Hawaii medical journal最新文献

Escherichia coli is a rare cause of bacterial endocarditis. We report a case of an elderly man with cirrhosis who developed bacterial endocarditis due to E.coli. We review the literature that summarizes a total of 41 cases, with a predominance of elderly women, diabetics, and patients with urinary tract infections and prosthetic heart valves. E.coli bacteremia may be mistakenly attributed to a more benign source such as urosepsis and overlooked as an indication of endocarditis. A delay in diagnosis may lead to higher mortality as the opportunity for early valve replacement in appropriate cases and more prolonged courses of antibiotics may not be considered.

This article introduces a promising new health care financing proposal for physician payment called Balanced Choice. It summarizes the implications of health care economics and current well-publicized health care reform proposals, each of which is problematic for physicians and their patients. The Balanced Choice proposal is for an integrated two-tier national system, which has an economically efficient universal plan similar to single-payer, but with an option for enhanced services using market forces at the doctor-patient level to manage care. The two tiers are linked together and balanced so that each complements and enhances the other. Balanced Choice solves the problems of other proposals in a way that would work well for doctors and for patients, and represents a fresh and uniquely American solution to the problem of health care financing.

Mammary carcinoma with osteoclast-like giant cells is an uncommon variant. The following case examines a 36-year-old woman incidentally found to have a left breast mass on routine physical exam. Initial ultrasound-guided core biopsies revealed infiltrating mammary carcinoma with focal mucinous features, for which a left breast lumpectomy and sentinel lymph node biopsy were performed. The sentinel lymph nodes were positive for metastatic mammary carcinoma with osteoclast-like giant cells on permanent section corresponding to the lumpectomy breast specimen, thus a left completion axillary node dissection was subsequently performed.

The need for physicians formally trained to deliver care to diverse patient populations has been widely advocated. Utilizing a validated tool, Weissman and Betancourt's Cross-Cultural Care Survey, the aim of this current study was to compare surgery and family medicine residents' perceptions of their preparedness and skillfulness to provide high quality cross-cultural care. Past research has documented differences between the two groups' reported impressions of importance and level of instruction received in cross-cultural care. Twenty surgery and 15 family medicine residents participated in the study. Significant differences were found between surgery and family medicine residents on most ratings of the amount of training they received in cross-cultural skills. Specifically, family medicine residents reported having received more training on: 1) determining how patients want to be addressed, 2) taking a social history, 3) assessing their understanding of the cause of illness, 4) negotiating their treatment plan, 5) assessing whether they are mistrustful of the health care system and÷or doctor, 6) identifying cultural customs, 7) identifying how patients make decisions within the family, and 8) delivering services through a medical interpreter. One unexpected finding was that surgery residents, who reported not receiving much formal cultural training, reported higher mean scores on perceived skillfulness (i.e. ability) than family medicine residents. The disconnect may be linked to the family medicine residents' training in cultural humility - more knowledge and understanding of cross-cultural care can paradoxically lead to perceptions of being less prepared or skillful in this area.

Background: We are often left with the differential diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH) versus hypovolemic hyponatremia. It is difficult to tell who will respond to isotonic saline infusion and who will not, if the urine sodium value is not completely suppressed (>10 mEq/L).

Aim: To examine the diagnostic accuracy of the urine sodium value.

Design: A retrospective observation.

Methods: The diagnostic accuracy of the urine sodium value was compared to that of a complete work-up and hospital course, including a response to saline infusion in patients with a final diagnosis of SIADH or hypovolemic hyponatremia. We also examined the diagnostic value of urine sodium-to-BUN ratio which should improve separation between SIADH and hypovolemia since the urine sodium and BUN move in opposite directions in these two conditions.

Results: The urine sodium value of 50 mEq/L was the most accurate in separating SIADH from hypovolemic hyponatremia: sensitivity 0.89, specificity 0.69, and accuracy 0.82. The diagnostic utility for SIADH versus hypovolemia, as quantified by the areas under the ROC curves, was not statistically different between urine sodium alone (0.89, 95% CI 0.77-0.96) and urine sodium-to-BUN ratio (0.93, 95% CI 0.83-0.98); p-value 0.33.

Conclusions: When the underlying cause is inconclusive between SIADH and hypovolemia, and when only basic laboratory results are available at the time of initial evaluation, the urine sodium alone will be adequate to guide initial fluid management. In contrast to traditional teaching, elevated urine sodium levels up to 50 mEq/L demonstrated clinically meaningful responses to isotonic saline infusion.

A field study with follow up investigations sought to: 1. determine whether cold packs (over-the-counter symptomtic treatments), coupled with in-office education, improve antibiotic-related knowledge, attitudes and behaviors more than in-office education alone in patient populations with high percentages of Asian Americans and Hawaiian/Pacific Islanders; 2. identify possible reasons for intervention outcomes as described by physicians who participated in the field study; and 3. explore potential future directions based on a large sample survey of physicians in the field study's highly ethnic county. The intervention resulted in a pre- to post-consultation decrease in perceived need for and an increase in knowledge about antibiotic risks but had no impact on frequency of reported receipt of an antibiotic prescription. Unexpectedly, in-office education alone was more effective in increasing knowledge than in-office education plus the cold pack. In-depth interviews of field study physicians and a large scale physician survey suggest that cold pack interventions targeting patient populations with high percentages of Asian Americans and Hawaiian/Pacific Islanders may be more likely to succeed if accompanied by mass public education regarding risks and physician training regarding effective ways to talk to patients. Use of in-office education with cold packs alone may not achieve desired results.

Objective: To examine BRCA1 and BRCA2 gene sequence testing results, specifically variants of uncertain clinical significance in the BRCA1 and/or BRCA2 sequences of an ethnically diverse population within a particular time constraint.

Methods: A retrospective chart analysis of BRCA1 and BRCA2 gene sequence testing cases was reviewed at Kapiolani Medical Center for Women and Children from October 1996 to November 2007. Information was extracted and categorized regarding each patient's age, age of cancer onset, types of can cer in family history, ethnicity/ancestry, type of test used for analysis, and specific characteristics of each variant.

Results: Of the 273 patients who received BRCA1/BRCA2 gene sequence testing, 45 patients demonstrated variants of uncertain clinical significance. A total of 48 variants of uncertain clinical significance were reported and 9 of the variants had previously never been observed before. Of the 45 patients, 33.3% were Caucasian, 40% were Asian, and 26.67% were of mixed ethnicity.

Conclusions: Within the local population at Kapiolani Medical Center for Women and Children, a significantly higher proportion of patients exhibited variants compared to the national average. A high percentage of variants existed among the ethnically diverse as well as the Caucasian population. Gene sequence testing is a valuable asset for physicians treating patients who are at risk for inherited cancer: however, the direction of treatment remains clinically questionable for patients with variants of unknown significance.

The rates of melanomas and skin cancers are increasing in the United States. Children attending elementary schools are in the most danger of acquiring these diseases later in life, and elementary school children in Hawaii have the greatest risk of all children in the United States. The parents and educators of Hawaii's elementary school age children are unaware of the potential risks for cancer that young children experience every day at school. Effective sun protection policies have been implemented in other jurisdictions, including Australia, that have similar risks for over-exposure to solar ultraviolet radiation in children. These proven policy models can inform sun protection practices in Hawaii. A simple policy whereby public elementary schools require that children wear ordinary long sleeves shirts and hats during the school's outdoor activities will protect Hawaii's children from overexposure to sun's ultraviolet radiation. Establishment of a state law codifying the implementation of this simple, yet scientifically proven strategy into the policies of Hawaii's public elementary schools can significantly reduce the incidence and deaths from melanoma and skin cancer in the state.

This community-based participatory research, conducted in partnership between a European-American academic researcher and a professional group of Filipino nurses, aimed to determine the diabetes research priority for the Filipino community on the island of Oahu in Hawaii, and to evaluate the multi-voting technique to seek input from the community. The study design was a qualitative, cross-sectional interactive process consisting of an educational presentation followed by data collection from the audience. Ten community presentations about the impact of diabetes on the Filipino community were conducted by a Filipino nurse with participants (N=265). Following the educational session, the participants selected priorities for research using a multi-vote technique developed as a Diabetes Bingo card. Community voting results identified prevention and a focus on adults as important priorities for research. Based on the results of the multi-voting, the research partners were able to come to consensus on a research priority area of prevention of type 2 diabetes in adults. Multi-voting using a Diabetes Bingo card, preceded by an educational presentation by a Filipino nurse, was a culturally competent community-based participatory research method that gave voice to the participants and direction to the research partners for future projects. The multi-voting technique was readily accepted and enjoyed by participants.