A review of predator exclusion fencing to create mainland islands in Hawai'i.

Background: Invasive species are the primary threat to island ecosystems globally and are responsible for approximately two-thirds of all island species extinctions in the past 400 years. Non-native mammals-primarily rats, cats, mongooses, goats, sheep, and pigs-have had devastating impacts on at-risk species and are major factors in population declines and extinctions in Hawai'i. With the development of fencing technology that can exclude all mammalian predators, the focus for some locations in Hawai'i shifted from predator control to local eradication. Methods: This article describes all existing and planned full predator exclusion fences in Hawai'i by documenting the size and design of each fence, the outcomes the predator eradications, maintenance issues at each fence, and the resulting native species responses. Results: Twelve predator exclusion fences were constructed in the Hawaiian Islands from 2011-2023 and six more were planned or under construction; all were for the protection of native seabirds and waterbirds. Fences ranged in length from 304-4,877 m and enclosed 1.2-640 ha. One-third of the 18 fences were peninsula-style with open ends; the remaining two-thirds of the fences were complete enclosures. The purpose of twelve of the fences (67%) was to protect existing bird populations, and six (33%) were initiated for mitigation required under the U.S. Endangered Species Act. Of the six mitigation fences, 83% were for the social attraction of seabirds and one fence was for translocation of seabirds; none of the mitigation fences protected existing bird populations. Rats and mice were present in every predator exclusion fence site; mice were eradicated from five of six sites (83%) where they were targeted and rats (three species) were eradicated from eight of 11 sites (72%). Mongoose, cats, pigs, and deer were eradicated from every site where they were targeted. Predator incursions occurred in every fence. Rat and mouse incursions were in many cases chronic or complete reinvasions, but cat and mongoose incursions were occasional and depended on fence type (i.e., enclosed vs. peninsula). The advent of predator exclusion fencing has resulted in great gains for protecting existing seabirds and waterbirds, which demonstrated dramatic increases in reproductive success and colony growth. With threats from invasive species expected to increase in the future, predator exclusion fencing will become an increasingly important tool in protecting island species.

How COVID-19 Impacted Colonoscopy Utilization and Colorectal Cancer Detection in Hawai'i in 2020.

The Coronavirus Disease of 2019 (COVID-19) pandemic had a profound impact on colorectal cancer (CRC) screening and diagnostic testing. During the initial months of the pandemic, there was a sharp decline in colonoscopies performed as many areas were on lockdown and elective procedures could not be performed. In later months, even when routine procedures started being scheduled again, some patients became fearful of contracting COVID during colonoscopy or lost their health insurance, leading to further delays in CRC diagnosis by colonoscopy. Previous studies have reported the dramatic decrease in colonoscopy rates and CRC detection at various institutions across the country, but no previous study has been performed to determine rates of colorectal screening by colonoscopy in Hawai'i where the demographics of CRC differ. The team investigated the pandemic's impact on colonoscopy services and colorectal neoplasia detection at several large outpatient endoscopy centers in Hawai'i and also classified new CRC cases by patient demographics of age, sex, and ethnicity. There were fewer colonoscopies performed in these endoscopy centers in 2020 than in 2019 and a disproportionate decrease in CRC cases diagnosed. Elderly males as well as Native Hawaiians/Pacific Islanders were most impacted by this decrease in CRC detection. It is possible there will be an increase in later stage presentation of CRC and eventual CRC related mortality among these patients.

Ku Like Kakou: Utilizing a Community-led Model of Collaboration to Respond to the COVID-19 Pandemic.

The outbreak of COVID-19 in 2020 brought significant challenges for Native Hawaiians (NH), Pacific Islanders (PI), and other communities of color worldwide. Rapidly increasing rates of infection and transmission of the virus in Native Hawaiian and Pacific Islander (NHPI) communities and incomplete or unavailable data signaled to Hawai'i's leaders that advocacy and action needed to take place to minimize the impact of COVID-19. The Native Hawaiian and Pacific Islander Response, Recovery, and Resilience team (NHPI 3R Team) emerged from an effort to lead and fill gaps in response to COVID-19. Through the swift, intentional, and collaborative work of the team and its partners, NHPI communities and the entities that serve them were better equipped to navigate the pandemic, improve health outcomes, and contribute to a reduction in the number of infections, a rise in vaccination uptake, and an increase in NH and PI representation on various levels of government agencies. As the world shifts its focus from COVID-19 to broader health topics, the NHPI 3R Team will continue to serve as a hub for the exchange of resources and a model of community-led work that can be used to tackle issues like COVID-19 and beyond.

The Impact of the COVID-19 Pandemic on Older Adults Who Participate in Group Physical Exercise Program.

The COVID pandemic exposed the vulnerability of older adults in myriad ways and social service organizations faced unprecedented challenges in safely providing support for older adults. Since 2007, Hawai'i Healthy Aging Partnership (HHAP) has offered Enhance®Fitness, an evidence-based program to reduce the risk of falls and promote health among older adults. Due to the pandemic, all the Enhance®Fitness sites had to close and stop offering the program. The HHAP started to provide alternative activities remotely in May 2020. To explore the pandemic's impact, the feasibility of online exercise programs, and the support needed among older adults to stay physically active, HHAP surveyed existing Enhance®Fitness participants and received 291 responses (59% response rate). The study used frequency distributions, comparison of means, and chi-square to analyze the survey data. Findings showed that the shutdown of the group exercise program during the pandemic led to a health status decline, a reduction in physical activities, and a shift from group to individual physical activities among older adult participants. Most respondents tried the remote exercise opportunities during the pandemic and would consider joining the remote programs in the future. However, about one-fourth of the respondents did not participate in remote exercise activities due to the lack of electronic devices, internet access, or interest in remote activity formats. To ensure equitable access to physical exercise programs for older adults in the post-pandemic era, it is critical to address the access challenges and resources needed for providing multiple programming options.

Impact of the COVID-19 Pandemic on Inpatient Pediatric Medical Student Education in Hawai'i.

The COVID-19 pandemic has had many effects on medical student education, ranging from safety measures limiting patient exposure to changes in patient diagnoses encountered by medical students in their clerkship experience. This study aimed to identify the impact of the pandemic on the inpatient experiences of third- and fourth-year medical students by assessing patient volumes and diagnoses seen by students. Frequency and types of notes written by medical students on hospital-based pediatric rotations at Kapi'olani Medical Center for Women and Children as well as patient diagnoses and ages were compared between 2 time periods: pre-pandemic (July 2018-February 2020) and pandemic (May 2020-September 2021). On average, the number of patients seen by medical students was significantly reduced in the pandemic period from 112 patients/month to 88 patients/month (P=.041). The proportion of patients with bronchiolitis or pneumonia were also significantly reduced in the pandemic period (P<.001). Bronchiolitis was diagnosed in 1.3% of patients seen by medical students during the pandemic period, compared with 5.9% of patients pre-pandemic. Pneumonia was diagnosed in 1.0% of patients seen by medical students in the pandemic period compared with 4.6% pre-pandemic. There was no significant difference in patient age between the 2 groups (P=.092). During the first 18 months of the COVID-19 pandemic, medical students in this institution had a remarkably different inpatient experience from that of their predecessors. They saw fewer patients, and those patients had fewer common pediatric respiratory diseases. These decreases suggest these students may require supplemental education to compensate for these gaps in direct pediatric clinical experience.

Participant Assessment of an Alternative Flexible Congregate Nutrition Meal Program for Older Adults.

Congregate Nutrition Services have long been a pillar of public health assistance, championing the independence and community engagement of older Americans. The advent of COVID-19, however, restricted access to these services due to the closure of physical locations. In response, Lanakila Meals on Wheels initiated a virtual congregate meal program, Kupuna U, in collaboration with community partners in Honolulu County. The program combined grab-and-go or home-delivered meals with virtual and in-person classes to improve both nutrition and socialization for older adults. This study aimed to capture participant feedback to assess and enhance the Kupuna U program, developing it as a flexible and scalable congregate meal solution applicable nationwide. Five focus group discussions were conducted with program participants (n = 34). The majority of participants were female (74%), Asian (73%), and living alone (56%). Participants found the program beneficial, enhancing their nutrition, social engagement, and learning experiences on various topics tailored for older adults. Supportive staff played a crucial role in motivating participants to stay engaged. Participants also identified potential enhancements to the program, including more activities and courses, expanded hours, additional in-person options at various locations, and culturally tailored meals.

Exploring Native Hawaiian and Pacific Islander Youths' E-Cigarette Resistance Strategies: Implications for Tobacco Product Use Prevention.

This study examined the e-cigarette and vaping resistance strategies used by Native Hawaiian and Pacific Islander (NHPI) youths in rural Hawai'i. Focus groups (N = 17) were conducted in eight geographically dispersed elementary, middle/intermediate, and multilevel schools in low-income communities on Hawai'i Island. Sixty-nine youths (67% NHPI, Mage = 12.5 years) participated in this study. The resistance strategies discussed across the greatest number of groups were "refuse" (saying no), "explain" (providing reasons for vaping refusal), "avoid" (avoiding people or places where e-cigarettes were used), and "leave" (walking away from a situation where e-cigarettes were being used). Participants described the challenges in using these strategies within contexts characterized by widespread peer and family vaping and strong social demands to use e-cigarettes. The findings suggest the need for multi-level interventions based on youths' resistance strategies to meaningfully reduce youth vaping use in rural and/or NHPI communities.

Describing the Medical Needs of Hawai'i's Houseless Population During COVID at Free Student Run Outpatient Clinics (Hawai'i HOME Project).

Hawai'i experiences some of the highest rates of houselessness per capita in the country. COVID-19 has exacerbated these disparities and made it difficult for these individuals to seek medical care. Hawai'i's Houseless Outreach in Medical Education (HOME) clinic is the largest student run free clinic in the state, which provides medical services to this patient population. This article reports the demographics, medical needs, and services provided to patients of Hawai'i's HOME clinic during the era of COVID-19. From September 2020 to 2021, the HOME clinic saw 1198 unique visits with 526 distinct patients. The most common chief complaints included wound care (42.4%), pain (26.9%), and skin complaints (15.7%). A large portion of the population suffered from comorbidities including elevated blood pressure (66%), a formal reported history of hypertension (30.6%), diabetes (11.6%), and psychiatric concerns including schizophrenia (5.2%) and generalized anxiety (5.1%). Additionally, a large portion of patients (57.2%) were substance users including 17.8% of patients endorsing use of alcohol, 48.5% tobacco and 12.5% marijuana. The most common services provided were dispensation of medication (58.7%), wound cleaning/dressing changes (30.7%), and alcohol or other drug cessation counseling (25.2%). This study emphasizes that the houseless are a diverse population with complex, evolving medical needs and a high prevalence of chronic diseases and comorbidities.

Impact of a Fast Pass on Emergency Department Wait Times for Oncology Patients with Febrile Neutropenia.

This pilot study examined differences in wait times for oncology patients who presented to the emergency department, with or without a Fast Pass, for febrile neutropenia (FN). Inadequate circulating neutrophils create a health risk for FN patients. An increased number of patients are receiving chemotherapy in an outpatient setting and may experience delays when seeking treatment in the emergency department. These delays in treatment may be due to overcrowding, patients who require life-saving medical interventions, and inconsistencies in recognizing febrile neutropenia, where fever may be the only presenting sign. The purpose of this study was to measure the impact on wait times, increasing possible risk of bacterial or viral exposure in the emergency department waiting room, for patients with a potential diagnosis of FN who presented their "Fast Pass" from the hospital cancer center's program upon arrival. Electronic medical records were reviewed over a period of 21 months, comparing wait times in the ED for oncology patients with potential FN before and after implementation of the Fast Pass program at an urban medical center in Hawai'i. Of the 1300 oncology patient chart reviews conducted, 6 patients met the study-defined inclusion criteria pre-Fast Pass and 10 met the study-defined inclusion criteria post-Fast Pass. Influence of the use of a Fast Pass on patient wait times was tested using a multivariate regression adjusted for ED patient volume. There were no differences in overall wait times pre- and post-Fast Pass.

A Patient Interview-Based Needs Assessment and Evaluation of Experiences with Periviable Pregnancies.

Given the complex ethical and emotional nature of births during the periviable period for both health care providers and families, this investigation sought to identify strategies for improved counseling of pregnant patients facing preterm birth at the cusp of viability at a tertiary care center in Hawai'i. As part of a larger quality improvement project on periviability counseling, 10 patients were interviewed during either individual or small focus groups using a progression of hypothetical scenarios. Interviews were analyzed independently by 3 investigators to identify themes of patient experience and potential areas for improvement when counseling patients who are carrying periviable pregnancies. Several common themes emerged from the interviews. Patients expressed the desire for more information throughout the process delivered in a jargon-free manner with unified messaging from the medical teams, and emotional support. These findings add to a limited body of literature which addresses patient perceptions of interactions with health care providers in the face of uncertainty, particularly in a Pacific Islander population. The authors recommend increasing provider training and developing a more structured process to counsel pregnant women facing periviable pregnancy loss to improve the patient experience.

Non-destructive identification of varieties of Hawaii-grown avocados using near-infrared spectroscopy: Feasibility studies using bench-top and handheld spectrometers.

Avocados are an important economic crop of Hawaii, contributing to approximately 3% of all avocados grown in the United States. To export Hawaii-grown avocados, growers must follow strict United States Department of Agriculture Animal and Plant Health Inspection Service (USDA-APHIS) regulations. Currently, only the Sharwil variety can be exported relying on a systems approach, which allows fruit to be exported without quarantine treatment; treatments that can negatively impact the quality of avocados. However, for the systems approach to be applied, Hawaii avocado growers must positively identify the avocados variety as Sharwil with APHIS prior to export. Currently, variety identification relies on physical characteristics, which can be erroneous and subjective, and has been disputed by growers. Once the fruit is harvested, variety identification is difficult. While molecular markers can be used through DNA extraction from the skin, the process leaves the fruit unmarketable. This study evaluated the feasibility of using near-infrared spectroscopy to non-destructively discriminate between different Hawaii-grown avocado varieties, such as Sharwil, Beshore, and Yamagata, Nishikawa, and Greengold, and to positively identify Sharwil from the other varieties mentioned above. The classifiers built using a bench-top system achieved 95% total classification rates for both discriminating the varieties from one another and positively identifying Sharwil while the classifier built using a handheld spectrometer achieved 96% and 96.7% total classification rates for discriminating the varieties from one another and positively identifying Sharwil, respectively. Results from chemometric methods and chemical analysis suggested that water and lipid were key contributors to the performance of classifiers. The positive results demonstrate the feasibility of NIR spectroscopy for discriminating different avocado varieties as well as authenticating Sharwil. To develop robust and stable models for the growers, distributors, and regulators in Hawaii, more varieties and additional seasons should continue to be added.

Temporal genomics in Hawaiian crickets reveals compensatory intragenomic coadaptation during adaptive evolution.

Theory predicts that compensatory genetic changes reduce negative indirect effects of selected variants during adaptive evolution, but evidence is scarce. Here, we test this in a wild population of Hawaiian crickets using temporal genomics and a high-quality chromosome-level cricket genome. In this population, a mutation, flatwing, silences males and rapidly spread due to an acoustically-orienting parasitoid. Our sampling spanned a social transition during which flatwing fixed and the population went silent. We find long-range linkage disequilibrium around the putative flatwing locus was maintained over time, and hitchhiking genes had functions related to negative flatwing-associated effects. We develop a combinatorial enrichment approach using transcriptome data to test for compensatory, intragenomic coevolution. Temporal changes in genomic selection were distributed genome-wide and functionally associated with the population's transition to silence, particularly behavioural responses to silent environments. Our results demonstrate how 'adaptation begets adaptation'; changes to the sociogenetic environment accompanying rapid trait evolution can generate selection provoking further, compensatory adaptation.

Coral species-specific loss and physiological legacy effects are elicited by an extended marine heatwave.

Marine heatwaves are increasing in frequency and intensity, with potentially catastrophic consequences for marine ecosystems such as coral reefs. An extended heatwave and recovery time-series that incorporates multiple stressors and is environmentally realistic can provide enhanced predictive capacity for performance under climate change conditions. We exposed common reef-building corals in Hawai'i, Montipora capitata and Pocillopora acuta, to a 2-month period of high temperature and high PCO2 conditions or ambient conditions in a factorial design, followed by 2 months of ambient conditions. High temperature, rather than high PCO2, drove multivariate physiology shifts through time in both species, including decreases in respiration rates and endosymbiont densities. Pocillopora acuta exhibited more significantly negatively altered physiology, and substantially higher bleaching and mortality than M. capitata. The sensitivity of P. acuta appears to be driven by higher baseline rates of photosynthesis paired with lower host antioxidant capacity, creating an increased sensitivity to oxidative stress. Thermal tolerance of M. capitata may be partly due to harboring a mixture of Cladocopium and Durusdinium spp., whereas P. acuta was dominated by other distinct Cladocopium spp. Only M. capitata survived the experiment, but physiological state in heatwave-exposed M. capitata remained significantly diverged at the end of recovery relative to individuals that experienced ambient conditions. In future climate scenarios, particularly marine heatwaves, our results indicate a species-specific loss of corals that is driven by baseline host and symbiont physiological differences as well as Symbiodiniaceae community compositions, with the surviving species experiencing physiological legacies that are likely to influence future stress responses.

Interannual variability in marine debris accumulation on Hawaiian shores: The role of North Pacific Ocean basin-scale dynamics.

Community-based marine debris removal efforts on the Hawaiian Islands of Kaua'i and Hawai'i, spanning 2013-2022, provided large datasets and documented remarkable variations in annual amounts of debris, mainly from abandoned, lost and derelict fishing gear. To test the hypothesis that the influx of marine debris on Hawaiian shores is determined by the proximity of the North Pacific garbage patch, whose pattern changes under the control of large-scale ocean dynamics, we compared these observational data with the output of an oceanographic drift model. The high correlations between the total mass of debris collected and the model, ranging between r = 0.81 and r = 0.84, validate the attribution of the strong interannual signal to significant migrations of the garbage patch reproduced in the model experiments. Synchronous variations in marine debris fluxes on the two islands, separated by >500 km, confirm the large scale of the interannual changes in the North Pacific marine debris system.

Detection and modeling of Staphylococcus aureus and fecal bacteria in Hawaiian coastal waters and sands.

Microbial pollution of recreational waters leads to millions of skin, respiratory, and gastrointestinal illnesses globally. Fecal indicator bacteria (FIB) are monitored to assess recreational waters but may not reflect the presence of Staphylococcus aureus, a global leader in bacterial fatalities. Since many community-acquired S. aureus skin infections are associated with high recreational water usage, this study measured and modeled S. aureus, methicillin-resistant S. aureus (MRSA), and FIB (Enterococcus spp., Clostridium perfringens) concentrations in seawater and sand at six beaches in Hilo, Hawai'i, USA, over 37 sample dates from July 2016 to February 2019 using culturing techniques. Generalized linear models predicted bacterial concentrations with physicochemical and environmental data. Beach visitors were also surveyed on their preferred activities. S. aureus and FIB concentrations were roughly 6-78 times higher at beaches with freshwater discharge than at those without. Seawater concentrations of Enterococcus spp. were positively associated with MRSA but not S. aureus. Elevated S. aureus was associated with lower tidal heights, higher freshwater discharge, onsite sewage disposal system density, and turbidity. Regular monitoring of beaches with freshwater input, utilizing real-time water quality measurements with robust modeling techniques, and raising awareness among recreational water users may mitigate exposure to S. aureus, MRSA, and FIB. PRACTITIONER POINTS: Staphylococcus aureus and fecal bacteria concentrations were higher in seawater and sand at beaches with freshwater discharge. In seawater, Enterococcus spp. positively correlated with MRSA, but not S. aureus. Freshwater discharge, OSDS density, water turbidity, and tides significantly predicted bacterial concentrations in seawater and sand. Predictive bacterial models based upon physicochemical and environmental data developed in this study are readily available for user-friendly application.

Understanding Hawaiian Identity and Well-being to Improve Mental Health Outcomes for Hawaiian Young Adults.

The mental health crisis among Native Hawaiian young adults is exacerbated by colonization-related risk factors, yet cultural identity stands as a key protective element. This study explored the link between cultural identity and stress, employing cultural reclamation theory, and surveyed 37 Native Hawaiians aged 18-24 through the Native Hawaiian Young Adult Well-being Survey. Engagement with culture, the significance of Hawaiian identity, and stress were assessed, revealing significant correlations between cultural and demographic factors and stress levels. Participants displayed high cultural engagement and valued their Hawaiian identity, with gender and education levels playing a notable role in stress. These findings highlight the importance of including Native Hawaiian perspectives in mental health research and may guide the development of targeted interventions.

Historical Inequities in Medical Education - Commitment to Opportunity, Diversity, and Equity at the University of Hawai'i School of Medicine.

Medical education in the US has contributed to institutionalized racism through historically exclusionary practices, which has led to health disparities and inequities in health care today. The 1910 Flexner report, which favored schools with greater resources, led to the closure of nearly half of medical schools in the Us, which were mostly small schools located in rural communities that served economically disadvantaged, ethnic minority, and female populations. Closing these schools ultimately limited the availability of physicians willing to serve disadvantaged and minority populations in impoverished and underserved communities. In order to transform medical education to be more equitable, medical schools must be proactive in opportunity, diversity, and equity efforts. This not only includes efforts in admissions and faculty hiring, but also curricula related to social and health disparities, interracial interactions between students and faculty, and service learning activities that engage and work with marginalized communities. The University of Hawai'i John A. Burns School of Medicine has a longstanding commitment to diversity, which is integral to the school's mission. Providing opportunities to underserved populations has been a priority since establishment of the school. As one of the most diverse univeristies in the US, the school of medicine continues to focus on opportunity, diversity, and equity priorities in both its strategic planning and overall mission.

'Tausi Feagaiga: A Project to Train Caregivers and Empower the American Samoan Community.

The 'Tausi Feagaiga (Covenant Keeper) project was a partnership to support the traditional values of tausi matua (caring for one's elders). The partners included a non-governmental organization (Pacific Youth and Community Development), a faith-based organization (Roman Catholic Diocese of Samoa-Pago Pago), and an institute of higher education (University of Hawai'i John A. Burns School of Medicine). The project was created to address the lack of community-based health care such as home health or hospice, and families needing to work outside the home. A culturally based caregiving curriculum was developed to educate caregivers and improve their knowledge and skills. Using a train-the-trainer model, 125 caregivers were trained in family caregiving from 2016-2020. Training was conducted through an intensive workshop followed by practicum at Hope House, the Catholic Diocese home for the aged. Participants who expressed a willingness and competency were mentored to be trainers to continue the 'Tausi Feagaiga project. The mean self-rated confidence in caregiving improved significantly from 3.17 ± 1.02 (mean SD) pre workshop to 3.53 ± 0.71 post workshop (P = .001). Competence in geriatric syndromes was improved from 18.04 ± 4.27 to 21.31 ± 4.30 after attending the workshop (P < .001) and the feedback was extremely positive. Technical assistance was provided to obtain funding through American Samoa Medicaid State Agency to improve the existing infrastructure of Hope House, obtain much needed supplies, and increase ability to hire the participants. 'Tausi Feagaiga positively impacted the lives of the residents of Hope House, the course participants, the elders in the community, and those who care for them.