Availability of Pharmacist-Prescribed Contraception in Hawai'i

In 2017, the state of Hawai'i passed Act 067 which allows trained pharmacists to prescribe hormonal contraceptives in an effort to expand access to contraception. The extent to which this policy has been implemented is not known. This study aimed to determine the proportion of Hawai'i pharmacies that currently provide pharmacist-prescribed hormonal contraceptives. In June 2020, a list of retail pharmacies was compiled using Google and Google Maps searches and pharmacy directories from major health insurance providers. Between June 23, 2020, and July 2, 2020, two trained interviewers called pharmacies and inquired about the availability of pharmacist-prescribed contraceptives using a "secret shopper" technique. Of the 175 pharmacies included in our analysis, 54 (31%) offered pharmacist-prescribed contraceptives. Kaua'i (40%) had the highest proportion of pharmacies offering pharmacist-prescribed contraceptives, followed by Maui (35%), O'ahu (30%), and Hawai'i Island (29%) (P=.88). Among pharmacies located in rural communities, 20 of 63 (32%) prescribed contraceptives, compared to 34 of 112 (30 %) pharmacies located in urban communities (P=.85). Of the 118 pharmacies that did not prescribe contraceptives and provided a reason for not doing so 33% cited lack of training and 28% lack of knowledge about Act 067. Thirty-one pharmacies provided information on the cost of pharmacist-prescribed contraceptives with 71% (22) stating that the patient would have to pay extra for the consultation (mean cost = $34.6, range $30-$45). Findings from this study can help inform future public health policies and implementation strategies aimed at improving contraceptive access in Hawai'i.

Extinction risk of the endemic vascular flora of Kauai, Hawaii, based on IUCN assessments

The International Union for Conservation of Nature's Red List of Threatened Species (IUCN Red List) is the world's most comprehensive information source on the global conservation status of species. Governmental agencies and conservation organizations increasingly rely on IUCN Red List assessments to develop conservation policies and priorities. Funding agencies use the assessments as evaluation criteria, and researchers use meta-analysis of red-list data to address fundamental and applied conservation science questions. However, the circa 143,000 IUCN assessments represent a fraction of the world's biodiversity and are biased in regional and organismal coverage. These biases may affect conservation priorities, funding, and uses of these data to understand global patterns. Isolated oceanic islands are characterized by high endemicity, but the unique biodiversity of many islands is experiencing high extinction rates. The archipelago of Hawaii has one of the highest levels of endemism of any floristic region; 90% of its 1367 native vascular plant taxa are classified as endemic. We used the IUCN's assessment of the complete single-island endemic (SIE) vascular plant flora of Kauai, Hawaii, to assess the proportion and drivers of decline of threatened plants in an oceanic island setting. We compared the IUCN assessments with federal, state, and other local assessments of Kauai species or taxa of conservation concern. Finally, we conducted a preliminary assessment for all 1044 native vascular plants of Hawaii based on IUCN criterion B by estimating area of occupancy, extent of occurrence, and number of locations to determine whether the pattern found for the SIE vascular flora of Kauai is comparable to the native vascular flora of the Hawaiian Islands. We compared our results with patterns observed for assessments of other floras. According to IUCN, 256 SIE vascular plant taxa are threatened with extinction and 5% are already extinct. This is the highest extinction risk reported for any flora to date. The preliminary assessment of the native vascular flora of Hawaii showed that 72% (753 taxa) is threatened. The flora of Hawaii may be one of the world's most threatened; thus, increased and novel conservation measures in the state and on other remote oceanic islands are urgently needed.

Evaluation of an Education-based Training Orientation for Resident Physicians in an Intensive Care Unit in Hawai'i

The need for multidisciplinary teams to provide complex care has increased as the population ages. As these teams become increasingly integrated, the knowledge, skills, and attitudes of resident physicians to practice safe and effective care in intensive care units (ICUs) evolves. A structured and multidisciplinary orientation day for resident physicians was implemented to assess improvements in physician confidence at Tripler Army Medical Center in Hawai'i from July 2019 to June 2020. ICU residents received an orientation day from a multidisciplinary team, with an emphasis on practical knowledge for common disease processes in a system-based fashion and competency in procedural skills. A total of 30 residents were asked to complete a pre- and post- orientation survey over a 1-year period, with 17 pre and post surveys completed for a response rate of 57%. The survey measured residents' perceived confidence in various tasks. Scores were compared using a paired 2-sampled t-test to assess statistical significance. The majority of resident physicians (76%) had at least 1 month of prior ICU experience. Statistically significant improvement was seen in self-reported abilities in performing 6 of the 10 elements assessed. With the diverse pathophysiology in critical care, it was essential to create a broad orientation with didactic and simulation-based learning, which resulted in observed improvement in more than half of the areas of interest. Adopting an orientation day for resident physicians rotating through the ICU can improve resident physician confidence, review important knowledge and skills, and highlight the role of each contributing multidisciplinary team member.

Time-gated Raman spectroscopy of recovered plastics

Raman spectroscopy is a powerful non-destructive technique for the identification and characterization of plastics, but a major shortcoming of this technique is that environmental weathering, dyes, and additives in the material can generate a strong fluorescence background that overwhelms the Raman scattering. Here, we demonstrate that time-gated Raman spectroscopy can be used to successfully reduce the fluorescence signal and measure Raman spectra of recovered plastics. Time-gating removes a significant amount of background signal from the Raman spectra such that the polymers and color additives can be identified using similar measurement times compared to continuous-wave Raman spectroscopy. Examples of this are shown for a small subset of samples recovered from Hawaiian marine environments and a nonweathered commercial plastic. Time-gated Raman spectroscopy can also be used to characterize samples that are black in color due to carbon-based additives like graphite, which can be challenging to characterize via other common vibrational spectroscopic techniques.

Low-level nutrient enrichment during thermal stress delays bleaching and ameliorates calcification in three Hawaiian reef coral species

Terrestrial-based nutrient pollution has emerged as one of the most detrimental factors to coral health in many reef habitats. Recent studies have shown that excessive dissolved inorganic nutrients can reduce coral thermal tolerance thresholds and even exacerbate bleaching during thermal stress, yet the effects of minor nutrient enrichment under heat stress have not been extensively studied. In this study, Lobactis scutaria, Montipora capitata, and Pocillopora acuta colonies under heated conditions (~30.5 °C) were exposed to low and balanced nitrogen and phosphorous concentrations over a 31-day heating period. Coral colonies were collected from Kāne'ohe Bay, O'ahu, which has a unique history of nutrient pollution, and held in mesocosms that allowed for environmental manipulation yet are also influenced by local field conditions. Principal findings included delays in the bleaching of nutrient-enriched heated colonies as compared to heated-only colonies, in addition to relatively greater calcification rates and lower proportions of early-stage paling. Species-specific outcomes were prevalent, with L. scutaria demonstrating no difference in calcification with enrichment under heat stress. By the end of the heating stage, however, many heated colonies were at least partially impacted by bleaching or mortality. Despite this, our findings suggest that low levels of balanced nutrient enrichment may serve as a mitigative force during thermal events. Further field-based studies will be required to assess these results in different reef habitats.

Evaluation of Payment Transformation in Hawai'i Based on Physician Perspective

The Hawai'i Medical Service Association's (HMSA) Population-based Payments for Primary Care (3PC) system has been in effect since 2016. There is limited literature regarding physician opinions on this payment transformation policy change. The objective of this study was to evaluate physician responses to a survey regarding the 3PC payment transformation system and identify methods to support physicians in Hawai'i. An online survey was sent to 2478 Hawai'i physicians and yielded 250 responses. A total of 77% respondents reported being unhappy with payment transformation, while 12.9% and 10.1% reported being indifferent and happy, respectively. Of responding physicians, 60.6% reported a decrease in overall income, whereas 24.9% and 14.5% reported no change or an overall increase, respectively. Open-ended responses were categorized into theme clusters: negative impact on primary care, increased administrative burdens, decreased quality of patient care, decreased physician reimbursement, preference to treat healthier patients, harm to private practice, harm to newer practices, ignored physician sentiments, and worsened physician shortage in Hawai'i. Respondents, especially those working in primary care, are dissatisfied with payment transformation. Future research is needed to compare the thematic clusters identified in the current study with relevant literature.

The early embryonic transcriptome of a Hawaiian Drosophila picture-wing fly shows evidence of altered gene expression and novel gene evolution

A massive adaptive radiation on the Hawaiian archipelago has produced approximately one-quarter of the fly species in the family Drosophilidae. The Hawaiian Drosophila clade has long been recognized as a model system for the study of both the ecology of island endemics and the evolution of developmental mechanisms, but relatively few genomic and transcriptomic datasets are available for this group. We present here a differential expression analysis of the transcriptional profiles of two highly conserved embryonic stages in the Hawaiian picture-wing fly Drosophila grimshawi. When we compared our results to previously published datasets across the family Drosophilidae, we identified cases of both gains and losses of gene representation in D. grimshawi, including an apparent delay in Hox gene activation. We also found a high expression of unannotated genes. Most transcripts of unannotated genes with open reading frames do not have identified homologs in non-Hawaiian Drosophila species, although the vast majority have sequence matches in genomes of other Hawaiian picture-wing flies. Some of these unannotated genes may have arisen from noncoding sequence in the ancestor of Hawaiian flies or during the evolution of the clade. Our results suggest that both the modified use of ancestral genes and the evolution of new ones may occur in rapid radiations.

Polyketides, diketopiperazines and an isochromanone from the marine-derived fungal strain Fusarium graminearum FM1010 from Hawaii

The fungal strain Fusarium graminearum FM1010 was isolated from a shallow-water volcanic rock known as "live rock" at the Richardson's Beach, Hilo, Hawaii. Eleven specialised metabolites, including two undescribed diketopiperazines, three undescribed polyketides, and one undescribed isochromanone, along with five known fusarielin derivatives were obtained from F. graminearum FM1010. The structures of the six undescribed compounds were elucidated by extensive analysis of NMR spectroscopy, HRESIMS, chemical reactions, and electronic circular dichroism (ECD) data. Kaneoheoic acids G-I showed mild inhibitory activity against S. aureus with the MIC values in the range of 20-40 μg/mL when assayed in combination with chloramphenicol (half of the MIC, 1 μg/mL), an FDA approved antibiotic. Kaneoheoic acid I exhibited both anti-proliferative activity against ovarian cancer cell line A2780 and TNF-α induced NF-κB inhibitory activity with the IC₅₀ values of 18.52 and 15.86 μM, respectively.

Aboveground carbon accumulation by second-growth forests after deforestation in Hawai'i

Successional processes ultimately determine and define carbon accumulations in forested ecosystems. Although primary succession on wholly new substrate occurs across the globe, secondary succession, often following storm events or anthropogenic disturbance, is more common and is capable of globally significant accumulations of carbon (C) at a time when offsets to anthropogenic carbon dioxide (CO₂ ) emissions are critically needed. In Hawai'i, prior studies have investigated ecosystem development during primary succession on lava flows, including estimates of C mass accumulation. Yet relatively little is known regarding secondary succession of Hawaii's native forests, particularly regarding C mass accumulation. Here we documented aboveground C mass accumulation by native- and nonnative-dominated second-growth forests following deforestation of mature native lowland rainforests in the Puna District of Hawai'i Island. We characterized species composition and stand structure of three distinct successional forest stand types: those dominated by the native tree, Metrosideros polymorpha ('Ōhi'a), and those dominated by invasive nonnative trees, Falcataria moluccana (albizia) and Psidium cattleianum (strawberry guava). We compared M. polymorpha-dominated and F. moluccana-dominated second-growth forests to adjacent mature M. polymorpha-dominated forests as well as young M. polymorpha-dominated forests undergoing initial stages of primary succession on 36-years-old lava fields. Aboveground carbon density (ACD) values of mature primary forest stands (171 Mg/ha) were comparable to those of mature continental tropical forests. M. polymorpha-dominated second-growth stands attained nearly 50% of ACD values of mature primary forests after less than 30 years of post-disturbance succession and exhibited aboveground carbon accumulation rates of ~3 Mg C·ha^-1 ·year^-1 . Such rates were comparable to those of second-growth forests in continental tropics. Rates of ACD accumulation by second-growth forests dominated by nonnative F. moluccana stands were similar, or slightly greater than, those of M. polymorpha-dominated stands. However, M. polymorpha individuals were virtually absent from stands dominated by either P. cattleianum or F. moluccana. Taken together, results demonstrated that re-establishment and rapid accumulation of C mass by M. polymorpha stands during secondary succession is certainly possible, but only where populations of nonnative species have not already colonized areas during early stages of secondary succession.

Just data representation for Native Hawaiians and Pacific Islanders: A critical review of systemic Indigenous erasure in census and recommendations for psychologists

The decennial Census survey marks the emergence of federal classifications of race and ethnicity by which the U.S. government has historically conflated Native Hawaiians and Pacific Islanders (NHPI, hereafter) as "Asian or Pacific Islander." This conflation amplifies health injustices and inequities of NHPIs through multiple mechanisms because it masks the complex and heterogeneous experiences of NHPIs, whose positions and relations with the settler state are qualitatively and substantially distinct from Asian Americans. This critical review examines federal documents and research to examine how the panethnic categorizations are often sustained through scientific inquiry and methodologies. We found that self-determination and self-identification for NHPIs are impeded by settler-colonial relations between U.S. colonization of parts of Oceania (e.g., Hawai'i, Sāmoa, Fiji, and Guam) and the forcefully imposed categorization that continues to be in use to legitimize the domination of Indigenous Peoples through race misclassification. Specifically, Census data collection fails to capture accurate and reliable data due to serious methodological limitations. These implications for psychological research compel us to make several recommendations for psychologists: (1) engage with NHPI community partners in all research processes; (2) critically examine Census research design and consider oversampling NHPI households to ensure just data representation; (3) meaningfully engage when, whether and how to aggregate Asian Americans with NHPIs; and (4) use Indigeneity as a critical framework.

Examination of Associations between Physical Activity and Eating Identities among College-aged Adults Living in Hawai'i

While physical activity and diet behaviors are correlated, mechanisms underlying associations have rarely been examined. This study examined associations between physical activity identity and eating identity among college-aged adults in Hawai'i to provide guidance for future multiple behavior change interventions. This study was a cross-sectional analysis of data collected between September 2013 and January 2014. Participants were 40 college students attending 4-year and 2-year institutions within the University of Hawai'i system. Total physical activity identity score and dimensions were measured using the Athlete Identity Questionnaire. Eating identity subtypes were measured using the Eating Identity Type Inventory. Associations between physical activity identity total score, 4 physical activity identity dimensions (appearance, importance, competence, and encouragement), and 4 eating identity subtypes (healthy, emotional, meat, and picky) were examined using multiple linear regressions. A significant positive association was found between total physical activity identity score and the healthy eating subtype and a negative association with the picky eating subtype. The physical activity dimension importance had a significant positive association with the healthy eating subtype, appearance a negative association with the emotional eating subtype, and competence a positive association with the meat eating subtype but a negative association with the picky eating subtype. The findings suggest important overlap in identities for physical activity and diet. Measurement of physical activity identity and eating identity as well as tailored intervention strategies should be incorporated into more behavior change research.

A Genome for Bidens hawaiensis: A Member of a Hexaploid Hawaiian Plant Adaptive Radiation

The plant genus Bidens (Asteraceae or Compositae; Coreopsidae) is a species-rich and circumglobally distributed taxon. The 19 hexaploid species endemic to the Hawaiian Islands are considered an iconic example of adaptive radiation, of which many are imperiled and of high conservation concern. Until now, no genomic resources were available for this genus, which may serve as a model system for understanding the evolutionary genomics of explosive plant diversification. Here, we present a high-quality reference genome for the Hawai'i Island endemic species B. hawaiensis A. Gray reconstructed from long-read, high-fidelity sequences generated on a Pacific Biosciences Sequel II System. The haplotype-aware, draft genome assembly consisted of ~6.67 Giga bases (Gb), close to the holoploid genome size estimate of 7.56 Gb (±0.44 SD) determined by flow cytometry. After removal of alternate haplotigs and contaminant filtering, the consensus haploid reference genome was comprised of 15 904 contigs containing ~3.48 Gb, with a contig N50 value of 422 594. The high interspersed repeat content of the genome, approximately 74%, along with hexaploid status, contributed to assembly fragmentation. Both the haplotype-aware and consensus haploid assemblies recovered >96% of Benchmarking Universal Single-Copy Orthologs. Yet, the removal of alternate haplotigs did not substantially reduce the proportion of duplicated benchmarking genes (~79% vs. ~68%). This reference genome will support future work on the speciation process during adaptive radiation, including resolving evolutionary relationships, determining the genomic basis of trait evolution, and supporting ongoing conservation efforts.

Ciguatoxin in Hawai'i: Fisheries forecasting using geospatial and environmental analyses for the invasive Cephalopholis argus (Epinephelidae)

Invasive species can precede far-reaching environmental and economic consequences. In the Hawai'ian Archipelago Cephalopholis argus (family Serranidae) is an established invasive species, now recognized as the dominant local reef predator, negatively impacting the native ecosystem and local fishery. In this region, no official C. argus fishery exists, due to its association with Ciguatera seafood poisoning (CP); a severe intoxication in humans occurring after eating (primarily) fish contaminated with ciguatoxins (CTXs). Pre-harvest prediction of CP is currently not possible; partly due to the ubiquitous nature of the microalgae producing CTXs and the diverse bioaccumulation pathways of the toxins. This study investigated the perceived risk of CP in two geographically discrete regions (Leeward and Windward) around the main island of Hawai'i, guided by local fishers. C. argus was collected and investigated for CTXs using the U.S. Food and Drug Administration (FDA) CTX testing protocol (in vitro neuroblastoma N2a-assay and LC-MS/MS). Overall, 76% of fish (87/113) exceeded the FDA guidance value for CTX1B (0.01 ng g^-1 tissue equivalents); determined by the N2a-assay. Maximum CTX levels were ≅2× higher at the Leeward vs Windward location and, respectively, 95% (64/67) and 54% (25/46) of fish were positive for CTX-like activity. Fisher persons and environmental understandings, regarding the existence of a geographic predictor (Leeward vs Windward) for harvest, were found to be (mostly) accurate as CTXs were detected in both locations and the local designation of C. argus as a risk for CP was confirmed. This study provides additional evidence that supports the previous conclusions that this species is a severe CP risk in the coastal food web of Hawai'i, and that ocean exposure (wave power) may be a prominent factor influencing the CTX content in fish within a hyperendemic region for CP.

Update on the Impact of the University of Hawai'i Family Medicine Residency Program on the Family Physician Workforce in Hawai'i

This study updates the previously-reported impact of the University of Hawai'i Family Medicine Residency Program (UHFMRP) on the state of Hawai'i family physician workforce. This study is a retrospective examination of all UHFMRP graduates from the program between 1996 and 2020. Graduate data regarding country or state of medical school, allopathic versus osteopathic training, current clinical practice, zip code of current clinical practice, current board certification, and current fellowship status were recorded between May and July 2020. Overall, 146 UHFMRP graduates completed the program between 1996 and 2020. Currently, 126 UHFMRP graduates have active medical licenses, with 121 graduates (96%, n=126) practicing in the United States, of whom 83 (69%, n=121) are practicing in Hawai'i. Of the 83 UHFMRP graduates practicing in Hawai'i, 67 graduates (81%, n=83) practice on O'ahu. UHFMRP graduates with active medical licenses in Hawai'i represent 23% (83 of 364) of the entire current family physician workforce in Hawai'i. The UHFMRP continues to make an impact on the Hawai'i State family physician workforce, and the retention rate of graduates in Hawai'i has remained relatively stable since 1996.

Discriminating and classifying odontocete echolocation clicks in the Hawaiian Islands using machine learning methods

Passive acoustic monitoring (PAM) has proven a powerful tool for the study of marine mammals, allowing for documentation of biologically relevant factors such as movement patterns or animal behaviors while remaining largely non-invasive and cost effective. From 2008-2019, a set of PAM recordings covering the frequency band of most toothed whale (odontocete) echolocation clicks were collected at sites off the islands of Hawai'i, Kaua'i, and Pearl and Hermes Reef. However, due to the size of this dataset and the complexity of species-level acoustic classification, multi-year, multi-species analyses had not yet been completed. This study shows how a machine learning toolkit can effectively mitigate this problem by detecting and classifying echolocation clicks using a combination of unsupervised clustering methods and human-mediated analyses. Using these methods, it was possible to distill ten unique echolocation click 'types' attributable to regional odontocetes at the genus or species level. In one case, auxiliary sightings and recordings were used to attribute a new click type to the rough-toothed dolphin, Steno bredanensis. Types defined by clustering were then used as input classes in a neural-network based classifier, which was trained, tested, and evaluated on 5-minute binned data segments. Network precision was variable, with lower precision occurring most notably for false killer whales, Pseudorca crassidens, across all sites (35-76%). However, accuracy and recall were high (>96% and >75%, respectively) in all cases except for one type of short-finned pilot whale, Globicephala macrorhynchus, call class at Kaua'i and Pearl and Hermes Reef (recall >66%). These results emphasize the utility of machine learning in analysis of large PAM datasets. The classifier and timeseries developed here will facilitate further analyses of spatiotemporal patterns of included toothed whales. Broader application of these methods may improve the efficiency of global multi-species PAM data processing for echolocation clicks, which is needed as these datasets continue to grow.

Hawai'i Rural Health Program: Shaping the Next Generation of Rural Doctors

Like many areas of the United States, Hawai'i and its rural communities are suffering from a significant physician shortage. The University of Hawai'i (UH) John A. Burns School of Medicine (JABSOM) developed the Hawai'i Rural Health Program (HRHP) in 2011 to help provide early and substantial rural training experiences for its medical students in hopes of generating more rural health care providers. Thus far, 20.6% of the students who participated in this program and have since graduated from residency are now practicing in rural communities. Final exam grades of students who participated in the program were not statistically different from those who did not participate, suggesting a similar quality of training between both the rural and traditional cohorts of students. Reflections from students who completed the program demonstrate the large and lasting impact that this immersive experience has on their medical education and desire to help rural communities.

Hawai'i Registered Dietitian Nutritionist 2019-2020 Workforce Assessment

There is scant literature available on the Registered Dietitian Nutritionist (RDN) workforce in the United States, but a review of healthcare systems suggests that implementation of RDNs in primary care settings may improve access to care, patient satisfaction, and quality of care. The Area Health Education Center (AHEC), in partnership with the Hawai'i Academy of Nutrition and Dietetics (HAND), investigated 395 providers to evaluate the status of Hawai'i's RDN workforce. The research team utilized all available provider information and direct calling methodology to collect data from August 2019 to February 2020. Microsoft Excel software allowed for data analysis and ArcGIS mapping software was used to visualize provider totals and Full-Time Equivalencies (FTEs) across the state. This study identifies trends in workforce demographics and provider supply. Researchers found 100 RDNs providing direct patient care for a total of 82.4 FTEs. Women account for 94% of survey respondents, and the average age of providers was 48. RDNs who self-identify as being Asian American (41%) or White (47%) were the largest ethnic groups providing direct patient care. Seventy percent of the RDN workforce was located on O'ahu, while RDN FTEs are concentrated in mainly 5 zip codes, 1 on each of O'ahu, Kaua'i, and Maui and 2 on Hawai'i Island. Provider demand trends, increased training and retention efforts, and integration of nutritional services in healthcare teams should be further investigated.

Building a Culturally Aware Native Hawaiian Health Professions Workforce

The Native Hawaiian Health Scholarship Program (NHHSP) strives to build a culturally aware Native Hawaiian health professional workforce through coaching, mentoring, and networking, who are committed to serving the unique health needs of Native Hawaiians throughout the State of Hawai'i. As of October 2020, 302 scholarships have been awarded to 277 recipients across 12 health disciplines with 90% remaining in Hawai'i. In 2019, NHHSP began re-imagining how to build a vibrant, culturally aware workforce, committed to service, leadership, and improvement of Native Hawaiian health through program expansion. This article describes the transformation of NHHSP to Mauli Ola Mālamalama (MOM), a success-oriented strategy-based Native Hawaiian Health Workforce Development Center of Papa Ola Lōkahi. Researchers conducted a qualitative assessment using surveys and interviews among alumni of the program to understand their experience of being a recipient and its meaning to them. Questions included work experience, challenges, solutions, impact of working in rural communities, mentorship, and legacy. The 5 themes identified by alumni were awareness, passion, inherent culture, reciprocity, and legacy. The overarching theme of the assessment, aloha, is embedded in the passion and desire to serve Native Hawaiian communities. Re-imagining the program from NHHSP to MOM began with examining the core values of suitability, commitment, and leadership. These values were then embedded in all aspects of the program and supports provided to recipients. MOM strives to ensure that recipients are culturally aware as they enter the workforce. This broader vision will help increase the number of Native Hawaiians in health care roles.

Increasing Geriatric Care Capability in Hawai'i's Healthcare Systems through the Pacific Islands Geriatrics Workforce Enhancement Program (GWEP) at the University of Hawai'i

There is an increasing shortage of skilled healthcare workers to provide care to the aging US population. In response, the Geriatrics Workforce Enhancement Program (GWEP) was developed in 2015 by the Health Resources and Services Administration (HRSA). This article describes the objectives, accomplishments, and lessons learned by the Pacific Islands GWEP at the University of Hawai'i (UH) over the past 5 years. The program's multi-pronged approach includes: (1) Developing partnerships between academia, primary care delivery sites/systems, and community-based organizations to educate a geriatrics workforce; (2) Training providers and students in medicine and allied health professions to address the primary care needs of older adults; (3) Transforming clinical training environments to become age-friendly health systems that incorporate the principles of value-based care and alternative-payment models; (4) Delivering community-based programs for patients, families, caregivers, and direct care workers to provide knowledge and skills to improve health outcomes for older adults; and (5) Providing training in Alzheimer's Disease and related dementias (ADRD), including the value of dementia-friendly communities. The GWEP provided education to over 3000 providers, 700 healthcare trainees, and 1000 patients and caregivers each year in a wide variety of care settings (eg, outpatient, home care, nursing facilities, care home, and hospice). Caregivers feel better able to care for themselves and/or others, find resources, and improve their practice of caregiving. The program is also transforming primary care delivery in underserved areas (eg, Community Health Centers, Family Medicine clinic, and the GRACE Team Care™ model). Outreach included rural areas, neighbor islands, and Pacific Islands.

Expanding Access to Contraception: Identifying Accessibility Gaps Across Hawai'i Communities

In 2019, Hawai'i ended its Title X program resulting in a loss of federal family planning funds. Additionally, physician shortages have decreased family planning resources available to patients. The objective of this study was to assess contraception availability by determining the number and location of healthcare providers in Hawai'i that prescribed at least one form of contraception. A list of healthcare providers was compiled using Google searches, major health insurance, and hospital provider directories. Providers were organized by physical location (ie, address). Each location was contacted to inquire about each provider's ability to prescribe different forms of contraception (eg, intrauterine device, implant, injection, pill, patch, or ring). Of the 1,020 locations contacted, 274 prescribed at least one form of contraception. Of the 1,810 providers surveyed at these locations, 744 prescribed at least one form of contraception. In regard to insurance, 201 locations and 609 providers accepted at least one form of Medicaid. Most prescribing providers were located on the island of O'ahu. The majority of providers across the state prescribed the pill, patch, or ring. There are many additional barriers that were not addressed in this study, including factors that affect physician prescribing practices. Identifying these barriers is important to further address gaps in contraceptive accessibility. Consideration of improved support for training in specialties such as Family Medicine, Internal Medicine, and Pediatrics can expand access to contraception within primary care settings.

Hawai'i Physician Workforce Assessment 2020

The Hawai'i Physician Workforce project, launched in 2010, investigates state physician workforce trends. Over the past decade, workforce demands have continued to climb as the state struggles to maintain the physician supply. This article describes the current state of the physician workforce, the physician age landscape, past trends, as well as initial changes to the physician supply with the COVID-19 pandemic. Data on practice location, full time equivalency of time spent providing patient care in Hawai'i, and specialty of non-military physicians were clarified and informed via survey, internet search, and direct calling methodologies. A proprietary microsimulation modeling methodology was used to assess physician demand. The current estimated physician shortage is between 710 and 1,008 full time equivalents, the largest shortage in a decade. The unmet demand for numbers of additional physicians is greatest on the largely urban island of O'ahu, however O'ahu's neighboring islands have the largest shortages by percentage of demand. In fact, Hawai'i island has over a 50% shortage of physicians for the first time since the supply has been calculated starting in 2010. Primary care has the greatest demand with a statewide shortage of 412 full time equivalents. The average age of physicians in Hawai'i is 54 compared to the national average of 52. The authors estimate that more than 52% of providers are utilizing telehealth and that 10% of providers have retired or closed their practices since the start of the COVID-19 pandemic. Hawai'i is now in an urgent state of need for recruitment and retention of physicians.

Laying the Kahua (Foundation): Incorporating Elements of Attitude and Purpose for Underrepresented Student Success at the University of Hawai'i John A. Burns School of Medicine 'Imi Ho'ōla Post-Baccalaureate Program

The 'Imi Ho'ōla Post-Baccalaureate Program is a proven pathway to medicine that has significantly increased the number of underrepresented and disadvantaged students that complete medical school in Hawai'i. A recent program evaluation indicated a relationship between student success and the significance of attitude and purpose from the Learning and Study Strategies Inventory. Curricular innovations in a 5-week introductory course during Phase 1, lay the foundation to promote a healthy attitude with purpose-led activities, such as personalized journal vision covers, weekly journal reflections, a multimedia autobiography, and projects focusing on medical specialties, well-being, and resiliency. Such purposeful innovations are vital for the success of underrepresented students, with the ultimate intent to diversify the physician workforce and to increase the number of physicians serving in underrepresented and underserved communities in Hawai'i and throughout the Pacific.

Quantifying wedge-tailed shearwater (Ardenna pacifica) fallout after changes in highway lighting on Southeast O'ahu, Hawai'i

Attraction to artificial light at night (ALAN) poses a threat to many fledgling seabirds leaving their nests for the first time. In Hawai'i, fledgling wedge-tailed shearwaters disoriented by lights may become grounded due to exhaustion or collision, exposing them to additional threats from road traffic and predation. While the timing and magnitude of shearwater fallout varies from year to year, little is known about how changing lighting and environmental conditions influence the risk of grounding for this species. We analyzed 8 years (2012-2019) of observations of road-killed shearwaters along the Kalaniana'ole Highway on O'ahu to quantify the timing and magnitude of fallout during the fledging season (November-December). Our goal was to compare fallout before (2012-15) and after (2016-19) a transition in highway lighting from unshielded high-pressure sodium (HPS) to full-cutoff light-emitting diode (LED) streetlights. To detect the shearwater response to the lighting regime, we also accounted for three potential environmental drivers of interannual variability in fallout: moon illumination, wind speed, and wind direction. The effects of these environmental drivers varied across years, with moon illumination, wind speed and wind direction significantly affecting fallout in at least one year. Altogether, the interaction between moon illumination and wind speed was the most important predictor, suggesting that fallout increases during nights with low moon and strong winds. The lack of an increase in fallout after the change from HPS to shielded 3000K - 4000K LED streetlights suggests the new streetlights did not worsen the light pollution impacts on wedge-tailed shearwaters on Southeast O'ahu. However, due to potential species-specific disparities in the behavior and light attraction of petrels, similar studies are needed before energy saving LED lights are implemented throughout the Hawaiian archipelago.

Two new species of the butterflyfish genus Roa (Perciformes: Chaetodontidae)

Two new species of Roa (Chaetodontidae) are described. Roa semilunaris sp. nov., based on six specimens from the Mascarene Ridge (south-western Indian Ocean), is most similar to Roa jayakari (Norman, 1939), distributed in the Red Sea and the northern Indian Ocean, in having scales on the upper jaw, interrupted pale lines within the second dark body band, and similar coloration and shape of the pelvic fin. However, the former is readily distinguished from R. jayakari by a wider whitish interspace between the second and third black bands [width of interspace at lateral line level 15.9%-18.5% of standard length (SL) in R. semilunaris sp. nov. (vs. 5.1%-8.5% of SL in R. jayakari)], with 9 or 10 pored lateral-line scales in the interspace (vs. 3-5); an oval or semicircular ocellated blotch on the soft-rayed portion of the dorsal fin (vs. a circular blotch); the head higher and longer [head length 35.0%-36.7% of SL (vs. 40.8%-44.1% of SL), head height 48.1%-50.5% of SL (vs. 52.0%-56.9% of SL)], and postorbital length 14.0%-15.1% of SL (vs. 17.0%-20.5% of SL). Roa uejoi sp. nov., based on three specimens from Guam (Mariana Islands), is most similar to Roa excelsa (Jordan, 1921) (now restricted to the Hawaiian Islands and Johnston Island), but is distinguished from the latter by having a circular dorsal-fin ocellated spot (vs. spot distinctly oval in the latter) and a much more elongate, filamentous first pelvic-fin soft ray, of length 119.0%-123.4% of 2nd ray (vs. not obviously filamentous, 104.9%-105.8%). A key to the eight valid species of Roa is provided.

Mediterranean seagrass Posidonia oceanica accumulates sunscreen UV filters

Certain ultra-violet filter (UVF) components of solar creams have negative impacts on coral reefs and have been prohibited in international tourism destinations (i.e., Hawaii, Florida, and Palau) to protect coral reefs. In the Mediterranean coasts which are also hotspots of international tourism and where endemic seagrass Posidonia oceanica forms extensive meadows, the accumulation of UVF components have not been studied. We report for the first time, that the rhizomes of P. oceanica internally accumulated UVFs BP3, BP4, AVO, 4MBC and MeBZT and the paraben preservative MePB. The components BP4 and MePB occurred in higher concentrations reaching up to 129 ng g^-1 dw and 512 ng g^-1 dw, respectively. This work emphasizes the need for more experimental studies on the effects of UVFs on seagrasses and check if we should follow suit to prohibit certain UVFs to protect this species as what has been done in other regions to protect corals.

Literature Review of Subscapularis Tear, Associated injuries, and the Available Treatment Options

The population of Hawai'i is uniquely connected to the Ocean and to open water sports. Shoulder injuries, particularly those to the rotator cuff, are among the most common injuries sustained to athletes participating in ocean sports such as surfing, paddling, and swimming. In addition, rotator cuff injuries increase in prevalence with advanced age. As a consequence, the number of patients in Hawai'i who present with an injury to the subscapularis tendon will continue to rise. However, limited research has been done to delineate the involvement of subscapularis injuries in this population. This article covers the anatomy and function of the subscapularis, the epidemiology and classification of tears in this tendon, and the management of tears. The anatomy section will cover innervation, vascular supply and insertional anatomy of the subscapularis tendon. The function of the subscapularis in regards to both stability and motion of the glenohumeral joint will be examined. The focus of the article will then shift to the tears of the subscapularis, starting with an in depth look at the epidemiology and classification of these tears. The article will then cover the different imaging modalities and their utility in regards to subscapularis tears. Finally, the operative and non-operative management and indications for each modality will be discussed in detail.

Oxybenzone contamination from sunscreen pollution and its ecological threat to Hanauma Bay, Oahu, Hawaii, U.S.A

Hanauma Bay is a 101-acre bay created by the partial collapse of a volcanic cone and once supported a vibrant coral reef system. It is the most popular swimming area in the Hawaiian Islands and has been reported to have averaged between 2.8 and 3.5 million visitors a year between the 1980s and the 2010s, with visitors averaging between 3000-4000 a day and peaking around 10,000-13,000 per day. Concentrations of oxybenzone and other common UV filters were measured in subsurface water samples and in sands from the beach-shower areas in Hanauma Bay. Results demonstrate that beach showers also can be a source of sunscreen environmental contamination. Hydrodynamic modeling indicates that oxybenzone contamination within Hanauma Bay's waters could be retained between 14 and 50 h from a single release event period. Focusing on only oxybenzone, two different Hazard and Risk Assessment analyses were conducted to determine the danger of oxybenzone to Hanauma Bay's coral reef system. Results indicate that oxybenzone contamination poses a significant threat to the wildlife of Hanauma Bay. To recover Hanauma Bay's natural resources to a healthy condition and to satisfactorily conserve its coral reef and sea grass habitats, effective tourism management policies need to be implemented that mitigate the threat of sunscreen pollution.

The Lives of Native Hawaiian Elders and Their Experiences With Healthcare: A Qualitative Analysis

Native Hawaiians are proud and resilient people who have endured significant impacts from colonization. Despite being in a time of vibrant cultural revitalization, Native Hawaiians have a shorter life expectancy than other racial and ethnic groups in Hawai'i. The primary aim of this paper was to share data from the first year of a 5-year study with Native Hawaiian kūpuna (elders) on their experiences with healthcare, along with barriers to accessing healthcare. Ten kūpuna living in rural areas of Hawai'i participated in three interviews each, which were held in an informal, talk-story style. The first interview focused on establishing rapport. The second interview focused on the kūpuna's strengths, resiliencies, and what they would like to pass to the next generation. The third interview focused on the elders' experiences with healthcare, which is the focus of this paper. All ten kūpuna reported growing up with limited access to Western healthcare; rather, their families successfully treated many illnesses and injuries with lā'au lapa'au (Hawaiian herbal medicine) and other traditional healing practices, as they had done for generations. As Western medicine became more prevalent and accessible, they used both, but many preferred holistic treatments such as prayer, a return to the traditional diet, and lā'au lapa'au. As a group, the kūpuna rated their health as fair to good; two had diabetes, two had cardiovascular disease, four had neuropathies, and five were cancer survivors. The kūpuna reported high turnover among providers in rural communities. Limited access to specialists often required them to travel to Honolulu for care, which was costly and especially difficult during coronavirus disease 2019 (COVID-19). Regardless of provider ethnicity, the kūpuna appreciated those who took the time to get to know them as people and respected Hawaiian cultural practices. They advised that Western providers speak honestly and directly, have compassion, and build connections to patients and their communities.

Variation in floral volatiles across time, sexes, and populations of wind-pollinated Schiedea globosa

PREMISE

Floral scent is a key aspect of plant reproduction, but its intraspecific variation at multiple scales is poorly understood. Sexual dimorphism and temporal regulation of scent can be shaped by evolution, and interpopulation variation may be a bridge to species differences. We tested whether intraspecific chemical diversity in a wind-pollinated species where selection from biotic pollination is absent is associated with genetic divergence across the Hawaiian archipelago.

METHODS

Floral volatiles from females, males, and hermaphrodites of subdioecious Schiedea globosa grown in a common environment from 12 populations were sampled day and night and analyzed by gas chromatography-mass spectrometry. Variation among groups was analyzed by constrained ordination. We also examined the relationships of scent dissimilarity to geographic and genetic distance between populations.

RESULTS

Flowers increased total emissions at night through higher emissions of several ketones, oximes, and phenylacetaldehyde. Females emitted less total scent per flower at night but more of some aliphatic compounds than males, and males emitted more ketones and aldoximes. Scent differed among populations during day and night. Divergence in scent produced at night increased with geographic distance within 70-100 km and increased with genetic distance for males during the day and night, but not for females.

CONCLUSIONS

Schiedea globosa exhibits diel and sex-based variation in floral scent despite wind pollination and presumed loss of biotic pollination. In males, interpopulation scent differences are correlated with genetic differences, suggesting that scent evolved with dispersal within and across islands.

Racial and ethnic representation among a sample of nutrition- and obesity-focused professional organizations in the United States

OBJECTIVE

Obesity is a chronic disease that disproportionately affects individuals from nonmajority racial/ethnic groups in the United States. Research shows that individuals from minority racial/ethnic backgrounds consider it important to have access to providers from diverse backgrounds. Health care providers and scientists from minority racial/ethnic groups are more likely than their non-Hispanic White counterparts to treat or conduct research on patients from underrepresented groups. The objective of this study was to characterize the racial/ethnic diversity of nutrition- and obesity-focused professional organizations in the United States.

METHODS

This study assessed race/ethnicity data from several obesity-focused national organizations including The Obesity Society, the Academy of Nutrition and Dietetics (AND), the American Society for Nutrition, and the American Board of Obesity Medicine (ABOM). Each organization was queried via emailed survey to provide data on racial/ethnic representation among their membership in the past 5 years and among elected presidents from 2010 to 2020.

RESULTS

Two of the three professional societies queried did not systematically track race/ethnicity data at the time of query. Limited tracking data available from AND show underrepresentation of Black (2.6%), Asian (3.9%), Latinx (3.1%), Native Hawaiian or Pacific Islander (1.3%), or indigenous (American Indian or Alaskan Native: 0.3%) individuals compared with the US population. Underrepresentation of racial/ethnic minorities was also reported for ABOM diplomates (Black: 6.0%, Latinx: 5.0%, Native American: 0.2%). Only AND reported having racial/ethnic diversity (20%) among the organization's presidents within the previous decade (2010-2020).

CONCLUSIONS

Findings suggest that (1) standardized tracking of race and ethnicity data is needed to fully assess diversity, equity, and inclusion, and (2) work is needed to increase the diversity of membership and leadership at the presidential level within obesity- and nutrition-focused professional organizations. A diverse cadre of obesity- and nutrition-focused health care professionals is needed to further improve nutrition-related health outcomes, including obesity, cardiovascular disease, diabetes, and undernutrition, in this country.

Demography and selection analysis of the incipient adaptive radiation of a Hawaiian woody species

Ecological divergence in a species provides a valuable opportunity to study the early stages of speciation. We focused on Metrosideros polymorpha, a unique example of the incipient radiation of woody species, to examine how an ecological divergence continues in the face of gene flow. We analyzed the whole genomes of 70 plants collected throughout the island of Hawaii, which is the youngest island with the highest altitude in the archipelago and encompasses a wide range of environments. The continuous M. polymorpha forest stands on the island of Hawaii were differentiated into three genetic clusters, each of which grows in a distinctive environment and includes substantial genetic and phenotypic diversity. The three genetic clusters showed signatures of selection in genomic regions encompassing genes relevant to environmental adaptations, including genes associated with light utilization, oxidative stress, and leaf senescence, which are likely associated with the ecological differentiation of the species. Our demographic modeling suggested that the glaberrima cluster in wet environments maintained a relatively large population size and two clusters split: polymorpha in the subalpine zone and incana in dry and hot conditions. This ecological divergence possibly began before the species colonized the island of Hawaii. Interestingly, the three clusters recovered genetic connectivity coincidentally with a recent population bottleneck, in line with the weak reproductive isolation observed in the species. This study highlights that the degree of genetic differentiation between ecologically-diverged populations can vary depending on the strength of natural selection in the very early phases of speciation.

Knowledge about how genetic barriers are formed between populations in distinct environments is valuable to understand the processes of speciation and conserve biodiversity. Metrosideros polymorpha, an endemic woody species in the Hawaiian Islands, is a good system to study developing genetic barriers in a species, because it colonized the diverse environments and diversified the morphology for a relatively short period of time. We analyzed the genomes of 70 M. polymorpha plants from a broad range of environments on the island of Hawaii to infer the current and past genetic barriers among them. Currently, M. polymorpha plants growing in different environments have substantially different genomes, especially at the genomic regions with genes putatively controlling physiology to fit in distinct environment. However, in its history, they had hybridized with one another, possibly because plants formerly growing in different environments came into close contact due to the climate changes. It is suggested that genetic barriers can easily strengthen or weaken depending on environments splitting the ecology of a species before reproductive isolation becomes complete.

Pregnancy health and perinatal outcomes among Pacific Islander women in the United States and US Affiliated Pacific Islands: Protocol for a scoping review

This scoping review examines the literature on pregnancy and perinatal outcomes among Pacific Islander women in the United States (U.S.) and U.S.-affiliated Pacific Islands. Our aim was to identify research that disaggregated Pacific Islanders from other population groups. We conducted a systematic search of MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCO), and PsycINFO (Ovid) databases and a hand-search of grey literature. Forty-eight articles published between January 2010 and June 2020 were included. The majority of studies were conducted in Hawaii and utilized clinical record data. Infant outcomes were more commonly reported than maternal outcomes. We highlighted several limitations of the existing literature that included aggregation of Pacific Islanders with Asian American and other ethnic groups; limited comparison between Pacific Islander sub-groups; inadequate definitions of the nationality and ethnic composition of Pacific Islander groups; a lack of hypothesis-driven primary data collection and clinical trials; and underrepresentation of Pacific Islanders in population-based studies. Researchers should address these limitations to improve pregnancy and perinatal outcomes among Pacific Islanders, who comprise the second fastest growing ethnic minority in the U.S.

Foliar ẟ15N patterns in legumes and non-N fixers across a climate gradient, Hawai'i Island, USA

Recent studies from the Hawaiian Islands showed that pedogenic thresholds demarcate domains in which rock-derived nutrient dynamics remain similar across wide variations in rainfall. These thresholds appear related to certain aspects of N cycling, but the degree to which they correspond to patterns of biological N fixation (BNF)-the dominant input of N into less-managed ecosystems-remains unclear. We measured aboveground plant biomass, foliar nutrient concentrations, and foliar δ¹⁵N along a climate gradient on ~ 150,000-year-old basaltic substrate to characterize foliar N sources and spatially relate them to soil nutrients. Patterns in legume δ¹⁵N correspond to known pedogenic thresholds along the rainfall gradient, with low δ¹⁵N values (~ 0 to - 2‰) occurring in the dry, biologically inactive domain and the wet, highly weathered domain. Elevated δ¹⁵N in the middle, fertile domain suggests a greater reliance of legumes on soil N where it has accumulated over time. Non-legume face N deficiencies throughout most of the gradient while legumes maintain low C:N ratios via symbiotic BNF. However, legume abundance declines outside the fertile domain, limiting ecosystem N inputs. Breakpoints in legume δ¹⁵N data suggest that P (and potentially other nutrients) limits BNF and, by extension, legume abundance in wet region. Nutrients may also constrain legume abundance in the dry domain, but pedogenic effects could not be isolated from climatic constraints at the dry sites. We conclude that pedogenic thresholds defined by climate can be informative of foliar δ¹⁵N patterns in cases where legumes are not directly constrained by climate, land use, or other external factors.

Lung Cancer Screening by Race and Ethnicity in an Integrated Health System in Hawaii

Importance

Racial and ethnic differences in lung cancer screening (LCS) completion and follow-up may be associated with lung cancer incidence and mortality rates among high-risk populations. Aggregation of Asian American, Native Hawaiian, and Pacific Islander racial and ethnic groups may mask the true underlying disparities in screening uptake and diagnostic follow-up, creating barriers for targeted, preventive health care.

Objective

To examine racial and ethnic differences in LCS completion and follow-up rates in a multiethnic population.

Design, Setting, and Participants

This population-based cohort study was conducted at a health maintenance organization in Hawaii. LCS program participants were identified using electronic medical records from January 1, 2015, to December 31, 2019. Study eligibility requirements included being aged 55 to 79 years, a 30 pack-year smoking history, a current smoker or having quit within the past 15 years, at least 5 years past any lung cancer diagnosis and treatment, and cancer free. Data analysis was performed from June 2019 to October 2020.

Exposure

Eligible for LCS.

Main Outcomes and Measures

Screening rates were analyzed by self-reported race and ethnicity and completion of a low-dose computed tomography (LDCT) test. Diagnostic follow-up results were based on the Lung Imaging Reporting and Data System (Lung-RADS) staging system.

Results

A total of 1030 eligible LCS program members had an order placed; their mean (SD) age was 65.5 (5.8) years, and 633 (61%) were men. The largest racial and ethnic groups were non-Hispanic White (381 participants [37.0%]), Native Hawaiian or part Native Hawaiian (186 participants [18.1%]), and Japanese (146 participants [14.2%]). Men and Filipino, Chinese, Japanese, and non-Hispanic White individuals had a higher proportion of screen orders for LDCT compared with women and individuals of the other racial and ethnic groups. The overall LCS completion rate was 81% (838 participants). There was a 14% to 15% screening completion rate gap among groups. Asian individuals had the highest screening completion rate (266 participants [86%]) followed by Native Hawaiian (149 participants [80%]) and non-Hispanic White individuals (305 participants [80%]), Pacific Islander (50 participants [79%]) individuals, and individuals of other racial and ethnic groups (68 participants [77%]). Within Asian subgroups, Korean (31 participants [94%]) and Japanese (129 participants [88%]) individuals had the highest completion rates followed by Chinese individuals (28 participants [82%]) and Filipino individuals (78 participants [79%]). Of the 54 participants with Lung-RADS stage 3 disease, 93% (50 participants) completed a 6-month surveillance LDCT test; of 37 individuals with Lung-RADS stage 4 disease, 35 (97%) were followed-up for additional procedures.

Conclusions and Relevance

This cohort study found racial and ethnic disparities in LCS completion rates after disaggregation of Native Hawaiian, Pacific Islander, and Asian individuals and their subgroups. These findings suggest that future research is needed to understand factors that may be associated with LCS completion and follow-up behaviors among these racial and ethnic groups.

Spatial distribution and sources of nutrients at two coastal developments in South Kohala, Hawai'i

Nutrient sources to coastal waters with coral reefs are not well-characterized. This study documented spatial distributions of nutrients within coastal waters along two developments with coral reefs, and identified nutrient sources through nutrient mixing plots, δ¹⁵N measurements in macroalgal tissue, and NO₃^- stable isotope mixing models. Nutrients decreased from fresh groundwaters to offshore waters, with some surface waters higher in concentrations than benthic ones. Conservative and non-conservative mixing between fresh and ocean waters occurred, the latter suggestive of local nutrient sources and biological removal. δ¹⁵N in macroalgal tissue and NO₃^- concurred that fresh groundwater, ocean water, and fertilizers were dominant nutrient sources. Benthic salinity and NO₃^- + NO₂^- concentrations illustrated that submarine groundwater discharge delivered nutrients to reefs in pulses ranging from minutes to days. Information generated from this study is imperative for developing management actions to improve water quality and make coral reefs more resilient to stressors.

Neighborhood Social Cohesion and the Health of Native Hawaiian and Other Pacific Islander Older Adults

Native Hawaiian and other Pacific Islander (NHPI) older adults experience various social and health challenges. There is a growing literature linking neighborhood conditions with health, yet few have focused on NHPI older adults. This study examines associations between neighborhood social cohesion and health outcomes (i.e., self-rated health, psychological distress, and memory) in this population. Data from the 2014 Native Hawaiian and Pacific Islander National Health Interview Survey (n=1,045 with respondents aged 50+) were analyzed with logistic regression models. The level of neighborhood social cohesion was determined by responses to items on perceptions of mutual help, dependability, trust, and close relationships within the neighborhood. Higher perceived neighborhood social cohesion was associated with lower odds of having serious psychological distress or memory problems. There was no statistical association of social cohesion with self-rated health. Socially cohesive neighborhoods are important to the health of NHPI. We discuss methods to improve neighborhood social cohesion as a way to promote health equity for NHPI older adults in the United States (U.S.).

Movement and retention of derelict fishing nets in Northwestern Hawaiian Island reefs

Derelict fishing nets pose hazards to marine systems as they travel through the ocean or become ensnared on coral reefs. Understanding of the movement of nets within shallow atolls can help to optimize operations to protect these shallow reefs. In 2018, six derelict fishing nets at Manawai (Pearl and Hermes Reef) in the Northwestern Hawaiian Islands were tagged with satellite-transmitting buoys and tracked for three years. This study reveals that nets that enter the atoll from the northeast travel southwest towards the center of the atoll, and nets in the center can remain ensnared on the same reef for at least three years. This study shows that satellite buoys are a successful approach to tracking derelict net movement, and can inform future debris removal missions.

Hawaiian Fungal Amplicon Sequence Variants Reveal Otherwise Hidden Biogeography

To study biogeography and other ecological patterns of microorganisms, including fungi, scientists have been using operational taxonomic units (OTUs) as representations of species or species hypotheses. However, when defined by 97% sequence similarity cutoff at an accepted barcode locus such as 16S in bacteria or ITS in fungi, these OTUs can obscure biogeographic patterns, mask taxonomic diversity, and hinder meta-analyses. Amplicon sequence variants (ASVs) have been proposed to alleviate all of these issues and have been shown to do so in bacteria. Analyzing ASVs is just emerging as a common practice among fungal studies, and it is unclear whether the benefits found in bacterial studies of using such an approach carryover to fungi. Here, we conducted a meta-analysis of Hawaiian fungi by analyzing ITS1 amplicon sequencing data as ASVs and exploring ecological patterns. These surveys spanned three island groups and five ecosystems combined into the first comprehensive Hawaiian Mycobiome ASV Database. Our results show that ASVs can be used to combine fungal ITS surveys, increase reproducibility, and maintain the broad ecological patterns observed with OTUs, including diversity orderings. Additionally, the ASVs that comprise some of the most common OTUs in our database reveals some island specialists, indicating that traditional OTU clustering can obscure important biogeographic patterns. We recommend that future fungal studies, especially those aimed at assessing biogeography, analyze ASVs rather than OTUs. We conclude that similar to bacterial studies, ASVs improve reproducibility and data sharing for fungal studies.

Early Impact of the COVID-19 Pandemic on Outpatient Neurologic Care in Hawai'i

In March 2020, Hawai'i instituted public health measures to prevent the spread of Coronavirus disease 2019 (COVID-19), including stay-at-home orders, closure of non-essential businesses and parks, use of facial coverings, social distancing, and a mandatory 14-day quarantine for travelers. In response to these measures, Hawai'i Pacific Neuroscience (HPN) modified practice processes to ensure continuity of neurological treatment. A survey of patients was performed to assess the impact of the COVID-19 pandemic and pandemic-related practice processes for quality improvement. Overall, 367 patients seen at HPN between April 22, 2020, and May 18, 2020, were surveyed via telephone. Almost half (49.6%) participated in a telemedicine appointment, with the majority finding it easy to use (87.4%) and as valuable as face-to-face appointments (68.7%). Many (44.5%) patients said they would have missed a health care appointment without the availability of telemedicine, and 47.3% indicated they might prefer to use telemedicine over in-person appointments in the future. Many reported new or worsening mental health problems, including depression (27.6%), anxiety (38.3%), or sleep disturbances (37.4%). A significant number reported worsening of their condition, with 33.1% of patients who experience migraines reporting increased symptom severity or frequency, 45.8% patients with Alzheimer's disease reporting worsened symptoms, 38.5% of patients with Parkinson's disease who had a recent fall, and 50.0% of patients with multiple sclerosis experiencing new or worsened symptoms. Insights from this survey applied to the practice's pandemic-related processes include emphasizing lifestyle modification, screening for changes in mental health, optimizing treatment plans, and continuing the option of telemedicine.

Influence of seasonal and climatic variables on coffee berry borer (Hypothenemus hampei Ferrari) flight activity in Hawaii

Coffee berry borer (CBB, Hypothenemus hampei Ferrari) is the most serious insect pest of coffee worldwide, yet little is known about the effect that weather variables have on CBB flight activity. We sampled flying female CBB adults bi-weekly over a three-year period using red funnel traps baited with an alcohol lure at 14 commercial coffee farms on Hawaii Island to characterize seasonal phenology and the relationship between flight activity and five weather variables. We captured almost 5 million scolytid beetles during the sampling period, with 81-93% of the trap catch comprised of CBB. Of the captured non-target beetles, the majority were tropical nut borer, black twig borer and a species of Cryphalus. Two major flight events were consistent across all three years: an initial emergence from January-April that coincided with early fruit development and a second flight during the harvest season from September-December. A generalized additive mixed model (GAMM) revealed that mean daily air temperature had a highly significant positive correlation with CBB flight; most flight events occurred between 20-26°C. Mean daily solar radiation also had a significant positive relationship with flight. Flight was positively correlated with maximum daily relative humidity at values below ~94%, and cumulative rainfall up to 100 mm; flight was also positively correlated with maximum daily wind speeds up to ~2.5 m/s, after which activity declined. Our findings provide important insight into CBB flight patterns across a highly variable landscape and can serve as a starting point for the development of flight prediction models.

Risk Assessment of Ozone Fumigation Under Vacuum to Control Potential Infestation of Coffee Berry Borer and Coffee Leaf Rust in Green Coffee Beans Imported Into Hawaii

Studies were conducted with ozone gas fumigation under vacuum as a methyl bromide alternative against life stages of coffee berry borer (CBB) Hypothenemus hampei (Ferrari) (Coleoptera: Curculionidae: Scolytinae), and the urediniospores of coffee leaf rust (CLR), Hemileia vastatrix Berkeley & Broome (Basidiomycota: Pucciniales) in green coffee, Coffea spp. L. Fumigation with 10,000 ppm O3 gas under -25.4 mm Hg vacuum1 at 13.0 ± 3.0°C for 6.0 h killed all CBB larvae, pupae, and adults, but did not kill all CBB eggs (~15% survival). Mortality of CLR urediniospores was 100% within the first hour of the 6-h fumigation. Ozone fumigation had no adverse effects on coffee quality. Results indicated that CBB adult hitchhikers may be the only target life stage of quarantine concern, and additional studies focused on this stage. CBB adult survival and reproduction decreased significantly at moisture contents ≤20%, and F1 generation survival did not occur in green coffee at moisture contents ≤15%. As the international standard for green coffee moisture content is 9-12%, adult CBB should not survive or reproduce in exported dry green coffee. Standard industry processing of harvested coffee cherries to the green coffee stage using either mechanical- or sun-drying eliminated CBB infestations from the field. A systems approach is recommended for exporting green coffee to control CBB and CLR that includes eliminating CBB life stages with standard processing methods, reducing moisture content to 9-12% to prevent egg deposition, survival or reproduction, and O3 fumigation to ensure quarantine security against potential CBB adult hitchhikers.

Getting butts off the beach: Policy alone is not effective at reducing cigarette filter litter on beaches in Maui, Hawai'i

Cigarette filters are made of non-biodegradable plastic and are one of the top littered items worldwide. Here, we determine if policy implementation is an effective strategy for reducing cigarette filter litter on beaches in Maui, Hawai'i by comparing cigarette filter counts before and after a policy banning tobacco use was implemented. We use a before-after control-impact (BACI) design to investigate whether changes in cigarette filter accumulation at an impact site, where tobacco use was banned, decreased relative to counts at a control site, where tobacco use was not banned. A total of 764 cigarette filters were removed with no significant difference detected in cigarette filter littering between the control and impact site after the policy went into place. This study shows that policy requiring a shift from social norms, such as tossing cigarette butts, needs to be accompanied by sustained law enforcement and awareness around the policy to be effective.

Advocating For a Culture of Support for Lactating Medical Residents in Hawai'i

Lactating medical residents face unique barriers due to intense clinical work schedules, limited support in the clinic and hospital workspaces, and competing pressures between career development and childcare. The objective of this project was to explore the perceived culture of breastfeeding support among medical trainees and design an action plan to improve support for lactating residents in Hawai'i. Resident and faculty representatives from the Hawai'i Residency Programs and the University of Hawai'i John A Burns School of Medicine participated in an 8 month national learning collaborative to review the existing resident lactation policy and resident perception of lactation support. In a pre-survey, the majority of residents (88%) agreed that 20-30 minutes every 2-3 hours should be allowed to express milk but only 18% felt comfortable asking for a change in schedule to accommodate time to pump. An action plan was created with the following objectives: (1) revamping the existing policy to address protected pumping times, lactation spaces, and responsibilities of administration, faculty, and residents; (2) improving lactation space through uniform provision of educational material on available facilities and efficiency tips for new parents, and (3) improving awareness of the unique challenges lactating residents face and empowering faculty and trainees to advocate for lactating residents through department and educational presentations. Medical residents in Hawai'i recognize the importance of breastfeeding but perceive a lack of support in the workplace. A comprehensive action plan to revamp the resident lactation policy and improve faculty and resident education may foster an increased culture of lactation support and healthy development of the physician workforce.

Diversity and health risk potentials of the Enterococcus population in tropical coastal water impacted by Hurricane Lane

Hurricane-caused stormwater runoffs transport diverse terrestrial pollutants, adversely impact microbiological water quality, and introduce fecal and other pathogens to coastal water environments. This study investigated the genotypic diversity, phylogenetic composition, antibiotic resistance patterns, and virulence gene repertoire of the Enterococcus population in the Hilo Bay coastal water after the immediate impact of Hurricane Lane. DNA fingerprinting of Enterococcus isolates exhibited large genotypic diversity, while 16S rRNA gene sequencing identified four major species, including E. faecalis (34.7%), E. faecium (22.4%), E. hirae (22.4%), and E. durans (18.4%). Four common enterococcal virulence genes (cylA, esp, asa1, and gelE) were detected in the Enterococcus population, with significant portions of E. durans (33.3%), E. faecalis (41.2%), E. faecium (36.4%), and E. hirae (27.3%) isolates possessing two or more virulence genes. Considerable antibiotic resistance to rifampin, erythromycin, tetracycline, and nitrofurantoin was detected in the Enterococcus population, with one E. durans isolate showing vancomycin resistance. The results indicate considerable health implications associated with Enterococcus spp. in the hurricane-impacted tropical coastal water, illustrating the needs for more comprehensive understanding of the microbiological risks associated with storm-impacted coastal water.

Spinosad resistance in field populations of melon fly, Zeugodacus cucurbitae (Coquillett), in Hawaii

BACKGROUND

Control of Zeugodacus cucurbitae, a serious agricultural pest worldwide, often includes or is dependent on the use of spinosad-based insecticides. This is especially the case in Hawaii, where GF-120, a protein bait containing spinosad as the active ingredient, has been in use as a key integrated pest management (IPM) tool against this Tephritid for the last two decades. Here, we report on resistance to spinosad [resistance ratios (RRs) and median lethal concentration (LC₅₀ )] in Hawaii's populations of Z. cucurbitae.

RESULTS

High resistance was found in populations from three farms on Oahu (RR = 102-303; LC₅₀  = 191-567 mg L^-1 ) and in a population from Maui (RR = 8.50; LC₅₀  = 15.9 mg L^-1 ). These will be problematic for control given that the most concentrated dilution ratio on the GF-120 label is 96 mg L^-1 of spinosad (1 part GF-120 to 1.5 parts water). Background resistance in a naïve wild population from the Island of Hawaii (RR = 2.73; LC₅₀  = 5.1 mg L^-1 ) was relatively low compared with a spinosad-susceptible laboratory colony (LC₅₀  = 1.87 mg L^-1 ). Resistance in the three Oahu and one Maui populations declined over generations in the absence of spinosad but remained elevated in some cases. Moreover, melon flies collected from one of the Oahu farms 1 year after the cessation of spinosad use revealed high persistence of resistance.

CONCLUSION

Compared with a 2008 survey of spinosad resistance, our findings indicate a 34-fold increase in resistance on one of the Oahu farms over 9 years. The evolution and persistence of high levels of resistance to spinosad in Z. cucurbitae in Hawaii highlights the need for alternative control tactics, particularly rotation of active ingredients. © 2021 The Authors. Pest Management Science published by John Wiley & Sons Ltd on behalf of Society of Chemical Industry.

Does Japanese Identity Buffer Stress or Intensify Symptoms of Depression Associated with Discrimination in Hawai'i?

Racism is a public health crisis-yet our knowledge remains limited about how different racial and ethnic groups cope with the stress of discrimination across the United States. Research suggests that ethnic identity plays a role in the relationship between perceived discrimination and mental health problems. The purpose of this study is to focus on whether a strong Japanese identity in Hawai'i can buffer the stress of discrimination to protect mental health. Data were from an anonymous survey of 222 students who self-identified as Japanese at a university in Hawai'i. The average age was 21 years, about half (53%) were women, and 10% were foreign-born. Less than half (42%) of the students self-reported ever experiencing discrimination in a lifetime due to race/ethnicity. However, non-specific unfair treatment based on the Everyday Discrimination Scale was self-reported by most students (90%). It primarily included being treated with less respect or courtesy than other people and people acting as if they were better than them. Levels of ethnic identity were assessed with the Multigroup Ethnic Identity Measure (mean, 2.07; range, 0-3). A statistically significant interaction effect was observed (ß = -0.50; P < .01), indicating a stronger ethnic identity counteracted the psychological distress associated with everyday discrimination. This finding suggested that strong Japanese identity, which involves pride and knowledge, participation in cultural practices, and a sense of belonging to one's ethnic group, can buffer the stress of frequent experiences of unfair treatment.