Asthma prevalence disparities and differences in sociodemographic associations with asthma, between Native Hawaiian/Other Pacific Islander, Asian, and White adults in Hawaii - Behavioral Risk Factor Surveillance System (BRFSS), 2001-2010.

OBJECTIVES: Despite high asthma prevalence, relatively little is known about the epidemiology of asthma in Hawaii or among Native Hawaiian/Other Pacific Islanders (NHOPI). We sought to better characterize racial/ethnic differences in asthma prevalence and in sociodemographic factors associated with asthma among Hawaii adults. DESIGN: We conducted multivariable logistic regression using 2001-2010 Behavioral Risk Factor Surveillance System data from Hawaii, and computed adjusted prevalence and ratios. RESULTS: Asthma prevalence markedly varied between self-identified census categories of race in Hawaii, with NHOPI having the highest estimates of both lifetime (20.9%, 95% confidence interval [CI]: 19.5%-22.4%) and current (12.2%, CI: 11.2%-13.3%) asthma. Highest asthma prevalence among NHOPI persisted after controlling for potential confounders and within most sociodemographic categories. Among females Asians reported the lowest asthma prevalence, whereas among males point estimates of asthma prevalence were often lowest for Whites. Females often had greater asthma prevalence than males of the same race, but the degree to which gender modified asthma prevalence differed by both race and sociodemographic strata. Gender disparities in asthma prevalence were greatest and most frequent among Whites, and for current asthma among all races. Sociodemographic factors potentially predictive of adult asthma prevalence in Hawaii varied by race and gender. CONCLUSION: Asthma disproportionately affects or is recognized more often among women and NHOPI adults in Hawaii, and occurs less or is under-reported among Asian women. The sociodemographic characteristics included in this study's model did not explain asthma disparities between races and/or gender. This investigation provides a baseline with which to plan additionally needed prevention programs, epidemiological investigations, and surveillance for asthma in Hawaii.

Acute kidney injury requiring hemodialysis in patients with anicteric leptospirosis.

BACKGROUND: Leptospirosis is an infrequent disease in the US, with most cases reported in the state of Hawaii. Renal involvement is common (44 - 67%), ranging from a mild prerenal azotemia in anicteric disease to renal failure requiring dialysis in Weil's syndrome (severe leptospirosis with jaundice, renal failure, and hemorrhage). METHODS: To describe the pattern of leptospiral renal disease at our institution, we performed a retrospective analysis (1992 - 2004) of all hospitalized cases of laboratory confirmed leptospirosis presenting with acute kidney injury (AKI), defined as a presenting serum creatinine > 1.5 mg/dl. RESULTS: During this time period, 18 patients were hospitalized with laboratory confirmed leptospirosis. Among these patients, 12 had AKI on presentation, and hemodialysis was required in 3 patients. Renal biopsies were performed in 2 of these patients, revealing acute tubulointerstitial nephritis. Interestingly, the patients who required dialysis did not have Weil's syndrome. They did not exhibit jaundice or hemorrhage, and serum AST (mean 51.7 U/l (range 36 - 60)), ALT (mean 51.0 U/l (range 38 - 64)), and total bilirubin (mean 1.2 mg/dl (range 0.8 - 1.8)) were either within normal limits or only slightly elevated, despite having the worst renal disease. CONCLUSIONS: This series adds to other evidence that severe AKI (requiring dialysis) can complicate anicteric leptospirosis in contrast to the notion that the AKI in anicteric disease is typically mild and prerenal. Leptospirosis should be considered in all patients who present with fever and AKI, especially if associated with thrombocytopenia or travel to an endemic area.

Feral Swine Leptospira Seroprevalence Survey in Hawaii, USA, 2007-2009.

Leptospirosis is considered the most widespread of zoonotic diseases. It was a notifiable disease in the United States until 1995 and was reinstated to the list of nationally notifiable diseases in 2014. During the time of national surveillance, Hawaii consistently led the nation in reported annual incidence rates. Leptospirosis has remained a reportable disease in Hawaii. Significant changes have been documented since the early 1970s in the predominant serogroup infecting humans in Hawaii: infections due to Icterohaemorrhagiae have declined while infections due to Australis have increased. A recent study from Hawaii demonstrated that Australis was an uncommon infecting serogroup for small mammal hosts. Swine have not been previously studied in Hawaii but are well-recognized maintenance hosts for leptospires belonging to the Australis serogroup. This study was undertaken to assess the prevalence of Leptospira antibody in feral swine in Hawaii. From January 2007 through December 2009, blood samples were collected opportunistically from feral swine. Using the microscopic agglutination test, we found antibody titres ≥1 : 100 to leptospires in 272 (33.8%) of 804 feral swine. The most frequently reacting serovars to the swine sera were Icterohaemorrhagiae (Icterohaemorrhagiae serogroup) (41.5%) and Bratislava (Australis serogroup) (33.8%). The high seroprevalence and presumptively infecting serovars suggest a link between swine and human infection.

Assessment of the clinical presentation and treatment of 353 cases of laboratory-confirmed leptospirosis in Hawaii, 1974-1998.

Leptospirosis is frequently misdiagnosed as a result of its protean and nonspecific presentation. Leptospirosis, a zoonosis with global distribution, commonly occurs in tropical and subtropical regions; most reported cases in the United States occur in Hawaii. All laboratory-confirmed leptospirosis cases in the State of Hawaii from 1974 through 1998 (n=353) were clinically evaluated. The most common presentation involved nonspecific signs or symptoms, including fever, myalgia, and headache. Jaundice occurred in 39% of cases; conjunctival suffusion was described in 28% of these cases. Initiation of antibiotics before the seventh day of symptoms was associated with a significantly shortened duration of illness. Because early recognition and initiation of antibiotic therapy are important, clinicians should familiarize themselves with the clinical presentation of leptospirosis, and when evaluating a patient with a febrile illness, they should obtain exposure and travel histories and entertain the possibility of leptospirosis in the differential diagnosis.

Biofragmentable bowel anastomosis ring: comparative efficacy studies in dogs.

Three studies were conducted in a total of 178 dogs to determine the efficacy of a biofragmentable bowel anastomosis ring (BAR) composed of polyglycolic acid and 12.5% barium sulfate. Wound strength and healing of BAR, suture, and staple colonic anastomoses were compared for intervals of up to 1 year. The effect of systemic steroid treatment and BAR size on anastomotic wound strength and healing was also studied. The BARs fragmented at a mean time of 15.06 days postoperatively and were passed in the feces without injury. Wound strength was determined by measurements of the pressure required to burst the anastomosed colonic segment and measurements of the tension required to break 10 mm wide longitudinal strips of the anastomosed segment. The studies demonstrated that wound strength had progressed to a point where continued mechanical support (with sutures or staples) was no longer required by 14 days in both nontreated and steroid-treated dogs. Gross healing evaluations at 21 days and beyond showed no differences due to anastomotic method. Microscopic evaluations suggested that residual granulation tissue was less at the sites of BAR asastomoses than at sites of suture or staple anastomoses at the 1-year interval, suggesting that healing may be better with BAR than with standard methods of colon anastomosis.

Acute fatty liver in the second trimester.

BACKGROUND: Acute fatty liver of pregnancy is a rare, potentially fatal disease that occurs in the late third trimester or early postpartum period. The case of a woman with acute fatty liver in the second trimester is presented. CASE: A 35-year-old woman, gravida 5, para 4, presented at 22 weeks' gestation with nausea, vomiting, malaise, weight loss, and moderately elevated liver transaminase levels. The differential diagnoses included viral gastroenteritis and cholelithiasis. During the next 12 days, her transaminase levels increased, jaundice developed, her sensorium changed, and coagulopathy appeared. After the patient was transferred to a tertiary care hospital, acute fatty liver of pregnancy was diagnosed. The woman rapidly improved after delivery. CONCLUSION: Although acute fatty liver of pregnancy usually occurs in the late third trimester or early postpartum period, it can occur in the second trimester.

Bernard-Soulier syndrome complicating pregnancy: a case report.

The pregnancy of a patient with Bernard-Soulier syndrome is described. Coagulation abnormalities were encountered, as well as isoimmunization from previous transfusions. Immune suppression was achieved with steroids and intravenous gamma globulin, and plasmapheresis was performed to allow platelet transfusion.

Postabortal laparoscopic tubal sterilization. Results in comparison to interval procedures.

This report documents our experiences in 3 groups of women undergoing laparoscopic tubal sterilization: those undergoing sterilization as an interval procedure, those performed in association with suction curettage, and those performed within 18 hours of second trimester pregnancy termination via intraaminiotic injection of prostaglandin F 2 alpha. As a postabortal sterilization procedure, laparoscopy is effective, logistically appealing, and convenient. There is, however, an increased risk of complications to the procedure when performed on the postabortal women. These include specifically, a 10-fold increased risk of infection and a 2.5-fold increased risk of bleeding complications as seen in our series. The results of these findings are discussed, and some suggestions for reducing these risks are offered.

Management of a rare blood type: Oh "Bombay" in pregnancy.

A rare blood type, Oh "Bombay," was observed in a 30-year-old Indian primigravida. The genetic mode of inheritance is discussed. The obstetric management, with anticipation for the need for blood transfusion, is outlined and the use of autotransfusion for patients with rare blood type is emphasized.

Ciguatera on Kauai: investigation of factors associated with severity of illness.

Epidemiologic characterization of ciguatera fish poisoning has been limited by lack of laboratory confirmation, absence of prospective follow-up, and incomplete analysis of age-related factors. A 1985 outbreak on the island of Kauai in the state of Hawaii that involved 15 persons of various ages was investigated to determine factors associated with disease severity. The presence of ciguatoxin was detected in leftover portions of the implicated fish by enzyme immunoassay. All cases were medically and epidemiologically investigated and followed prospectively. Ten of the 15 cases demonstrated bradycardia; seven were hospitalized, including two requiring placement in intensive care. Bradycardia was associated with increasing age and body weight (P < 0.01 and < 0.05, respectively) as well as the amount of toxic fish consumed (P < 0.01). Duration of illness ranged from two to 132 days. Increasing duration of illness was correlated with both increasing age and weight (rs = 0.64 and rs = 0.72, respectively, both P < 0.01) and was independent of amount and components of toxic fish consumed. The correlation between increasing age and weight with duration and severity of symptoms may be explained by prior subclinical toxin exposure and is consistent with the observation that repeated ciguatoxin exposures are associated with more severe illness. The association between amount of toxic fish consumed and bradycardia is consistent with an increased dose of ciguatoxin. The findings of this outbreak investigation support previously unconfirmed observations.

An absorbable catheter system for use in microvascular and peripheral vascular surgery: an experimental study in the canine.

An absorbable catheter for use in regional anticoagulation in microvascular and peripheral vascular surgery was studied in 20 sites in 10 adult beagle dogs to answer three questions: (1) Could the polyglycolic acid and trimethylene carbonate catheter withstand intraarterial pressures of infusion and completely absorb over a predictable time interval? (2) Could the catheter be filled with heparin and maintain patency for reuse after a 24-hour interval? (3) Could the catheter be placed in a side branch of a major artery and, after catheter dissolution, maintain long-term patency of the primary feeding artery? The catheters were completely absorbed from 24 to 34 weeks following implantation. The catheters were able to withstand intraarterial pressures, and no evidence of significant thrombosis of the primary feeding artery was seen in any animal studied. No complications of catheter leak, hematoma formation within the catheter placement sites, or sepsis were noted in any of the 20 catheter sites studied.

Autologous transfusion in obstetrics and gynecology.

Two cases are presented which illustrate the use of autologous blood transfusion for elective surgery in obstetrics and gynecology. The advantages and disadvantages are described and review of the pertinent literature over the past century is summarized.

Aortic perforation sustained at laparoscopy.

PIP: A major type of complication associated with laparoscopic sterilization has been overcome by changing from electrocautery to either the Hulka clip or silicone rubber band technique, but major puncture and laceration injuries continue at the rate of 0.5% to 2%. The only case of major vascular injury incurred in over 4000 laparoscopic sterilization procedures performed from 1974 through 1980 at the Hermann Hospital in Houston, Texas is reported. A 40-year-old white female, para 3-0-1-3, was admitted for a laparoscopic sterilization procedure. The physical examination was within normal limits. The procedure was carried out by insufflating the peritoneal cavity with 2 liters of CO2 through a 12-cm Verres needle placed subumbilically while testing the abdomen with towel clips. Insufflating pressure never rose above 15 mm of mercury, and an adequate pneumoperitoneum was obtained. With the patient in the Trendelenburg position the trocar was inserted and the laparoscope placed with no apparent difficulty. The Falope Ring applicator sleeve was inserted suprapublically under direct vision. After placing the rings bilaterally, the cul-de-sac was noted to contain approximately 300 cc of blood. This was aspirated, but blood slowly reaccumulated in the cul-de-sac. Laparoscopic examination provided inadequate visualization of the posterior surface of the mesosalpinges, and it was decided to perform laparotomy. Upon opening the abdomen, the pulse rose from 85 to 110 per minute and the blood pressure fell from 90/60 to 50/0 mm HG. Rapid infusion of isotonic crystalloid and 3 units of packed red blood cells restored the patient's vital signs to normal. Examination of the abdominal wall and pelvic organs was normal, but a retroperitoneal hematoma was discovered in the area of the sacral promontroy. The posterior peritoneum was opened, and a 13 x 15-cm hematoma was evacuated. A 3-mm puncture wound was noted in the anterior wall of the aorta 3 cm cephalad to the bifurcation. The square defect was isolated with vascular clamps and repaired with a single layer of simple interrupted Prolene sutures. Abdominal exploration revealed a 3-mm defect in the small bowel mesentery that was repaired with interrupted chromic sutures, and the abdomen was closed. This report illustrates the perpetual caution that must be exercised in the performance of a routine gynecologic procedure. The blind puncture of the abdominal wall with the Verres needle and the laparoscope trocar must be performed with great care.^ieng

Complications of laparoscopic sterilization.

PIP: The 855 laparoscopic sterilizations performed at Hermann Hospital, the primary teaching hospital of the University of Texas Medical School at Houston, were reviewed, and the medical and surgical complications encountered in this series were examined. The patients had a mean age of 29 years and an average parity of 2.8. Of the 88.6% using contraception prior to the sterilization, half were using oral contraceptives (OCs). There were operative complications in 50 patients. The most frequent was tubal transection with or without bleeding of the mesosalpinx. The 2nd most common complication was uterine perforation, with a dilatation and curettage performed concurrently with sterilization. A total of 5 pregnancies were identified in this sterilization group; 2 of them were luteal phase ones. No ectopic pregnancies have resulted thus far. There were very few medical complications. The most common was occasional premature ventricular contractions. In none of these cases was termination of the procedure or lidocaine therapy required. No abdominal or pelvic infections occurred as a result of the tubal sterilization procedure. In patients with intrauterine contraceptive devices removed at laparoscopy, antibiotic prophylaxis was used. There were no cases of trauma to any of the gastrointestinal organs. No abdominal hernias have been identified on follow-up examinations. 2 concomitant umbilical herniorrhaphies were performed during sterilization procedures. Certain complications, such as thermoelectrical burns, have been greatly reduced in this series by the use of a silastic banding technique. Bipolar cautery is still reserved for the control of small bleeding sites and for use when the fallopian tubes cannot be drawn up into the ring applicator device. Care needs to be taken during cauterization to completely visualize the tube and surrounding structures. Management of a suspected bowel burn, as long as it is superficial, may be conservative.^ieng

Leptospirosis on Oahu: an outbreak among military personnel associated with recreational exposure.

In December 1992, a common-source waterborne outbreak of leptospirosis occurred on the island of Oahu in the state of Hawaii. Two male service persons were hospitalized with culture-confirmed leptospirosis. Eighteen others had similar histories of exposure to the same freshwater swimming site. Although six men developed signs and symptoms comparable to those of the two confirmed cases, none manifested culture or serologic evidence of leptospirosis. The increased incidence of leptospirosis in Hawaii coupled with an increased risk in young males characterize the military population in Hawaii as a high-risk population with respect to leptospirosis.

[The use of prostaglandins to perform terminations of pregnancy in the second trimester (author's transl)]. / Utilisation des prostaglandines pour les interruptions de grossesse au second trimestre.

The authors report 48 cases of termination of pregnancy between the 12th and the 20th week using prostaglandins. Two methods were used: An injection of 40 mg of Prostaglandin F2 alpha (1) intra-amniotically: used on 38 women in group i. 10 patients had 5 mg of 15 (S) 15 methylprostaglandin F2 alpha administered vaginally in group ii. In the first group all women aborted with a mean induction expulsion time of 16 hours and 20 minutes. In the second group 9 women aborted with a mean time of 14 hours and 2 minutes. Side effects were very marked in the second group, whereas they seemed to be acceptable in the first group.

Chlamydia trachomatis: a frequently overlooked public health menace.

Genital Chlamydia trachomatis infections affect 3-4 million Americans each year and are considered to be the most prevalent of all sexually transmitted diseases in the United States. Complications arising from chlamydial infections include scarring of the fallopian tubes, leading to ectopic pregnancy and infertility. Because a significant proportion of chlamydial infections are asymptomatic, this disease is frequently overlooked. Recent developments in low cost, rapid, antigen-detection assays have made widescale screening programs possible. This article reviews clinical and epidemiological aspects of chlamydial infections and discusses control strategies.

Prevalence of systemic lupus erythematosus in Hawaii: is there a difference between ethnic groups?

This population-based study in Hawaii collected cases of systemic lupus erythematosus from medical facilities and a patient support group. A total of 454 cases was found and the prevalence was estimated at 41.8 per 100,000 population for 1989. The prevalence odds ratio for all non-Caucasians compared to Caucasians was 1.2 (0.9-1.5), for Japanese 1.3 (1.0-1.7), for Filipinos 1.5 (1.1-2.0), for Chinese 2.4 (1.7-3.4), and for Hawaiians 0.8 (0.6-1.1). Mortality rates were 3 times higher for non-Caucasians than for Caucasians in 1985 to 1989. Despite the observed differences, it remains unclear whether individuals with Asian or Pacific Islander ancestry are at higher risk for systemic lupus erythematosus. The variation in prevalence rates may be a result of differences in access to medical care and in survival.

The Hawaii Chlamydia Network Project: a successful program incorporating close intra-agency cooperation.

The Hawaii State Department of Health's Chlamydia Network Project screened 272 asymptomatic females for chlamydia; 20 (7.4 per cent) were found to be positive. When interviewed, 75 per cent (15/20) of the cases gave information such that their sexual partner(s) could be located. Ninety per cent (14/16) of the locatable partners were brought to examination within seven days. Keys to success were the training of family planning clinic staff in STD (sexually transmitted disease) control methods, and close intra-agency cooperation.