Racial disparities in hospitalization characteristics among Native Hawaiians, Pacific Islanders and Asian American subgroups with Parkinson's disease.

BACKGROUND: Differences among Native Hawaiians/Pacific Islanders (NHPI) and Asian American (AA) subgroups have not been adequately studied in Parkinson's disease (PD). OBJECTIVE: To determine differences in demographics, comorbidities, and healthcare utilization among NHPI, AA subgroups, and White hospitalized PD patients. METHODS: We conducted a retrospective cross-sectional analysis of Hawai'is statewide registry (2016-2020). Patients with PD were identified using ICD10 code G20 and categorized as White, Japanese, Filipino, Chinese, NHPI, or Other. Variables collected included: age, sex, residence (county), primary source of payment, discharge status, length of stay, in-hospital expiration, Charlson Comorbidity Index (CCI) and Deep Brain Stimulation (DBS) utilization. Bivariate analyses were performed: differences in age and CCI were further examined by multivariable linear regression and proportional odds models. RESULTS: Of 229,238 hospitalizations, 2428 had PD (Japanese: 31.3 %, White: 30.4 %, Filipino: 11.3 %, NHPI: 9.6 %, Chinese: 8.0 %). NHPI were younger compared to rest of the subgroups [estimate in years (95 % CI): Whites: 4.4 (3.0-5.8), Filipinos: 4.3 (2.7-5.9), Japanese: 7.7 (6.4-9.1), Chinese: 7.9 (6.1-9.7), p < 0.001)]. NHPI had a higher CCI compared to White, Japanese, and Chinese (p < 0.001). Among AA subgroups, Filipinos were younger and had a higher CCI compared to Japanese and Chinese (p < 0.001). There were no significant differences in DBS utilization among subgroups. CONCLUSIONS: NHPI and Filipinos with PD were hospitalized at a younger age and had a greater comorbidity burden compared to other AAs and Whites. Further research, ideally prospective studies, are needed to understand these racial disparities.

FOXO3 longevity genotype attenuates the impact of hypertension on cerebral microinfarct risk.

OBJECTIVE: The G -allele of FOXO3 SNP rs2802292 , which is associated with human resilience and longevity, has been shown to attenuate the impact of hypertension on the risk of intracerebral hemorrhage (ICH). We sought to determine whether the FOXO3 G -allele similarly attenuates the impact of hypertension on the risk of cerebral microinfarcts (CMI). METHODS: From a prospective population-based cohort of American men of Japanese ancestry from the Kuakini Honolulu Heart Program (KHHP) and Kuakini Honolulu-Asia Aging Study (KHAAS) that had brain autopsy data, age-adjusted prevalence of any CMI on brain autopsy was assessed. Logistic regression models, adjusted for age at death, cardiovascular risk factors, FOXO3 and APOE-ε4 genotypes, were utilized to determine the predictors of any CMI. Interaction of FOXO3 genotype and hypertension was analyzed. RESULTS: Among 809 men with complete data, 511 (63.2%) participants had evidence of CMI. A full multivariable model demonstrated that BMI [odds ratio (OR) 1.07, 95% confidence interval (CI) 1.01-1.14, P  = 0.015) was the only predictor of CMI, while hypertension was a borderline predictor (OR 1.44, 95% CI 1.00-2.08, P  = 0.052). However, a significant interaction between FOXO3 G -allele carriage and hypertension was observed ( P  = 0.020). In the stratified analyses, among the participants without the longevity-associated FOXO3 G -allele, hypertension was a strong predictor of CMI (OR 2.25, 95% CI 1.34-3.77, P  = 0.002), while among those with the longevity-associated FOXO3 G -allele, hypertension was not a predictor of CMI (OR 0.88, 95% CI 0.51-1.54, P  = 0.66). CONCLUSION: The longevity-associated FOXO3 G -allele mitigates the impact of hypertension on the risk of CMI.

Incidence of Alzheimer's Disease in Men with Late-Life Hypertension Is Ameliorated by FOXO3 Longevity Genotype.

BACKGROUND: It is well established that mid-life hypertension increases risk of dementia, whereas the association of late-life hypertension with dementia is unclear. OBJECTIVE: To determine whether FOXO3 longevity-associated genotype influences the association between late-life hypertension and incident dementia. METHODS: Subjects were 2,688 American men of Japanese ancestry (baseline age: 77.0±4.1 years, range 71-93 years) from the Kuakini Honolulu Heart Program. Status was known for FOXO3 rs2802292 genotype, hypertension, and diagnosis of incident dementia to 2012. Association of FOXO3 genotype with late-life hypertension and incident dementia, vascular dementia (VaD) and Alzheimer's disease (AD) was assessed using Cox proportional hazards models. RESULTS: During 21 years of follow-up, 725 men were diagnosed with all-cause dementia, 513 with AD, and 104 with VaD. A multivariable Cox model, adjusting for age, education, APOEɛ4, and cardiovascular risk factors, showed late-life hypertension increased VaD risk only (HR = 1.71, 95% CI = 1.08-2.71, p = 0.022). We found no significant protective effect of FOXO3 longevity genotype on any type of dementia at the population level. However, in a full Cox model adjusting for age, education, APOEɛ4, and other cardiovascular risk factors, there was a significant interaction effect of late-life hypertension and FOXO3 longevity genotype on incident AD (ß= -0.52, p = 0.0061). In men with FOXO3 rs2802292 longevity genotype (TG/GG), late-life hypertension showed protection against AD (HR = 0.72; 95% CI = 0.55-0.95, p = 0.021). The non-longevity genotype (TT) (HR = 1.16; 95% CI = 0.90-1.51, p = 0.25) had no protective effect. CONCLUSION: This longitudinal study found late-life hypertension was associated with lower incident AD in subjects with FOXO3 genotype.

Forkhead box O3 longevity genotype may attenuate the impact of hypertension on risk of intracerebral haemorrhage.

OBJECTIVE: Since the G allele of forkhead box O3 ( FOXO3 ) single nucleotide polymorphism (SNP) rs2802292 is associated with resilience and longevity, ostensibly by mitigating the adverse effects of chronic cardiometabolic stress on mortality, our aim was to determine the association between the FOXO3 SNP rs2802292 genotype and risk of hypertension-mediated intracerebral haemorrhage (ICH). METHODS: From a prospective population-based cohort of Japanese American men from the Kuakini Honolulu Heart Program (KHHP), age-adjusted prevalence of ICH by hypertension was assessed for the whole cohort after stratifying by FOXO3 genotype. Cox regression models, adjusted for age, cardiovascular risk factors and, FOXO3 and APOE genotypes, were utilized to determine relative risk of hypertension's effect on ICH. All models were created for the whole cohort and stratified by FOXO3 G -allele carriage vs. TT genotype. RESULTS: Among 6469 men free of baseline stroke, FOXO3 G -allele carriage was seen in 3009 (46.5%) participants. Overall, 183 participants developed ICH over the 34-year follow-up period. Age-adjusted ICH incidence was 0.90 vs. 1.32 per 1000 person-years follow-up in those without and with hypertension, respectively ( P  = 0.002). After stratifying by FOXO3 genotype, this association was no longer significant in G allele carriers. In the whole cohort, hypertension was an independent predictor of ICH (relative risk [RR] = 1.70, 95% confidence interval [CI] 1.25, 2.32; P  = 0.0007). In stratified analyses, hypertension remained an independent predictor of ICH among the FOXO3 TT -genotype group (RR = 2.02, 95% CI 1.33, 3.07; P  = 0.001), but not in FOXO3 G -allele carriers (RR = 1.39, 95% CI 0.88, 2.19; P  = 0.15). CONCLUSIONS: The longevity-associated FOXO3   G allele may attenuate the impact of hypertension on ICH risk.

Difference in rural and urban Medicare prescription pattern for Parkinson's disease in Hawai'i.

Background: Medical management of Parkinson's Disease (PD) is becoming complex. Increasing evidence suggests that patients have better outcomes when they are managed by neurologists. However, access to neurologists can be limited in rural areas. Analysis of prescription pattern can provide insight into access gap rural patients face. Methods: This retrospective observational study used National Medicare Provider Utilization and Payment Data: Part D Prescriber Public Use Files from 2013 to 2018. Query was made for levodopa, dopamine agonists and other antiparkinsonian medications. The data elements obtained included drug name, number of prescribers, prescriber specialty, number of claims, number of standardized 30-day Part D prescriptions, and number of Medicare beneficiaries in the state of Hawai'i. Individual prescribing providers were categorized as urban or rural based on their cities of practice. Prescription patterns of urban and rural providers in Hawai'i as well as difference in provider specialty were compared, using standardized 30-day prescriptions as the primary measure of utilization. Results: Practice patterns differed between rural and urban areas. In rural Hawai'i, Rytary, Rotigoitne and selegiline were rarely prescribed. Levodopa percentage was higher in urban Hawai'i. In urban Hawai'i, 74.4% of the prescriptions were provided by movement disorders and general neurologists. In rural Hawai'i, 25.1% of the prescriptions were written by neurologists and 74.9% by general practitioners. Conclusions: In the state of Hawai'i, there is an urban-rural access gap to neurologists as evidenced by Medicare prescription pattern. Further study is needed to understand the reasons for rural-urban differences in prescription patterns and their impact on outcomes.

Delayed Respiratory Failure After Blunt Chest Trauma.

BACKGROUND: Patient factors associated with delayed respiratory failure (DRF) after blunt chest trauma are not well documented. Earlier identification and closer monitoring may improve outcomes for these patients. The purpose of this study was to identify the prevalence and clinical predictors of DRF in patients after blunt chest trauma. MATERIALS AND METHODS: A retrospective review of adult patients admitted to a Level 1 trauma center after blunt chest trauma between January 1, 2009 and December 31, 2013, was conducted. Patients with early respiratory failure were compared to patients with DRF using Fisher's exact tests, chi square, and Student's t-tests. A P-value of <.05 was considered significant. RESULTS: 1299 patients had blunt chest trauma and at least 1 rib fracture, of which 830 met inclusion criteria. 5.8% of patients progressed to respiratory failure. Respiratory failure was delayed in 25% of these patients. DRF patients had significantly lower ISS (16.5 vs. 22.7, P = .04), more bilateral rib fractures (66.7% vs. 28.7%, P = .02) and fewer pulmonary contusions (16.7% vs. 50.0%, P = .04). DISCUSSION: Injury patterns, including bilateral rib fractures without pulmonary contusions and low but severe Injury Severity Score burden, may help identify high-risk patients who may benefit from closer monitoring and more aggressive therapy.

Impact of Statewide Telestroke Network on Acute Stroke Treatment in Hawai'i.

Hawai'i faces unique challenges in providing access to subspecialty care, particularly on the islands outside of O'ahu. Telemedicine allows remote treatment of patients with acute ischemic stroke by a neurologist with stroke expertise. The Hawai'i Telestroke Program was implemented in 2012 to connect hospitals with limited neurology coverage to a tertiary stroke center on O'ahu with 24/7 stroke neurology coverage. By 2017, seven hospitals were included in the program. The clinical data and revascularization therapy rate for all telestroke cases between January 2012 and July 2017 were analyzed. Annual telestroke consultations increased from 11 in 2012 to 203 in 2016. Among a total of 490 telestroke consultations, 318 patients (64.9%) were diagnosed with ischemic stroke while the remaining 172 patients had other diagnoses. Revascularization therapies, including intravenous tissue plasminogen activator and mechanical thrombectomy, were provided in 190 patients (38.8%). Using the discharge modified Rankin Scale, 141 (44.3%) patients were functionally independent at the time of hospital discharge, while 162 (50.9%) were disabled or dependent, and 15 (4.7%) died while in the hospital. Of the 490 telestroke consultations, 151 patients (30.8%) were transferred to the hub hospital while 69.2% of patients were able to remain in their local hospital. In summary, development of the Hawai'i Telestroke Program resulted in an increasing number of acute telestroke consultations and revascularization therapies at seven hospitals with limited neurological subspecialty coverage. Utilization of telemedicine in acute stroke treatment is feasible and may help address existing disparities of subspecialty care in Hawai'i.

Temporal Trends of Hospitalization, Mortality, and Financial Impact Related to Preeclampsia with Severe Features in Hawai'i and the United States.

The temporal trend of hospitalizations, cost, and outcomes associated with preeclampsia with severe features have been inadequately studied. The publicly available Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) database was accessed to examine the temporal trend of total number of discharges, age, death, and mean charges per admission associated with preeclampsia with severe features. Eleven-year temporal trends (2004 to 2014) of these measures were compared using linear regression and run charts using the statistical process control rule. From 2004 to 2014, the total number of discharges related to preeclampsia with severe features increased both for Hawai'i and the U.S. (United States) (Hawai'i: 104 to 231; U.S.: 35,082 to 55,235; both P<.0001). The corresponding rates of discharges per 100,000 population also both increased (Hawai'i: 8.2 to 16.3; U.S.: 12.0 to 17.3; both P<.0001). Comparing the temporal trends between Hawai'i and the U.S., Hawai'i had a significantly higher average annual increase in the rate of incidence than the national level (an annual increase rate of 9.2% in Hawai'i vs 4.2% nationally; P=.0004). The cost of hospitalization for preeclampsia with severe features also showed an increased trend for both Hawai'i and the U.S. (Hawai'i: 33.1% increase, P=.0005; U.S.: 41.1% increase, P<.0001). In the U.S., in-hospital mortality rates associated with this condition decreased from 0.09% in 2004 to 0.02% in 2014 (P=.03). In conclusion, the number of discharges related to preeclampsia with severe features increased over an 11-year period in Hawai'i and the U.S., and the rate of increase was higher in Hawai'i than the U.S. Maternal mortality rates from this condition also declined over the study period.

Temporal trends of cirrhosis associated conditions.

BACKGROUND: Chronic liver disease and cirrhosis is the 12th leading cause of death in the United States. Patients with decompensated-cirrhosis, especially with hepatic encephalopathy/coma (HC), have a higher rate of early readmission and contribute to higher healthcare cost. AIM: To evaluate the national inpatient trends of discharges, mortalities and financial impacts associated with four common conditions of cirrhosis. METHODS: The publicly available Healthcare Cost and Utilization Project National Inpatient Sample database was utilized to examine the temporal trends of total number of discharges, mortalities and inpatient costs related to hospitalization with a primary diagnosis of HC, transjugular intrahepatic portosystemic shunt (TIPS), esophageal varices with bleeding (EV) and spontaneous bacterial peritonitis (SBP) from 2005 to 2014. The ten-year temporal trends were assessed using simple linear regressions and multiple regression analysis. Two-sided P < 0.05 was considered statistically significant. RESULTS: From 2005 to 2014, the total number of discharges with cirrhosis-associated complications trended up for HC, SBP and EV (HC by 70% increase, P < 0.0001; SBP by 819% increase, P = 0.0002; EV by 9% increase, P = 0.016), but not for TIPS (P = 0.90). HC related to viral hepatitis showed faster increase by 357% (P < 0.0001) in comparison to HC not related to viral hepatitis by 33 % (P = 0.0006). Overall, in-hospital mortality rates for each condition decreased from 2005 to 2014 (HC by 29% reduction, P = 0.0024; SBP by 26% reduction, P = 0.0038; TIPS by 32% reduction, P = 0.021) except for EV (P = 0.34). After adjustment for inflation, aggregate cost of hospitalization for EV, HC, and SBP significantly increased by 20%, 86%, and 980%, respectively, from 2005 to 2014 (all P < 0.02), while TIPS had trend toward decreasing cost by 3% (P = 0.95). CONCLUSION: The number of hospitalizations and costs for some of the cirrhosis-associated conditions increased. However, the inpatient mortality rates for most of these conditions decreased.

Gender Differences in the Rate of 30-Day Readmissions after Percutaneous Coronary Intervention for Acute Coronary Syndrome.

BACKGROUND: It has been reported that women have higher 30-day readmission rates than men after acute coronary syndrome (ACS). However, readmission after percutaneous coronary intervention (PCI) for ACS is a distinct subset of patients in whom gender differences have not been adequately studied. METHODS: Hawaii statewide hospitalization data from 2010 to 2015 were assessed to compare gender differences in 30-day readmission rates among patients hospitalized with ACS who underwent PCI during the index hospitalization. Readmission diagnoses were categorized using an aggregated version of the Centers for Medicare and Medicaid Services Condition Categories. Multivariable logistic regression was applied to evaluate the effect of gender on the 30-day readmission rate. RESULTS: A total of 5,354 patients (29.4% women) who were hospitalized with a diagnosis of ACS and underwent PCI were studied. Overall, women were older, with more identified as Native Hawaiian, and had a higher prevalence of cardiovascular risk factors compared with men. The 30-day readmission rate was 13.9% in women and 9.6% in men (p < .0001). In the multivariable model, female gender (odds ratio [OR], 1.32; 95% confidence interval [CI], 1.09-1.60), Medicaid (OR, 1.48; 95% CI, 1.07-2.06), Medicare (1.72; 95% CI, 1.35-2.19), heart failure (1.88; 95% CI, 1.53-2.33), atrial fibrillation (OR, 1.54; 95% CI-1.21-1.95), substance use (OR, 1.88; 95% CI, 1.27-2.77), history of gastrointestinal bleeding (OR, 2.43; 95% CI, 1.29-4.58), and chronic kidney disease (OR, 1.78; 95% CI, 1.42-2.22) were independent predictors of 30-day readmissions. Readmission rates were highest during days 1 through 6 (peak, day 3) after discharge. The top three cardiac causes of readmissions were heart failure, recurrent angina, and recurrent ACS. CONCLUSIONS: Female gender is an independent predictor of 30-day readmission after ACS that requires PCI. Our finding suggests women are at a higher risk of post-ACS cardiac events such as heart failure and recurrent ACS, and further gender-specific intervention is needed to reduce 30-day readmission rate in women after ACS.

Preliminary guideline- and pathophysiology-based protocols for neurocritical care.

BACKGROUND: Because of the complex pathophysiological processes involved, neurocritical care has been driven by anecdotal experience and physician preferences, which has led to care variation worldwide. Standardization of practice has improved outcomes for many of the critical conditions encountered in the intensive care unit. MAIN BODY: In this review article, we introduce preliminary guideline- and pathophysiology-based protocols for (1) prompt shivering management, (2) traumatic brain injury and intracranial pressure management, (3) neurological prognostication after cardiac arrest, (4) delayed cerebral ischemia after subarachnoid hemorrhage, (5) nonconvulsive status epilepticus, and (6) acute or subacute psychosis and seizure. CONCLUSION: These tentative protocols may be useful tools for bedside clinicians who need to provide consistent, standardized care in a dynamic clinical environment. Because most of the contents of presented protocol are not supported by evidence, they should be validated in a prospective controlled study in future. We suggest that these protocols should be regarded as drafts to be tailored to the systems, environments, and clinician preferences in each institution.

Optimal Hematoma Volume Cut Points to Predict Functional Outcome After Basal Ganglia and Thalamic Hemorrhages.

BACKGROUND: Basal ganglia hemorrhage (BG-ICH) and thalamic hemorrhage (TH-ICH) have been historically grouped into a single "deep" hemorrhage group in prior studies. We aimed to assess whether BG-ICH and TH-ICH have different optimal hematoma volume cut points in predicting functional outcome. METHODS: Patients with BG-ICH and TH-ICH with no preexisting disabilities who were enrolled in a single-center intracerebral hemorrhage (ICH) cohort study were studied. The hematoma volume of patients who achieved modified Rankin Scale (mRS) of ≤2 and ≤3 at 3 months were compared between BG-ICH and TH-ICH groups. Receiver operating characteristic (ROC) curves were created to determine the optimal hematoma volume cut points in predicting 3-month mRS of ≤2 and ≤3 for BG-ICH and TH-ICH groups. RESULTS: A total of 135 (81 BG-ICH and 54 TH-ICH) patients were studied. The hematoma volume among those with 3-month mRS ≤ 2 (BG-ICH: 9.5 ± 5.4 cm3 vs. TH-ICH: 5.1 ± 4.9 cm3, p = 0.01) and 3-month mRS ≤ 3 (BG-ICH: 14.2 ± 13.4 cm3 vs. TH-ICH: 4.7 ± 4.1 cm3, p = 0.001) were smaller in TH-ICH than BG-ICH. The area under the ROC curve in predicting mRS ≤ 2 was 0.838 for BG-ICH (optimal hematoma volume cut point: 18.0 cm3, sensitivity 72.1%, specificity 95.0%) and 0.802 for TH-ICH (optimal hematoma volume cut point: 4.6 cm3, sensitivity 83.8%, specificity 70.6%); and in predicting mRS ≤ 3 was 0.826 for BG-ICH (optimal hematoma volume cut point: 28.8 cm3, sensitivity 71.4%, specificity 93.8%) and 0.902 for TH-ICH (optimal hematoma volume cut point: 5.5 cm3, sensitivity 92.9%, specificity 76.9%). CONCLUSION: TH-ICH have smaller optimal hematoma volume cut points than BG-ICH in predicting functional outcome.

Disparities in Functional Outcome After Intracerebral Hemorrhage Among Asians and Pacific Islanders.

BACKGROUND: Disparities in outcome after intracerebral hemorrhage (ICH) among Asians, Native Hawaiians, and other Pacific Islanders (NHOPI) have been inadequately studied. We sought to assess differences in functional outcome between Asians and NHOPI after ICH. METHODS: A multiracial prospective cohort study of ICH patients was conducted from 2011 to 2016 at a tertiary center in Honolulu, HI, USA to assess racial disparities in outcome after ICH. Favorable outcome was defined as 3-month modified Rankin Scale (mRS) score ≤2. Patients with no available 3-month functional outcome, race other than Asians and NHOPI, and baseline mRS > 0 were excluded. Multivariable analyses using logistic regression were performed to assess the impact of race on favorable outcome after adjusting for the ICH Score, early do-not-resuscitate (DNR) order and dementia/cognitive impairment. RESULTS: A total of 220 patients (161 Asians, 59 NHOPI) were studied. Overall, 65 (29.5%) achieved favorable outcome at 3 months. NHOPI were younger than Asians (p < 0.0001) and had higher prevalence of diabetes (p = 0.007), obesity (p < 0.0001), and lower prevalence of dementia/cognitive impairment (p = 0.02), early DNR order (p = 0.0004), and advance directive presence (p = 0.0005). NHOPI race was a predictor of favorable outcome in the unadjusted model [odds ratio (OR) 2.47, 95% confidence interval (CI): 1.32-4.62] and after adjusting for the ICH Score (OR 2.30, 95% CI: 1.06-4.97) but not in the final model (OR 2.04, 95% CI: 0.94-4.42). In the final model, the ICH Score was the only independent negative predictor of outcome (OR 0.26, 95% CI: 0.17-0.41 per point). CONCLUSION: NHOPI are more likely to achieve favorable functional outcome after ICH compared with Asians even after controlling for ICH severity. However, this association was attenuated by the DNR and dementia/cognitive impairment status.

Racial and Ethnic Disparities in Hospital Mortality among Ischemic Stroke Patients in Hawaii.

BACKGROUND: We evaluated disparities in in-hospital mortality rates among whites, Native Hawaiians and other Pacific Islanders (NHOPI), Filipinos, and other Asian groups in Hawaii who were hospitalized for acute ischemic stroke. MATERIALS AND METHODS: Using a statewide hospital claims database, we performed a retrospective study including sequential acute ischemic stroke patients between 2010 and 2015. We compared in-hospital mortality rates among whites, NHOPI, Filipinos, other Asian groups excluding Filipinos, and other races (Blacks, Hispanics, Native Americans, mixed race). RESULTS: A total of 13,030 patient discharges were included in this study. The mean (±SD) age in years at the time of stroke was 63.5 ± 14.3 for NHOPI, 69.6 ± 14.4 for Filipinos, 67.8 ± 14.2 for other race, 71.4 ± 13.8 for whites, and 76.1 ± 13.5 for other Asians (P < .001). NHOPI patients had higher rates of diabetes (48.8%), obesity (18.4%), and tobacco use (31.3%) compared with patients in other racial-ethnic categories. Filipino patients had the highest rate of hemorrhagic transformation (9.7%). Age-adjusted stroke mortality rates were highest among Filipinos (15.9%; 95% confidence interval [CI] = 14.3%-17.6%), followed by other Asian groups (15.1%; 95% CI = 14.0%-16.2%), NHOPI (14.8%; 95% CI = 12.8%-16.8%), other race (14.4%; 95% CI = 11.3%-17.4%), and lowest among whites (12.8%; 11.5%-14.2%). After adjusting for other confounding variables, Filipinos had higher mortality (odds ratio = 1.22, 95% CI = 1.03-1.45), whereas other Asian groups, NHOPI, and other race patients had mortality rates that were similar to whites. CONCLUSION: In Hawaii, Filipino ethnicity is an independent risk factor for higher in-hospital stroke mortality compared with whites.

Insights in Public Health: Ambulatory Blood Pressure Monitoring: Underuse in Clinical Practice in Hawai'i.

Hypertension is one of the leading causes of death and disability worldwide. Blood pressure reduction and control are associated with reduced risk of stroke and cardiovascular disease. To achieve optimal reduction and control, reliable and valid methods for blood pressure measurement are needed. Office based measurements can result in 'white coat' hypertension, which is when a patient's blood pressure in a clinical setting is higher than in other settings, or 'masked' hypertension, which occurs when a patient's blood pressure is normal in a clinical setting, but elevated outside the clinical setting. In 2015, the US Preventative Services Task Force recommended Ambulatory Blood Pressure Monitoring (ABPM) as the "best method" for measuring blood pressure, endorsing its use both for confirming the diagnosis of hypertension and for excluding 'white coat' hypertension. ABPM is a safe, painless and non-invasive test wherein patients wear a small digital blood pressure machine attached to a belt around their body and connected to a cuff around their upper arm that enables multiple automated blood pressure measurements at designated intervals (typically every 15 to 30 minutes) throughout the day and night for a specified period (eg, 24 hours). Patients can go about their typical daily activities wearing the device as much as possible, except when they are bathing, showering, or engaging in heavy exercise. Given the importance of blood pressure monitoring and control to population public health, this article provides details on the relevance and challenges of blood pressure measurement broadly then describes ABPM generally and specifically in the Hawai'i context.

Racial-ethnic Disparities in Postpartum Hemorrhage in Native Hawaiians, Pacific Islanders, and Asians.

The objective of this study was to assess racial-ethnic differences in the prevalence of postpartum hemorrhage (PPH) among Native Hawaiians and other Pacific Islanders (NHOPI), Asians, and Whites. We performed a retrospective study on statewide inpatient data for delivery hospitalizations in Hawai'i between January 1995 and December 2013. A total of 243,693 in-hospital delivery discharges (35.0% NHOPI, 44.0% Asian, and 21.0% White) were studied. Among patients with PPH, there were more NHOPI (37.1%) and Asians (47.6%), compared to Whites (15.3%). Multivariable logistic regression was used to assess the impact of maternal race-ethnicity on the prevalence of PPH after adjusting for delivery type, labor induction, prolonged labor, multiple gestation, gestational hypertension, gestational diabetes, preeclampsia, chorioamnionitis, placental abruption, placenta previa, obesity, and period with different diagnostic criteria for preeclampsia. In the multivariable analyses, NHOPI (adjusted odds ratio [aOR], 1.40; 95% confidence interval [CI], 1.32-1.48) and Asians (aOR, 1.45; 95% CI, 1.37-1.53) were more likely to have PPH compared to Whites. In the secondary analyses of 12,142 discharges with PPH, NHOPI and Asians had higher prevalence of uterine atony than Whites (NHOPI: 77.2%, Asians: 73.9% vs Whites: 65.1%, P < .001 for both comparisons).