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Hawaii has a long tradition of commitment to care of the seriously disabled mentally ill. Over the years, some of the more innovative programs and policies were initiated first by the Territory and then by the State to provide humane treatment of this special population in need.
As a conceptual model for reviewing the range of psychosocial rehabilitation services available to the seriously disabled mentally ill (SDMI) population in Hawaii, this report utilizes the program spectrum and criteria developed by Vogelmann-Sine and Sine for the Mental Health Division of the State Department of Health (see Appendix A). The 5 types of psychosocial rehabilitation programs to be reviewed include: (1) Vocational programs, (2) pre-vocational programs, (3) day-treatment programs, (4) social clubs and (5) drop-in centers. Some of these programs are provided by the private sector through contractual arrangements and others are provided in the public sector at the local community mental health centers (CMHC).
The Public Citizen Health Research Group survey sought to answer the following question: "If I had a seriously mentally ill member of my family, in which states would the person be most likely to receive good care?" Our task in presenting this paper is to ask a similar question: "Would my long-term, mentally ill relative have an appropriate community residential placement in Hawaii?"
The incidence of clinically unrecognized myocardial infarctions among 7331 Japanese-American men in Hawaii, aged 45 to 68 years and free of coronary heart disease at entry, was studied on the basis of electrocardiographic changes between successive examinations during 6 years of follow-up. The proportion of asymptomatic myocardial infarction accounted for 33% of transmural (Q-wave) myocardial infarctions identified by temporal changes on electrocardiogram and 22% of all nonfatal infarctions ascertained by either repeated examinations or hospital surveillance. The 10-year prognosis of unrecognized infarction, in terms of mortality from all causes, cardiovascular disease, and coronary heart disease, was worse (with risk ratios of 1.5 to 1.7) than that of recognized infarction, even after adjusting for age and other possible determinants, although the differences were not statistically significant. These findings suggest that regular health check-ups with an electrocardiogram would be important to detect asymptomatic myocardial infarction and to increase the opportunity of taking secondary preventive measures. However, the conclusion should await further studies based on intervention trials to determine the comparative effects of the secondary prevention on the prognosis of clinically recognized vs unrecognized infarction.
By February 1988, 1,000 Hawaii infants had been prescribed cardiorespiratory monitors for use at home. By 1986, 12.3/1000 live births were being monitored, principally for apnea related to prematurity but also following Apparent Life Threatening Episodes, (ALTE) as subsequent siblings of Sudden Infant Death Syndrome (SIDS) victims, and for an increasing variety of other conditions. Less than 3% of families used the monitor less than 1 week; 30% discontinued sooner than the program recommended. Twenty-seven percent of the monitored infants were judged to have experienced real apnea or bradycardia while on their monitors. Seventeen of the patients are known to be dead, with 2 of these deaths occurring while the symptomatic patient was not monitored. Parents responding to a quality assurance questionnaire were highly enthusiastic about monitoring and felt it was a source of reassurance rather than a stressor. Major problems encountered by monitoring families were related to equipment performance.
Case records of hospitalized children (age 4 to 18 years) with acute rheumatic fever on Oahu, HI, were reviewed for the 4-year period from Oct 1, 1980, to Sept 30, 1984. Ninety-eight cases met the modified Jones criteria. The overall incidence of rheumatic fever was 13.4 hospitalized children per 100,000 children per year and that for recurrent attacks was 2.5. Of the 98 with rheumatic fever, 73 had polyarthritis, 33 had carditis, and ten had chorea. Polynesian/part-Polynesian children accounted for 76 of the 98 cases. The incidence of rheumatic fever in Hawaiian/part-Hawaiian was 18.0 and for Samoan children was 206 hospitalized children per 100,000 per year. The relative risks were 7.7 and 88 times that of the white children, respectively. Rheumatic fever continues to cause significant morbidity in children in Hawaii, especially in Polynesian children.
This report presents preliminary findings from 3 case-control studies in Hawaii in which we are examining the relationship of dietary vitamin A and ascorbic acid intake to the risk for cancers of the lung, bladder, and prostate. All 3 studies involved home interviews of cancer patients and neighborhood controls and use of quantitative dietary history method. In the lung cancer study, we found an inverse dose-response effect for total vitamin A intake in males only, with an odds ratio of 1.8 (P less than .05) for the lowest intake quartile relative to the highest; we found no association for ascorbic acid. In the bladder cancer study, we found lower (but not statistically significant) mean intakes of both vitamins in patients compared with controls, with the effect stronger for ascorbic acid. In the prostate cancer study, no effect was detected for total vitamin A or ascorbic acid in men less than 70 years old, but a direct association of vitamin A only with a dose-response gradient was found for men 70 years or older (odds ratio = 1.87; P less than .05, for the highest relative to the lowest intake quartile). Our findings at present indicate that vitamin A has a protective effect against lung and bladder cancers but not against prostate cancer and that ascorbic acid has a protective effect against bladder cancer as well. In our later analyses, we will examine the possibility that the effects of vitamin A vary with histologic type and that this may account for the lack of an association with lung cancer in women.
We based our systematic review of the cancer incidence rates of 48 anatomic sites of Japanese in Japan (Miyagi, Osaka, and Fukuoka Prefectures) and Japanese and Caucasians in the United States (Hawaii, San Francisco Bay Area, and Los Angeles County) on the cancer incidence data included in volume IV of "Cancer Incidence in Five Continents." Cancer sites were classified into 10 categories according to the trend of cancer incidence among the 3 groups. To evaluate the influences of environmental and racial factors, we used the ratio of cancer incidence in Japanese living in the United States to that of native Japanese, and the ratio of cancer incidence in Caucasians to that of Japanese living in the same areas of the United States. The present study revealed that the risks of cancers of the prostate, corpus uteri, colon, thyroid, breast, ovary, and testis were elevated, whereas those of the stomach, esophagus, and cervix uteri were decreased in the United States. Caucasians were more susceptible to melanoma, cancers of the mouth, lip and vermilion border, tongue, oropharynx, and larynx than were the Japanese, but the Japanese were more susceptible to cancers of the stomach, gallbladder, and liver. The difficulties we encountered in differentiating the influences of environmental factors from those of genetic racial factors are discussed. The necessity for further observations of the life-style (especially dietary habits) and the cancer incidence of Japanese living in the United States and comparisons with those of native Japanese and Caucasians are emphasized.
A confirmed case of penetration into the stomach wall by an anisakine nematode, to our knowledge the first in the United States, is reported. A viable third-stage larva of Anisakis simplex was removed from a woman in Hawaii who had eaten fresh, raw salmon. A serodiagnostic test showed the serum of the patient to be positive for A. simplex-specific IgE at days 11 and 60 postinfection. Our results indicate that eating fresh, raw salmon exposes consumers to a significant health risk.
Prospective epidemiologic studies among Hawaii Japanese indicate that serum PG I levels below 20 micrograms/1 are highly specific for the presence of intestinal metaplasia and the intestinal type of gastric cancer; but this test shows a low level of sensitivity. Substitution of the PG I/PG II ratio for the PG I level results in a modest improvement in the level of sensitivity at the expense of some loss in specificity. Antral gastritis and intestinal metaplasia are gastric cancer precursors in this population. Abnormally low values of serum PG I or the PG I/PG II ratio predict high stage tumors in the majority of cases. It therefore does not seem likely that estimates of serum pepsinogen are likely to increase the frequency of the diagnosis of early intestinal type carcinoma of the antral portion of the stomach in this population.
Serum specimens were obtained from over 6800 men of Japanese ancestry in Hawaii from 1971 to 1975. Since then, the following numbers of newly diagnosed cancer cases have been identified: 81 colon, 74 lung, 70 stomach, 32 rectum, and 27 urinary bladder. The stored sera of the cases and 302 controls were tested to determine their beta-carotene, vitamin A, and vitamin E levels. There was no association of either vitamin A or E with any of the cancers. For serum beta-carotene, there was a significant association only with lung cancer (20.0 micrograms/dl in cases versus 29.0 in controls, P less than 0.005). The lung cancer odds ratio for men in the lowest quintile of beta-carotene was 3.4 relative to men in the highest quintile. These findings suggest that a low serum beta-carotene level is a predictor of increased lung cancer risk in men.
This study examined the completeness and accuracy of reporting induced abortions to the official agency by following up documented cases of abortions performed in hospitals in Hawaii for the years 1970--74. The following two sets of records were initially linked by computer on the basis of first name, maiden name, date of the event, age, and ethnic background: (a) a total of 18,531 induced abortions ascertained in hospitals with complete linking information and (b) official fetal death and live birth records filed at the State health department. Overall, 96.1 percent of the hospital abortions were matched in the official certificates. Of 17,550 abortions classified as elective, 98.7 percent were so recorded in the certificate file, whereas the remainder were reported as mostly either therapeutic or unknown for cause of fetal death. When the probability of matches for those abortions without complete linking information and possible errors in the information were considered, the estimates of underreporting to the health department were a maximum of 3.9 percent and a minimum of 1.2 percent; the mean value was 2.6 percent. The extent of underreporting of induced abortions is becoming serious with the widespread practice of abortion procedures in nonhospital institutions in recent years. The results of the study also demonstrated the utility of the record-linkage process in checking data for completeness and accuracy or studying separate vital events on the same persons.
Japanese men long resident in Honolulu, Hawaii have significantly more ischemic heart disease but significantly fewer small cardiac scars than men in Hiroshima, Japan. These scars occur in three forms:(1)small scars in the mural myocardium which account for the difference in frequency of small lesions in the two cities and are of uncertain etiology; (2)areas of diffuse fibrosis in the papillary muscles. These are equally frequent in the two cities and are associated with advancing age and sclerosis of papillary muscle arteries; and(3)focal scars in the papillary muscles. These are more frequent in Honolulu than Hiroshima. They are healed infarcts due to ischemic heart disease and are associated with a severe degree of extramural coronary artery atherosclerosis. Small mural myocardial scars, when present, are usually found in multiple sites. Their increased frequency in Hiroshima is not explained by differences in age or heart weight. They are more common in the presence of sclerosis of intramural small arteries, but this association also fails to explain the intercity difference. It is supected that the excess of these small cardiac scars in Hiroshima males reflects past privation. There is no evidence that is is related to A-bomb radiation exposure.
To obtain more information on mechanisms by which influenza virus is perpetuated in swine, retrospective and prospective seroepizootiologic observations were made in swine herds in Hawaii, beginning in 1974. An epizootic of swine influenza (Hsw1N1) virus was observed in November and December 1976, involving 31 of 41 herds. Features of the epizootic included (1) infection of all herds within one geographic location, during a short period; (2) no obvious introduction of virus from the outside in most herds; (3) epizootics mainly in herds with serologic history of infection; (4) no evidence that lungworms were involved; and (5) little clinical disease associated with infection. There was evidence of viral activity in some herds before the epizootic period and afterward in two of three herds monitored. Evidence of viral transmission by feral animals was not obtained. Data indicated that swine influenza virus persists through latently or chronically infected swine, with epizootics occurring when herd immunity reaches a critically low degree.
From September 1974 to January 1978, about 25% of 254 swine farms, studied on four of six Hawaiian islands, had swine with antibody to A/Hong Kong/68 (H3N2) subtype of influenza virus. Of 290 swine 2 to 5 years of age in a single herd, 72% had antibody. Antibody titers were consistently higher to A/England/42/72 and A/Port Chalmers/1/73 antigens than to A/Victoria/3/75 or A/Hong Kong/1/68 antigen. Few swine had antibody to the A/Hong Kong/68 antigen. Antibodies to H3N2 and Hsw1N1 subtype of virus persisted at high titer in the same animals for more than 3 years; however, titers to the Hsw1N1 subtype were considerably higher. The occurrence of H3N2 infection in swine appeared shortly after the occurrence of the same H3N2 variant in human population. To date there is no evidence that the H3N2 subtype has become established in swine in Hawaii.
During the past decades much effort has been taken to encourage community - based treatment and service for mental patients, and to reduce the share of the large custodial institutions within mental health care systems. Both in the United States and in W-Germany (FRG) there has been a growing awareness that major inadequacies occur especially with providing community--based out-care for the seriously mentally ill. Much of these inadequacies refer to those released from the mental hospital with such needs as help to structure their everyday lives, adequate housing, nutrition, support for the families and neighborhoods involved, financial support, and further treatment. Part 1 delines the growing awareness of these problems with reference to the expectations of "reformists" both for the U.S. and the F.R.G. The paper then describes empirical data about the care given to patients released from the psychiatric hospital within a 90 days' period in the State of Hawaii, U.S.A. It also gives a structural description of agencies involved in the aftercare services, and relates this both to the empirical findings and reformists' views on aftercare needs.
The survival experience of 2,956 invasive breast carcinoma cases identified among the 5 major ethnic groups in Hawaii between 1960 and 1979 was studied. The study population consisted of 1,174 Caucasian, 972 Japanese, 458 Hawaiian, 226 Chinese, and 126 Filipino women. A multivariate analysis based on the proportional hazards regression model revealed that after simultaneous adjustment for stage of disease, age, and socioeconomic status (SES), Filipino and Hawaiian patients had significantly poorer survival than Japanese and Caucasian patients. Hawaiian women also had a significantly poorer survival than Chinese women. Survival was higher in patients between the ages of 45 and 54 years compared to those younger or older, in patients with localized tumors compared to those with more advanced tumors, and in patients with middle or high SES compared to those with the low SES. Histology and marital status were not associated with survival. The possibility that other factors such as obesity, estrogen receptor status, treatment, and nutritional and hormonal status could explain the remaining observed racial differences in breast cancer survival is discussed.
Incidence rates for many sites of cancer show wide variations among the main ethnic groups in Hawaii (Caucasians, Japanese, Chinese, Filipinos, and Hawaiians). Major shifts in cancer rates among migrants to the islands suggest that environmental factors are at least in part responsible for these variations. One prominent area of difference among these ethnic populations is their diets, which can vary substantially, not only in the consumption of particular food items but also in mean nutrient intakes. In aggregate correlational analyses based on data from representative samples of these ethnic groups and corresponding population-based cancer incidence rates, we found significant associations between ethnic-sex-specific intakes of dietary fat (including total fat, as well as animal, saturated, and unsaturated fats) and breast, endometrial, and prostate cancers. Animal protein intake showed associations similar to those for dietary fat, but these two nutrients were highly correlated in the data. Cholesterol intake showed significant correlations with lung and laryngeal cancers. Analyses of both nutrient and food item data suggested an association of stomach cancer incidence with the consumption of fish products, particularly dried/salted fish, and with a lower intake of vitamin C. Preliminary findings from ongoing case-control studies showed the following relationships: an inverse association between lung cancer risk and the intake of food sources of vitamin A, especially foods containing carotenes; an inverse association between cancers of the lower urinary tract and vitamin A consumption, especially from supplements; a positive association between prostate cancer risk and dietary fat intake in men above age 69, but not in younger men; and a positive association between breast cancer risk and the intake of dietary fat (particularly saturated fat) and animal protein in postmenopausal women, especially the Japanese. Two large cohorts (50,000 and 5,000 subjects) on whom dietary information was collected between 1975 and 1980 are being followed prospectively for their occurrence of cancer.