June 2007, Volume 66, No. 6, ISSN: 0017-8594
HUMAN SERUM ALBUMIN LEVELS AND CARDIOVASCULAR RISK
FACTORS IN ELDERLY JAPANESE-AMERICAN MEN:
THE HONOLULU HEART PROGRAM
Chung-Eun Ha PhD, et al
CULTURALLY SENSITIVE STRATEGIES DESIGNED TO TARGET
THE SILENT EPIDEMIC OF HEPATITIS B IN A FILIPINO COMMUNITY
Michelle Marineau PhD, APRN, et al
A RARE CASE OF A PANCREATIC TUMOR IN ASSOCIATION
WITH THE SYNDROME OF INAPPROPRIATE ANTIDIURETIC
Sean Hirota MSIII, et al
MEDICAL SCHOOL HOTLINE
Is Clinical Empathy Teachable? A Medical Humanities Initiative
Carolyn Riederer Annerud MD, FACEP
CANCER RESEARCH CENTER HOTLINE
Emerging Bone Health Issues in Women with Breast Cancer in Hawai‘i
Jennifer Fu Carney MD and James Davis
MEDICAL LEGAL HOTLINE
Issues in Medical Malpractice XII
S.Y . T an MD, JD
Russell T . Stodd MD
See why the biggest change in medicine involves no change at all.
™Graphical Health Record
TheCatalis.com I 888.241.1325
Catalis®and Accelerator™ GHR are trademarks of Catalis, Inc.
The future has arrived.
Catalis®Accelerator™ version 4.111 is CCHIT CertifiedSMfor Ambulatory EHR 2006.
HAWAI‘I MEDICAL JOURNAL, VOL 66, JUNE 2007
Published monthly by the
Hawai‘i Medical Association
Incorporated in 1856 under the Monarchy
1360 South Beretania, Suite 200
Honolulu, Hawai‘i 96814-1520
Phone (808) 536-7702; Fax (808) 528-2376
Editor: S. Kalani Brady MD
Editor Emeritus: Norman Goldstein MD
Contributing Editor: Russell T. Stodd MD
Contributing Editor: Satoru Izutsu PhD
Contributing Editor: Carl-Wilhelm Vogel MD, PhD
Contributing Editor: James Ireland MD
Contributing Editor: S.Y. Tan MD, JD
John Breinich MLS, Satoru Izutsu PhD,
Myron E. Shirasu MD, Frank L. Tabrah MD,
Alfred D. Morris MD
Copy Editor: Ann Catts MD
Copy Editor: April Troutman
Copy Editor: Niranda Chantavy
Production Manager: Drake Chinen
President: Linda Rasmussen MD
President-Elect: Cynthia Goto MD
Secretary: Thomas Kosasa MD
Treasurer: Calvin Wong MD
Immediate Past President: Patricia L. Blanchette MD
Hawai‘i: Jo-Ann Sarubbi MD
Honolulu: Gary Okamoto MD
Maui: Howard Barbarosh MD
West Hawai‘i: Kevin Kunz MD
Kauai: Christopher Jordan MD
2040 Alewa Drive
Honolulu, Hawai‘i 96817
Phone (808) 595-4124
Fax (808) 595-5087
The Journal cannot be held responsible for opinions expressed
in papers, discussion, communications or advertisements. The
advertising policy of the Hawai‘i 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 Hawai‘i Medical Journal
(USPS 237640) is published monthly by the Hawai‘i Medical
Association (ISSN 0017-8594), 1360 South Beretania Street,
Suite 200, Honolulu, Hawai‘i 96814-1520.
Postmaster: Send address changes to the Hawai‘i Medical
Journal, 1360 South Beretania Street, Suite 200, Honolulu, Hawai‘i
96814. Periodical postage paid at Honolulu, Hawai‘i.
Nonmember subscriptions are $25. Copyright 2007 by the
Hawai‘i Medical Association. Printed in the U.S.
Aloha Laboratories, Inc
…when results count
“Best Doctors in America“Best Doctors in America
Phone (808) 842-6600
Fax (808) 848-0663
HAWAI‘I MEDICAL JOURNAL, VOL 66, JUNE 2007
Human Serum Albumin Levels and
Cardiovascular Risk Factors in Elderly
Japanese-American Men: The Honolulu
Chung-Eun Ha PhD, Kamal H. Masaki MD, Helen Petrovitch MD, Randi Chen MS,
Lenore Launer PhD, Nadhipuram V. Bhagavan PhD, Alan T. Remaley MD, PhD,
and J. David Curb MD
The objective of this study is to investigate the relation-
ship between low levels of human serum albumin (HSA)
and the incidence of coronary heart disease (CHD) in a
cohort of elderly Japanese-American men. Using data
from the Honolulu Heart Program’s fourth examination
(1991-1993), HSA levels of 998 Japanese American
men aged 71-93 years was compared with plasma
levels of fibrinogen, total cholesterol, HDL cholesterol,
LDL cholesterol, triglycerides, diastolic BP, BMI, and
fasting blood glucose. HSA was significantly negatively
associated with age and fibrinogen, and significantly
positively associated with total cholesterol, HDL cho-
lesterol, LDL cholesterol, triglycerides, diastolic BP,
BMI and fasting blood glucose. After adjusting for age,
tertiles of HSA were significantly positively associated
with total cholesterol, HDL cholesterol and triglycerides,
and significantly negatively associated with fibrinogen.
Using multivariate stepwise regression, significant
correlations were seen between HSA and fibrinogen,
cholesterol, age, HDL cholesterol and triglycerides, and
a borderline correlation was seen with systolic blood
pressure. However, the model R-square for all variables
was only 0.10. In conclusion, HSA levels are significantly
associated with several traditional cardiovascular risk
factors, particularly serum lipid levels.
Coronary heart disease (CHD) is the leading cause of
morbidity and mortality worldwide. The understanding
of traditional risk factors, cigarette smoking, hyperten-
sion, obesity, diabetes mellitus, physical inactivity, and
plasma levels of total cholesterol, low-density lipopro-
tein cholesterol (LDL-C), high-density lipoprotein cho-
lesterol (HDL-C) and triglycerides has made significant
contribution in reducing the morbidity and mortality of
CHD.1 The major risk factors, nevertheless, are impli-
cated in only as many as 75% of CHD cases.2 Several
epidemiological studies have supported the observation
that a high concentration of HDL-C is cardio-protective.
However, this inverse relationship between HDL-C and
CHD is not applicable to a significant number of CHD
patients. For example, 27% of the men participating in
the Framingham Heart Study cohort showed premature
CHD but did not have HDL-C levels in the bottom 10th
percentile.3 Thus, non-traditional risk factors may play
a significant role in CHD risk. One of these is human
serum albumin (HSA). Many observational epide-
miological studies have demonstrated an association
between low levels of HSA and increased incidence
of CHD.4-12 In particular, a population based study
regarding the relationship between the levels of HSA
and total cholesterol and mortality among the Japanese
general population showed that a combination of low
levels of HSA and above-average total cholesterol were
associated with higher mortality.13 Furthermore, this
study showed that the low serum albumin level group
(≤43 g/L) was associated with higher cardiovascular
mortality for men.
There is evidence that HSA levels may be dependent
on, or influence other cardiovascular risk factors such
as serum lipid levels. Before exploring the possible
direct relationship of HSA levels to CHD incidence,
it is important to determine the interactions that exist
between HSA levels and proven CHD risk factors that
might act as mediators. In this report, we examined the
relationship between HSA and several other traditional
cardiovascular risk factors in a cohort of elderly Japa-
The Honolulu Heart Program (HHP) is a prospective
epidemiologic observational study of cardiovascular
disease that began in 1965. The identification of the
study cohort was undertaken by using World War II
Selective Service registration cards which were on file in
Honolulu. This process led to the finding of registration
Chung-Eun Ha PhD
Kamal H. Masaki MD
Helen Petrovitch MD
Randi Chen MS
Lenore Launer PhD
HAWAI‘I MEDICAL JOURNAL, VOL 66, JUNE 2007
50 50Years of…
The Board of Directors at Physicians Exchange of Honolulu invite you to experience the only service designed by
and for Physicians in Hawaii.
President: Franklin Young M.D.
Vice President: Stephen Kemble M.D.
Secretary: Paul DeMare M.D.
Treasurer: David Young M.D.
Richard Ando Jr. M.D.
Linda Chiu M.D.
Robert Marvit M.D.
Richard Philpott ESQ.
Ann Barbara Yee M.D.
Manager: Rose Hamura
Discover the difference of a professional answering service. Call today for
HAWAI‘I MEDICAL JOURNAL, VOL 66, JUNE 2007
10/10-10/13OMF American Association of Oral
and Maxillofacial Surgeons
Hawai‘i Convention Center,
89th Annual Meeting
& Scientific Sessions
T el: (847) 678-6200
10/16-10/20American Society for Bone and
Hawai‘i Convention Center,
29th Annual Meeting T el: (202) 367-1161
10/18-10/20GEStanford Hospital & Clinics Mauna Lani Bay Resort,
GI CancersT el: (650) 724-7166
10/20-10/24ORSOrthopaedic Research Society Hawai‘i Convention Center,
6th Combined Meeting of the
Orthopaedic Research Societies
T el: (847) 698-1625
10/22-10/27 GYNMayo Clinic College of
Continuing Medical Education
Hyatt Regency, Maui20th Annual T echniques in
T el: (480) 301-4580
10/28-11/2R University of California,
Hyatt Regency Resort & Spa,
Diagnostic Radiology Seminar T el: (415) 476-5808
11/10-11/13 MultiAmerican Medical Association Hawai‘i Convention Center,
AMA Interim Meeting
OFFICE TO SHARE
OFFICE TO SHARE: KUAKINI MEDICAL PLAZA. 3 exam rooms, 2 consultation rooms.
T erms Negotiable. Call: 524-5225.
HMA members.– As a benefit of membership, HMA members may place a complimentary one-time classified ad in HMJ as space is available. Non-
members.– Rates are $1.50 a word with a minimum of 20 words or $30. Not commissionable. For more information call (808) 536-7702, Ext. 101
EVEN THE SMALLEST ADS ARE SEEN: IN THE HAWAI‘I MEDICAL JOURNAL. Call:
808-536-7702 for more info.
YOUR AD HERE
psychology, sociology, comparative religions, and the impact on
patient-doctor decisions, art and music as disciplines for expres-
sion and for enhancing observational skills, writing from different
perspectives (doctor, patient, and family), drama, and dance.
Collaboration between JABSOM and UH Manoa Department of
Arts and Humanities is seen as an appropriate and complimentary
use of expertise and resources.
Desired outcomes would extend this medical humanities cur-
riculum to include other important members of the medical team,
nurses, health and social workers. Future programs might include
continuing medical education courses (CME) for physicians and a
fellowship in medical humanities at JABSOM.
The practice of medicine delicately balances humanism and sci-
ence. The goal is to foster a greater understanding of the human
condition; how health, illness, and suffering are experienced by
both patient and physician. As such, humanism can be modeled by
teachers, but is also reflected in philosophy, ethics, theology, his-
tory, literature, art, music, language, and the social sciences. It is
hoped that a balance of science and humanism will help to create
physicians with an enhanced understanding of the holistic nature of
good medicine, public and social issues in health care, and the need
for cooperation with patients, families, allied health professionals,
and alternative care providers.11
Life and medicine are not only about the collection and synthesis
of facts, but the ability to explore. JABSOM is geographically,
culturally, academically, and philosophically ripe for development
of such a program.
2. Wear, D., Viewpoint: “Trends and Transitions in the Medical Humanities”, AAMC Reporter: October
3. Porter R. The greatest benefit to mankind. London. Carper Collins 1997 pp 64.
4. Larkin, G, Binder, L, Houry, B. and Adams, J. Defining and Evaluating Professionalism: A core com-
petency for graduate emergency medicine education. Acad Emerg Med 2002, 9(11):1249-1256
5. Curriculum Management and Informational T ool (CurrMIT). www.aamc.org/meded/curric search on
Medical Humanities. Advisor, Consultant Dr. Jay Jacobs, University of Hawai‘i John A. Burns School
of Medicine. 2007.
6. Curry C, Annerud C, Jensen S, Symmons, D, Lee M, Sapuri M. The first year of a formal emergency
medicine training programme in Papua New Guinea. Emerg Med Australasia 2004 (16):343-347.
7. Rucker L and J Shapiro. Becoming a Physician: Students’ creative projects in a third year IM clerkship.
Apr 2003 78(4):391-397.
8. Campo R. “The Medical Humanities,” for lack of a better term. JAMA 2005. 294(9):1009-1011.
9. Spiro H. The Medical humanities and medical education. Letters Section and Reply. JAMA 2006.
10. Wachtler, C, S. Lundin, and M. Troein, Humanities for medical students? A qualitative study of a
medical humanities curriculum in a medical school program. BMC Med Educ 2006. 6: 16. Published
online 2006 March 6.
Medical School Hotline, from p. 162
HAWAI‘I MEDICAL JOURNAL, VOL 66, JUNE 2007
Russell T. Stodd MD, Contributing Editor
Russell T. Stodd MD
Contents of this column do not necessarily refl ect the opinion or position of the Hawai‘i Ophthalmological Society and the Hawai‘i Medical Association. Editorial comment is strictly
that of the writer.
❖ TECHNOLOGY IS RAPIDLY
FILLING OUR LIVES WITH
DEVICES SMARTER THAN
While the concept of a “bionic eye” has
been around for decades, a device to help
a blind person actually see is approaching
reality. At Stanford University, physicist
Daniel Palanker, PhD, and associates have
developed a three millimeter chip which
can be implanted behind the failing retina
to theoretically produce a ten degree fi eld
with visual acuity of 20/80. The patient
would wear a pair of goggles mounted
with a mini-video camera. The camera
transmits a wireless message to a wallet-
size computer which relays the message
back to an infra-red screen on the goggles, which is then transmitted to the
retinal implant. Voila! The patient can read the headlines, enjoy Saturday
Night Live, and live independently. Please don’t step on the goggles.
❖ RESULTS OF THE TEXAS CHAIN SAW MASCARA.
Dry eye disease affl icts millions of Americans, especially women over age
forty. It is estimated that 25% of eye-doctor visits are for dry eye complaints.
Multiple factors can be a cause such as hormone imbalance, contact lens
wear, after eyelid or lasik surgery, or environmental conditions such as air
conditioning, wind, dust, and allergies. For some the problem can be serious
and debilitating, but typically these patients receive perfunctory treatment.
The doctor is likely to recommend increased blinking, or lacrimal punctum
plugs, or over the counter moistening agents. These may yield transient
relief, but are only temporarily effective. Allergan’s prescription eye drop,
Restasis, works for some, but fails for others. Moreover, many solutions
are expensive. Pharmaceutical people now recognize that the market for
a successful product can reach annual sales of $1.5 billion. Now there are
about 20 products in various stages of research, such as Alcon’s low-dose
steroid eye drop which should hit the FDA in 2009. AMO also has a dry-
eye development program underway. Show me the money!! gets action
❖ PLEASE NO MORE CHEESE! I JUST WANT OUT OF THE
So what is next? Doctors with badges and issuing subpoenas? Six states,
California, Delaware, Nevada, New Jersey, Oregon, and Pennsylvania, now
require physicians to report people who may be unfi t to drive, such as elderly
patients with signifi cant disease. Moreover, the feds even want doctors to
document immigrants who come for help. Obviously it is necessary to report
child abuse or elder abuse, but what about the pregnant sixteen-year-old
girl who had consensual sex with an adult male? Failing to report is risky
and may make the physician vulnerable to serious penalties, such as fi nes
or even imprisonment. And is it wise to report female abuse when the
police fail to lock up the abuser, and the woman has to return to the same
home? Will patients seek help if they think the physician cannot be trusted
to keep medical care confi dential? It is the physician’s role to always do
what he/she feels is medically best for the patient within the parameters of
ethics and logic. Please get the politicians and various government agencies
out of the house of medicine.
❖ MAUI BUMPER STICKER - YOU WOULD DRIVE BETTER
WITH THAT CELL PHONE UP YOUR A***.
A survey released by Nationwide Mutual Insurance showed that DWD,
“driving while distracted,” is very prevalent. Of those who responded,
59% do not consider themselves distracted drivers, but 80% admit to multi-
tasking on the road. As might be expected 73% confess to talking on cell
phones, and 37% of young adults admit to text-messaging! Almost half of
respondents (48%) said they eat a full meal while motoring. Less common
DWD events were reading a book, putting on contact lenses, watching a
movie, nursing a baby, and even changing seats with a passenger. OMG
(oh my god) be careful out there!
❖ WOW! THIS LOOKS REALLY WEIRD. MOVE THE CAMERA
OVER THIS WAY.
In Massachusetts, state representative Martin Walsh, a Democrat, has
introduced a bill that would require licensed hospitals to make video and
audio recordings of all surgeries. His expectation is that this would protect
patients and possibly expose medical errors. Just what is needed in the
OR; putting doctors and patients in adversarial positions! Both doctors
and plaintiff attorneys do not like the bill and state that it would do more
harm than good. The Massachusetts Medical Society is against the bill
and President Kenneth Peelle, MD, stated that the measure implies that
the surgeon is not to be trusted. Also, it is one more distraction to impair
the surgeon’s judgement.
❖ IF A WOMAN’S PLACE IS IN THE HOME, WHAT WAS SHE
DOING IN THAT PICKUP?
In Arlington, Texas, a 38-year-old man arrived home earlier than expected.
He found his wife having sex in the back of a pick-up parked in the driveway.
When the woman saw her husband she screamed rape, so the man shot and
killed the “rapist.” Subsequent investigation revealed that the sex was not
rape, and that the woman had a relationship with the victim. The husband
was not prosecuted and the police accepted that he was trying to defend his
wife. The grand jury indicted the wife for “reckless behavior which caused
the death” and she faces from two to thirty years in prison if convicted.
❖ THERE’S A SNAKE IN THE GARDEN OF WAL-MART!
In central Florida a man shopping in the garden section of a Wal-Mart store
was bitten by a pygmy rattlesnake. The man tried to shake off the snake
which was clinging to his fi nger, stepped backward into his shopping cart
and fell, injuring his back. The snake’s venom is poisonous and the man was
hospitalized when his hand was paralyzed. Subsequent research revealed that
at least seven other cases of snake bite have occurred at Wal-Mart garden
centers. Of course, no need to worry at Hawai‘i’s Wal-Mart stores since
snakes are banned in our state, but do the snakes know that?
❖ THE OTHER SENSES BELIEVE THEMSELVES. THE EARS
BELIEVE OTHER PEOPLE.
In recent years media moguls Larry King, Paul Harvey, and others have
been extolling the benefi ts of garlic with the claim that it lowers low den-
sity (bad) cholesterol (LDL). Oops! According to a study done at Stanford
University and published in the Archives of Internal Medicine, it just ain’t
so. Researchers studied 192 adults with moderately high cholesterol for six
months, and each was given either raw garlic or a garlic supplement while
a control group received a placebo. The effect on LDLs was zero. It was
noted that the placebo did not cause as many people to back away.
❖ EDUCATED INTELLIGENCE IS NO MATCH FOR NATURAL
A book on sale at the Grand Canyon National Park describes how this
natural wonder was actually formed about fi ve thousand years ago by
Noah’s biblical fl ood. Apparently, in order to avoid offending religious
fundamentalists, the National Park Service was directed to suspend its belief
in geology. Most geologists agree that the Grand Canyon was formed by
the Colorado River about six or seven million years ago. The American
Geological Institute and seven geo-science organizations sent letters to
the Park Service asking that the book be removed. Because many park
employees were enraged, the book was moved from the natural science
section of the bookstore to the inspirational rack. The book completely sold
out, presumably to non-scientifi c park visitors for something to read while
waiting for the “rapture.”
❖Memo to Al Gore: There’s global warming on Mars. According to the US
Geological Survey in Flagstaff, Arizona, Mars southern ice cap is shrinking
and has lost billions of tons of carbon dioxide over the last four Martian
years, and air temperatures may have increased as much as four deg. Celsius.
Something should be done. More hybrid cars, perhaps?
Aloha and keep the faith — rts■
O P I
M B S A
Saturday, September 15, 2007
Save the Date
of Cynthia J. Goto, MD
HMA’s Physician of the Year Award
The HMA Presidential Inauguration
visit us at www.hmaonline.net for more information
Please RSVP by September 7, 2007. Mail completed form and payment to HMA, 1360 S. Beretania St. #200, Honolulu, HI 96814 or fax to (808) 528-2376,
toll-free (866) 528-2376. Seats are also available online at www.hmaonline.net. Tickets will not be mailed; reservations are held at the door.
Ola Pono Ike purchases are non-refundable. Call (808) 536-7702, toll-free (888) 536-2792 for more information.
City State Zip
Table of 10: $1,500 x
Check or money order payable to HMA (enclosed) Visa MasterCard AMEX
Individual Seat: $150 x Donation: $
Card # Expiration Date
Cardholder Billing Zip Code
Signature Total Payment $
Medical Insurance Exchange
of California (MIEC)