) :1877-82.

11. Marzinski LR. The tragedy of dementia: Clinically assessing pain in a confused nonverbal elderly. Journal of Gerontological Society 1991 ;17:25-28.

12. Sengasteken EA. King SA. The problem of pain and its detection among geriatric nursing home residents. Journal of American Geriatric Society 1993:41(541-544).

13. American Geriatr'1c Society Panel on Chronic Pain ·,n Older Persons. The management of chronic pain in older persons. Journal of American Geriatric Society; 1998. p. 635-51.

14. Simons W, Malabar R. Assessing pain in elderly patients who cannot respond verbally. J Adv Nurs 1995;22(4):663-9.

15. Cook AK, Niven CA, Downs MG. Assessing the pain of people with cognitive impairment lnt J Geriatr Psychiatry 1999; 14(6):421-5.

16. Hurley AC, Volicer BJ. Hanrahan PA, Houde S, Volicer L. Assessment of discomfort in advanced Alzheimer patients. Research on Nursing Health 1992;15:369-77.

17. Craig KD, Prkachin KM. Non-verbal measures of pain. In: Melzack R, editor. Pain Measurement and Assessment New York: Raven: 1983. p. 173-78.

18. Linton SJ. MelinJ, Stjernlof K. The effects of applied relaxation and operant activity training on chronic pain. behavioral Psychotherapy 1985;13:87 -100.

19. Keefe F, Block AR. Development of an observation method for assessing pain behavior in chronic low back pain patients. Behavior Therapy 1982;13:363-75.

20. Melzack R. The McGill Pain Questionnaire: major properties and scoring methods. Pain 1975;1 (3):277-99.

21. Ohnhaus E, Adlev R. Methodological problems in the measurement of pain: a comparison between verbal rating scales and visual analog scale. Pain 1975;1 :379-84.

22. Wong DL. Whaley and Wong's Nursing Care of Infants and Children. 5 ed: Mosby-Year Book, Inc.; 1995.

23. Nelson E, Wasson J, KirkJ, Keller A, Clark D, Dietrich A, et al. Assessment of function in routine clinical practice: description of the COOP Chart method and preliminary findings. J Chronic Dis 1987;40(Suppl 1 ):55S-69S.

24. Fishman B, Pasternak S, Wallenstein SL, Houde RW, Holland JC, Foley KM. The Memorial Pain Assessment Card. A valid instrument for the evaluation of cancer pain. Cancer 1987;60(5):1151-8.

25. Ferrell BA, McGuire DB, Donovan MI. Knowledge and beliefs regarding pain in a sample of nursing faculty. Journal of Professional Nursing 1993;9:79-88.

26. Coyne ML, Reinert B, Cater K, Dubuisson W, Smith JF, Parker MM, et al. Nurses' knowledge of pain assessment, pharmacologic and nonpharmacologic interventions. Clin Nurs Res 1999;8(2):153-65.

27. Nilchaikovit T, Hill JM, Holland JC. The effects of culture on illness behavior and medical care: Asian and American differences. General Hospital Psychiatry 1993;15:41-50.

28. Bates MS, Edwards WT. Ethnic variations in the chronic pain experience. Ethnicity and Disease 1992;2:63-83.

29. Parmelee PA, Smith B, Katz IR. Pain complaints and cognitive status among elderly institution residents. Journal of American Geriatric Society 1993;41 :523-30.

HAWAII MEDICAL JOURNAL. VOL 61. JUNE 2002 123

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l!i Medical School Hotline

Center on Aging John A. Burns School of Medicine

Kathryn L. Braun, DrPH, Director/Professor Michael Cheang, DrPH, Assistant Professor

Never before in human history have so many individuals lived so long. This phenomenon has implications for individuals who expe­rience a greater range ofbiological, psychological and social changes over a lengthening life span. It also has implications for families, communities, and societies that are influenced by, and must adjust to, a growing number and proportion of older adults.

The Center on Aging (COA) at the University of Hawaii is dedicated to enhancing the quality of life for Hawaii's adults and elders. We accomplish this through: I) undergraduate and graduate education; 2) continuing education for professionals and parapro­fessionals; 3) research and evaluation; 4) organizational assistance with program and policy development; and 5) individual, commu­nity, and workplace education and outreach.

The COA was established in 1988 by the U.H. Board of Regents, which recognized the need for an interdisciplinary, campus-wide program for training students and facilitating education, research, and service in gerontology. Among its first achievements were the establishment of undergraduate and graduate certificates in aging and the production of a nationally distributed and acclaimed 13-hour telecourse on aging, called Growing Old in aNew Age (1993). This video series is available at the Sinclair Library, University of Hawaii at Manoa.

In 1993, the COA was transferred to the School of Public Health and, with the demise of that school, integrated into the John A. Burns School of Medicine (JABSOM) in 2000. Since its inception, the COA has realized a number of accomplishments in each of its five activity areas.

Undergraduate and Graduate Education • 44 students have been awarded an Advanced Certificate in Ger

ontology. • 16 students have been awarded an Undergraduate Certificate in

Aging. • The Masters in Public Health (MPH) in gerontology was ap­

proved in 2001. Two students are graduating in 2002. • Student research projects are funded through annual Lenzer­

Goodfriend awards. • The local chapter of Sigma Phi Omega, the National Gerontology

Honor Society, is sponsored by the Center.

Continuing Education for Professionals and Paraprofessionals • Staff serves as co-trainers of Educating Physicians in End­of-Life Care (EPEC). • Staff provides training in end-of-life care for nursing home

personnel, community-based service providers, and paraprofes­sional workers on Oahu and the Big Island.

• COA sponsors gerontology study tours to other countries and organizes study tours for professionals visiting Hawaii.

• Staff works with Papa Ola Lokahi to mentor Native Hawaiians who want to pursue research careers.

Research and Evaluation • Our focus is on Asian and Pacific Islander aging, end-of-life care,

family caregiving, successful aging, and Hawaiian health. • Skills includes community-based participatory research, qualita­

tive methods, developing and testing educational materials, and program evaluation.

• Since 1995, COA staff collaborated on and published 2 books, Teaching Students Geriatric Research with Peggy Perkinson, and Cultural Issues in End-of-L(fe Decision Making with Jim Pietsch (UH School of Law) Patricia Blanchette (JABSOM), 8 book chapters, 50 journal articles, 16 technical reports, and the 2nd, 3'd, and 4'h editions of the study and faculty guides for Growing Old in aNew Age.

• Staff has secured more than $2,000,000 in extramural funds.

Organizational Assistance with Program and Policy Development • Staff assists governmental and non-governmental agencies with

needs assessments, grant writing, policy development, program evaluation, and health communications.

• COA initiates contracts to implement programs of Hawaii's Executive Office on Aging related to population aging, client satisfaction, data management, elder abuse prevention, end-of­life care, family caregiving, and self-determination.

• We assist other UH units and several non-UH agencies in securing their own grant funds, including the Executive Office on Aging, the Hawaiian Islands Hospice Organization, Papa Ola Lokahi, and the Hawaii Intergenerational Network.

Individual, Community, and Workplace Education and Outreach • Publication of a semi-annual newsletter for faculty, students,

alumni, and interested community members. • Public training programs in advance directives, the aging process,

care of the dying, care of the bereaved, coping with caregiver stress, cultural issues in caregiving and help-seeking, end-of-life decision making, and funeral planning.

Two of CO A's current projects include the End-of-Life Care for Hawaii's Ohana (ECH 0) and the Paraprofessionals in Aging Project (PAP). The purpose of the ECHO project is to explore the impact of group-targeted messages and individually tailored support on end-of-life planning by multi-ethnic caregivers of elders receiving long-term care services. To fit the needs of caregivers, ECHO uses the seven stages of care giving outlined by Montgomery and Kosloski (2000) to design tailored, culturally sensitive end-of-life care mes­sages for targeted groups of caregivers. This three-year project (funded by the Administration on Aging's National Family Caregiver Support Program) includes the following community partners: Hawaii Meals on Wheels, Honolulu Gerontology Program, Kokua Kalihi Valley Comprehensive Family Services, Maluhia Founda­tion, and Project Dana. The PAP is a 30-hour educational workshop

Continued on p. 129 -HAWAII MEDICAL JOURNAL, VOL 61, JUNE 2002 125

cancer Research ~~ Center Hotline

SELECT (Opportunity for Prostate Cancer Prevention)

James Tom, CRA, SELECT Study Coordinator, Clinical Trials Unit

Cancer Research Center of Hawaii

Cancer primary prevention clinical trials are different from disease­specific treatment trials. Prevention trials typically I) include participants who are otherwise healthy, devoid of symptoms and thus require that toxicities or side effects from any intervention be minimal, 2) require large numbers of subjects to detect a difference between the intervention and control groups, and 3) require long study and follow-up periods to detect differences in outcomes related to all-cause survival, cancer-specific survival and quality of life. SELECT, the Selenium and Vitamin E Cancer Prevention Trial presented here, offers the opportunity to men in Hawaii to partici­pate in a clinical trial and contribute to our scientific understanding and control of prostate cancer.

Carcinoma of the prostate is the most common tumor in the United States with 189,000 new cases and 30,200 deaths expected in 2002. In Hawaii, estimates for prostate cancer in 2002 are 700 new cases and 100 prostate cancer-related deaths. 1 Histologic evidence of the disease may occur in as many of 34% of men in their fifth decade, and up to 70% of men 80 years of age and older. While one in five U.S. men will be diagnosed with prostate cancer during his lifetime, only 3% of men are expected to die of the disease. The menu of treatment options for localized prostate cancer includes radical prostatectomy, external-beam radiation therapy, brachytherapy, hormonal treatments or surveillance. Issues that confound the choice of treatment include side effects of treatment, the inability to predict the natural history of a given cancer, and patient comorbid conditions that may ultimately affect the patient's likelihood of succumbing to prostate cancer morbidity and mortality. The ques­tion of whether screening digital rectal examination and PSA improve mortality and morbidity awaits the results of ongoing clinical trials such as the Prostate, Lung, Colon, and Ovarian (PLCO) trial sponsored by the National Cancer Institute. However, prostate screening appears to have resulted in a substantial stage migration in diagnosed prostate cancers to earlier, potentially cur­able stages; metastatic prostate cancer at initial diagnosis may become a historical footnote.

Factors that increase the risk for prostate cancer include increas­ing age, prostate cancer in first degree male relatives, the male hormonal testosterone milieu, race and dietary fat. Some studies associate increased dietary intake of fruits and vegetables with a reduced risk of prostate cancer.

Although it may be increasingly evident that dietary choices play a role in the development of prostate and other cancers, changing patterns of dietary behavior and life-long intervention makes this strategy difficult in practice. Since the 1980's, chemoprevention, the use of natural or synthetic substances to reduce the risk of

developing cancer, has become an important focus of National Cancer Institute-sponsored clinical trials. Since the development of prostate cancer appears to be age-dependent, any intervention that reduces the incidence of clinically significant disease by five, I 0 or 15 years would significantly reduce prostate cancer morbidity and mortality. For the chemoprevention of prostate cancer, a number of options have been considered: retinoids, DFMO, inhibitors of cho­lesterol biosynthesis, alpha-tocopherol, anti-androgens and 5-alpha reductase inhibitors. 2 Recognition of the importance of the andro­genic milieu on the prostate in the development of prostate cancer resulted in the Prostate Cancer Prevention Trial (PCPT) using finasteride (Proscar). This trial began accrual in October 1993 and ended in May 1997 with enrollment of over 18,000 participants nationwide. The study tests the ability of finasteride, a 5-alpha reductase inhibitor, on reducing prostate gland dihydrotestosterone and, hence, a possible reduction in the incidence of prostate cancer. Final analysis is expected in 2004.

Primary prevention of prostate cancer through dietary supple­mentation now appears to be a promising strategy to reduce the morbidity and mortality of this disease. Secondary analyses of data from two prospective, randomized cancer prevention trials with selenium and vitamin E suggested these two agents for a second large-scale clinical trial. In a clinical trial conducted by Clark eta!., prostate cancer incidence was reduced by two-thirds among men receiving daily selenium supplementation.3 In the Alpha-Toco­pherol, Beta-Carotene (A TBC) Cancer Prevention Study carried out in Finland, there was a one-third reduction in prostate cancer incidence and a 40% reduction in prostate cancer mortality in men randomized to receive vitamin E.4 A confirmatory trial, SELECT, the Selenium and Vitamin E Cancer Prevention Trial, with prostate cancer incidence as one of the primary endpoints will substantiate these findings.

The primary objective of SELECT is to assess the effect of selenium and vitamin E, either alone or in combination, on the incidence of prostate cancer diagnosed during routine clinical prac­tice. Secondary objectives include assessing the impact of selenium and vitamin Eon the incidence of lung cancer, colon cancer and all other cancers; on cancer-specific survival and overall survival. Quality of life, evaluation of molecular and genetic markers of cancer risk, other biomarkers, and measures of nutrient intake will also be assessed. An ancillary study called PREADVISE for Prevention of Alzheimer's Disease by Vitamin E and Selenium Trial, will recruit from the SELECT participant pool, screening for changes in short-term memory or other forms of dementia.

Enrollment to SELECT, a National Cancer Institute-sponsored trial, began in July 2002. More than 32,000 men at over 400 sites in the United States, Puerto Rico, and Canada will be recruited. Enrollment is estimated to take five years, with the entire duration of the trial being 12 years. The University of Hawaii Minority­Based Clinical Oncology Program, administered by the Cancer Research Center of Hawaii, is one of the sites selected to conduct this study.

Eligible males must be age 55 or older (age 50 and older for African-American men), have had a non-suspicious DRE and a total PSA less than or equal to 4.0 ng/ml within 364 days of randomiza-

Continued on p. I 29

-HAWAII MEDICAL JOURNAL. VOL 61. JUNE 2002

126

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"Medical School Hotline," continuedfrom p. 125

intended to provide paraprofessionals working in elder care with background information about aging. The workshop for home health aides, care aides and adult day care assistants on the Big Island includes the following five training modules: the aging process , health and wellness, illness and disability, basic caregiving skills, and death, dying and bereavement.

In 2002, the COA embarked on a strategic planning process to determine how to better serve the Center' s constituents. The primary commitment is to serve the University of Hawaii system, including students, staff, and faculty. As academics, the staff creates and disseminates new knowledge. As a state-supported educational unit, however, it is responsible to state and local agencies to improve the quality of life for adults and elders, as well as to recognize and help meet the needs of the aging public.

For more information on the Center on Aging, call 956-5001 or visit the web site at www .hawaii.edu/aging.

References 1. Growing Old in a New Age. (1993) . Video Series 1 -13. University of Hawaii at Manoa. Honolulu, Hawaii. 2. Montgomery, R.J . & Kosloski, K. D. (2000). Family care giving: Change. continuity, and diversity. In Lawton, P. & Rubernstein, L. (Eds.).

(2000). Interventions in dementia care. New York: Spring Publishing.

"Cancer Research Center Hotline," continued from p. 126

tion. (Additional eligibility criteria may be obtained by contacting the study site.) Participants will receive either 200 meg of selenium, 400 mg of vitamin E, both, or placebos for up to 12 years. Blood samples and toenail clippings will be requested from all participants. Participants will also be asked to take part in the PREADVISE. However, declining to provide samples or to take part in the PREADVISE will not affect their participation in SELECT.

For more information in Hawaii, contact the Clinical Trials Unit, (808)586-2979. For information on study sites outside of Hawaii, call the Cancer Information Service of Hawaii at l-800-4-CANCER. In Canada, call the Canadian Cancer Society ' s Cancer Information Service at l-888-939-3333.

References 1. American Cancer Society: Cancer Facts and Figures-2002. Atlanta, GA: American Cancer Society, 2002. 2. Thompson IM, Coltman CA, Brawley OW, et al. Chemoprevention of prostate cancer. Seminars in Urology XIII, No.2: 122-129, 1995. 3. Clark LC, Combs GF Jr, Turn bull BW, et al. Effects of selenium supplementation for cancer prevention in patients with carcinoma of the skin.

A randomized controlled trial. Nutritional Prevention of Cancer Study Group. JAMA 276:1957-1963, 1996. 4. Heinonen OP, Albanes D. Huttunen JK, et al. Prostate cancer and supplementation with alpha-tocopherol and betacarotene: incidence and

mortality in a controlled trial. J Natl Cancer lnst 90:440-6, 1998.

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Physician Wanted

KAUAI, HAWAII- Seeking a BC/BE Primary Care Internist, interests in rheumatology, infectious diseases and geriatrics are welcome. Proficiency in treadmill stress testing desired. Kauai Medical Clinic is a 65-physician multispecialty medical group affiliated with Wilcox Memorial Hospital and Hawaii Pacific Health. This opportunity offers excellent quality of life in a safe, spectacularly beautiful, family oriented, rural commu­nity. Competitive salary, benefits and relocation pack­age. Send/fax CV to: M. Keyes-Saiki, Kauai Medical Clinic, 3-3420 Kuhio Hwy., Suite B, Lihue, HI 96766-1098. Fax: (808) 246-1625. Email: mkeyes­saiki@wilcoxhealth.org

KAUAI, HAWAII-Kauai Medical Clinic, a 65-physician multispecialty medical group is seeking aBC/BE PM&R Physician. The Ideal Candidate will have experience with epidural steroid injections and facet blocks and an interest in overseeing patient care in our inpatient and outpatient rehabilitation units and long term care. inter­est and ability in the care of spinal disorders, neuro rehab and alternative modalitites such as manipulation highly desired. We are affiliated with Wilcox Hospital, a 181-bed community hospital, and Hawaii Pacific Health. Our opportunity offers excellent quality of life in a safe, beautiful, family oriented, rural community. Competi­tive salary, benefits and relocation package. Send/tax CV to: M. Keyes-Saiki, Kauai Medical Clinic, 3-3420 Kuhio Hwy., Suite B, Lihue, Hl96766-1 098. Fax: (808) 246-1625. Email: mkeyes-sajki@wilcoxhealth.org

WI The Weathervane Russell T. stodd MD

It's A Happy Talent When You Know How To Play. In the 2002 winter Olympic games at Utah, the United States luge and bobsled teams performed, not merely better than ever. but beyond expecta­tions. Part of the great improvement in results is attributed to the "visual training'' directed by Barry Seiler, M.D., a practicing ophthalmologist at the Visual Fitness Institute, at Vernon Hills, Illinois. The devices used include high-tech computer displays and various string and bead tools. Exercises are designed to evaluate and improve visual skills such as peripheral vision, depth perception, contrast sensitivity, speed of focusing, tracking with eye­hand-body coordination and visual acuity. By providing the athletes with a high degree of visual confidence and reaction, correct moves can save hundredths of a second in extremely high speed events. Visual fitness and training seems sure to become a routine part of athletic training for high speed events.

He Has The Body Of A God •••••• Buddha. It is known that one in three Americans is overweight and one in five is obese. Rand Corporation of Santa Monica, California, completed a cost analysis of I 0,000 adults ages 18 to 65 in evaluating medical expenditures. While there has been a proliferation of prevention programs in schools and workplaces about tobacco, substance abuse and alcohol consumption, body weight has not been seen as anything to worry about. The study found that obesity is associated with an average increase in medical costs of $325 annually, smoking is linked to an increase of $230, and drinking problems with an increase of $150 beyond the average. (I believe that the last figure is misleading since many auto crashes, home accidents, and domestic violence are actually due to alcohol abuse.) The Rand report was summa­rized, "We can't nail down costs exactly, but the very strong effects of obesity are clear."

Advertising: The Cheapest Way Of Selling Goods, Especially Ones Of Questionable Value. Pill pushing is very big business in the United States. Europe, with a greater population than the U.S., spends less for drugs. The European Union has a ban on prescription drug advertising which is believed to help keep health care costs under controL Now, what a surprise, the drug makers want the ban removed, and argue that it unfairly crimps patients' access to informa­tion, and thereby access to drugs. Two thirds of the $6 billion in world wide sales in 2000 was racked up by U.S. contributions to the pharmaceutical industry. The European commission is considering allowing drug makers to market treatments for AIDS, diabetes and respiratory problems. If approved, the measure would allow patients to seek out information on web sites, but would not permit other direct ads. Consumer groups argue that relaxing the ban will bloat drug companies marketing budgets, push prices up, and do nothing to enhance health care. Amen.

The Judge: A Law Student Who Marks His Own Examination Papers. The American Tort Reform Association (ATRA) reports that 27 states have no limits on non-economic damages for malpractice complaints. When laws have been passed in the legislatures, personal injury attorneys file suit and fund the cases that have led to limits being struck down. In Oregon, a state court struck down limits established by the legislature, and jury awards of $8 million, $10 million and $17 million resulted shortly thereafter. Nevada has no limits either and insurance premiums have soared. The Los Angeles Times reported that some liability premiums in Las Vegas moved from $37,000 to $250,000. Many doctors are taking the only logical step­they are either quitting or leaving. Already doctor poor, Nevada ranks 47'h in number of doctors per unit population. Everyone involved in medical liability knows that the California MICRA statute is the bellwether for controlling expenses, which is why trial lawyers in other states, fight so vigorously whenever it is proposed.

In Matters Of Style, Go With The Flow. In Matters Of Prin· ciple, Stand Like A Rock. Hawaii's very own 800 pound gorilla, Hawaii Medical Services Associa­tion (HMSA), made the front page of the American Medical News, March 25, 2002. The concern is one of personal privacy for physicians who participate in HMSA 's preferred provider organization (PPO). About 70%

of Hawaii doctors are now required to sign a contract to allow HMSA to conduct whatever search deemed appropriate into the doctor's personal medical records. The American Medical Association has policy opposing any contract to provide care that requires access to a physician's own medical records. That policy does not discourage HMSA .. Richard Chung, M.D. HMSA credentialing chairman, says that most physicians are granting the authority, but Gerald McKenna, M.D., HMA president, and a handful of Hawaii's doctors (including your editor) have raised opposition. Do doctors take time to read the contract? Do they understand what the gorilla is ordering? Didn't Mr. Lincoln sign a proclamation about slavery?

Any Woman Is Happy As Long As She Looks Younger Than Her Daughter. The world of narcissism remains wide open for creative surgeons. In New York, a cosmetic surgeon is capitalizing on the trend of navel-baring and low-rise jeans by building a better belly button. The youthful navel is vertical, but after weight gain and child-bearing, women often sport a poochy, round, less appealing perspective. By doing a little lipo-suction, a mini-tummy tuck, tightening a few stomach muscles, and giving the skin a vertical stretch, voila!- the teen age belly button returns. Price tag- $8000 to $12,000, cash in advance, please.

Civilization Is The Progress Toward A Society Of Privacy. Where does the matter of privacy prevail when weighed against suspected drug use? A 16 year old honor student, choir member, musician, and member of the academic team (and later accepted to Dartmouth) was randomly drug tested (her English teacher and academic team leader outside the door, listening). The test was negative. The student was angry and filed a lawsuit alleging invasion of privacy. The school district said the random testing is a response to "a longstanding problem of drug use" in the community. In all, 484 tests were conducted on students involved in extra­curricular activities over a two year period, and three were positive. Tecumseh, Oklahoma, is not a high drug use community. The U.S. district court supported the school's program, but was reversed by the U.S. appeals court, saying drug use among students subject to the testing policy was negligible. The case has percolated up to the Supreme Court of the United States.

It Is Not A Fragrant World. And on more "reefer madness" in Ottawa, Canada, a school board suspended a 15 year old boy because a drug-sniffing dog barked at his jacket. No drugs were found, and the student claimed to have nothing to do with marijuana or any other drugs. The jacket could have hung next to a drug-contaminated coat in a closet made contact on a bus, or even brushed against one in the street, or perhaps the dog was wrong. So, whom do you believe, the dog? The boy? A police spokesman who handles drug­searching dogs, said much more than a bark from a drug-sniffing dog is required for evidence, but the "zero tolerance" school board at the Catholic school has refused to back off. Book 'em, Danno!

Ah, The Power Of The Electorate. Wishing to allow service people to have a vote by the Internet in the last national election, the Pentagon established a project for soldiers to cast their ballots using computer science. Cost of the project was $6.2 million, and the number of votes cast-- eight-four ( 84 ). The cost per vote was $7 4.000! Your tax dollars at work.

ADDENDA •:• Eyelashes recycle in 90 days. •:• Each day, Americans eat 18 acres of pizza. •:• Doctors claim cheerful people resist disease better than grumpy ones. The surly bird catches the germ. •:• What do you get when you date a clown') Carnival knowledge.

Aloha and keep the faith -rts•

Contents of' this column do not necessarily reflect the opinion or position of the

Hawaii Ophthalmological SocietY and the Hawaii Medical Association. Editorial

comment is strictly that of' the writer.

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