Orthopedic surgery in Palau-Current capacity, needs, and future directions.

BACKGROUND: Palau, an island nation in Micronesia, is a medically underserved area with a shortage of specialty care services. Orthopedic diagnoses in Palau remain among the three most common reasons for costly off-island medical referral. The purpose of this study was to assess Palau's current orthopedic surgery capacity and needs to inform interventions to build capacity to improve care access and quality. METHODS: Orthopedic needs and capacity assessment tools developed by global surgical outreach experts were utilized to gather information and prompt discussions with a broad range of Palau's most knowledgeable stakeholders (n = 6). Results were reported descriptively. RESULTS: Finance, community impact, governance, and professional development were the lowest-scored domains from the Capacity Assessment Tool for orthopedic surgery (CAT-os), indicating substantial opportunity to build within these domains. According to administrators (n = 3), governance and finance were the greatest capacity-building priorities, followed by professional development and partnership. Belau National Hospital (BNH) had adequate surgical infrastructure. Skin grafting, soft tissue excision/resection, infection management, and amputation were the most commonly selected procedures by stakeholders reporting orthopedic needs. CONCLUSIONS: This study utilizes a framework for orthopedic capacity-building in Palau which may inform partnership between Palau's healthcare system and orthopedic global outreach organizations with the goal of improving the quality, safety, and value of the care delivered. This demonstration of benchmarking, implementation planning, and subsequent re-evaluation lays the foundation for the understanding of capacity-building and may be applied to other medically underserved areas globally to improve access to high-quality orthopedic care.

Chemical composition, anticancer, antimicrobial activity of Aloysia citriodora Palau essential oils from four different locations in Palestine.

The primary aim of this investigation was to determine the anticancer and antimicrobial properties of essential oils (EOs) extracted from the leaves of Aloysia citriodora Palau, which were procured from four separate locations in Palestine, in addition to analyzing their chemical composition. These areas include Jericho, which has the distinction of being the lowest location on Earth, at 260 m below sea level. The EOs were acquired by hydrodistillation, and their chemical composition was examined utilizing gas chromatography-mass spectrometry (GC-MS). The minimum inhibitory concentration (MIC) of EOs was assessed against six bacterial strains and one fungal species using 96-well microtiter plates. The primary components found in these oils are geranial (26.32-37.22%), neral (18.38-29.00%), and α-curcumene (7.76-16.91%) in three regions. α-Curcumene (26.94%), spathulenol (13.69%), geranial (10.79%), caryophyllene oxide (8.66%), and neral (7.59%) were found to be the most common of the 32 chemical components in the EO from Jericho. The EOs exhibited bactericidal properties, particularly against Staphylococcus aureus, methicillin-resistant Staphylococcus aureus (MRSA), and showed highly effective fungicidal activity. Nevertheless, the antifungal efficacy of the EO was found to surpass its antibacterial activity when administered at lower dosages. The EOs exhibited anticancer activities against melanoma cancer cells, as indicated by their IC50 values, which ranged from 4.65 to 7.96 µg/mL. A. citriodora EO possesses substantial antifungal and anticancer characteristics, rendering it appropriate for utilization in food-related contexts, hence potentially enhancing the sustainability of the food sector.

Toward Healthy Aging in Palau.

BACKGROUND AND OBJECTIVES: Palau is facing a rapidly aging population and developing a comprehensive national aging policy to address the growing needs of older adults, but more research is needed to understand their circumstances and needs in relation to healthy aging. This study aims to investigate these factors and contribute to developing the National Policy on Care for the Aging. RESEARCH DESIGN AND METHODS: The study adopted a participatory action research design and included focus groups with older adults, public consultations, and stakeholder interviews, providing insights into the needs of an aging population and how to address them. Thematic analysis was conducted to understand the experiences and needs of older adults and possible system changes to address these needs. RESULTS: This study identified the need to recognize cultural changes and optimize social and physical environments to improve the health and well-being of older adults. Older adults are valued in Palauan society, but harmful stereotypes and mistreatment of older adults exist. To address those needs and challenges, our stakeholders proposed a range of services, programs, and policies across sectors to create a healthy-enabling environment. Our findings also highlight the importance of health systems proactively reaching individuals and families to address lifelong health needs. DISCUSSION AND IMPLICATIONS: Our results show the vital role of various sectors in fostering healthy aging and the importance of environmental and cultural perspectives in creating an age-friendly society, which can be an inspiration for other Pacific Island countries.

Dental Health Utilization in Palau: Feasibility of an Oral Cancer Screening Program.

Background: Cancer is the second leading cause of death in the Western Pacific region. The prevalent tradition of chewing betel nut in Palau, an island nation in this region, is a risk factor in the development of oral cancer. Oral cancer is the fifth most common cancer in Palau, and the prognosis can be improved with early detection facilitated by visual inspection of the oral cavity by dentists. The purpose of this study is to assess the feasibility of oral cancer screening using existing dental health infrastructure in Palau. Methods: A mixed methods approach was used to explore topics related to the use of dental care resources in Palau. Primary outcome measures were collected using an electronic survey with closed- and open-ended questions addressing dental health utilization as well as barriers and facilitators to accessing dental care. Secondary measures assessed knowledge, attitudes, and beliefs about betel nut use and oral cancer. Open-ended survey questions were analyzed and coded to develop themes based in grounded theory. Results: Two hundred twenty-three surveys were completed. The mean age was 42.7 years, 80% identified as female, and most (94.3%) report having seen a dentist in Palau. Dental care is seen as important (mean score 82.3/100), and 57.9% reported it was easy to access a dentist. Themes regarding facilitators include multilevel resources and transportation. Themes regarding barriers include cost and availability of dentists/appointments. Approximately half of the respondents were current users of betel nut. Conclusion: Our results suggest facilitators are in place to promote seeking and obtaining dental care; however, existing infrastructure may not support an oral cancer screening program. These data provide important areas to address that can improve access and support the implementation of oral cancer screening through existing dental care in the future.

Patient Characteristics During Early Transmission of SARS-CoV-2, Palau, January 13-February 24, 2022.

Palau had no reported evidence of COVID-19 community spread until January 2022. We chart reviewed hospitalized patients who had a positive SARS-CoV-2 test result during early community transmission. Booster vaccinations and early outpatient treatment decreased hospitalizations. Inadequate hospital infection control practices contributed to iatrogenic COVID-19 and preventable deaths.

Sociodemographic and behavioral factors related to obesity among adults in the Republic of Palau based on the WHO STEPwise approach to NCD risk factor surveillance 2011-2013: A cross-sectional study.

BACKGROUND: Pacific islanders face drastic increase of obesity-related noncommunicable disease (NCD) due to lifestyle shifts of unhealthy diets and physical inactivity. To date, however, obesity related factors have not been well elucidated in Republic of Palau. This study aimed to investigate sociodemographic and behavioral factors related to obesity using the national level data in Palau. METHODS: This is a cross-sectional, population-based study analyzing random sampling data of 2133 adults aged 25-64 years (of 20 thousand national population) from the WHO STEPwise approach to NCD risk factor surveillance (STEPS) implemented between 2011 and 2013. Sociodemographic and behavioral factors were obtained by the STEPS standardized questionnaire for NCD risk factors plus the question on betel nut chewing because of its common behavior in Micronesian countries. Logistic regression analysis was performed to estimate multivariable odds ratio (OR) of general obesity (body mass index ≥30.0 kg/m2) and central obesity (waist circumference ≥90 cm in men and ≥80 cm in women). RESULTS: Means of body mass index, prevalence of general obesity and central obesity were higher in women (29.9 kg/m2, 45.5% and 85.4%) than in men (29.3 kg/m2, 40.4% and 67.6%). After adjusted by other potential factors, native Palauan (OR 4.4, 95% CI, 2.7-7.0 for men and 3.6, 2.3-5.6 for women), betel nut chewing (1.5, 1.1-2.1 for men and 1.6, 1.2-2.3 for women), men who work at government office (1.6, 1.2-2.1), women with higher household income (1.4, 1.0-1.8) were positively associated with general obesity, while frequent vegetable intake were inversely associated with it among women (0.71, 0.54-0.93). Similar associations were observed between the aforementioned factors and central obesity. CONCLUSIONS: Native Palauan, people with betel nut chewing behavior, government employment and higher income appeared to be associated with obesity, while frequent vegetable consumption were inversely associated with obesity. Further interventions for prevention and control of obesity are necessary through the enhancing public relation activities to understand harmful health effects on betel nuts chewing and recommending domestic production of vegetables.

Volatile Compounds and Biological Activity of the Essential Oil of Aloysia citrodora Paláu: Comparison of Hydrodistillation and Microwave-Assisted Hydrodistillation.

Aromatic plants are a remarkable source of natural products. Aloysia citrodora Paláu (Verbenaceae), commonly known as lemon verbena, is a relevant source of essential oils with potential applications due to its lemony scent and bioactive properties. Studies carried out on this species have focused on the volatile composition of the essential oil obtained by Clevenger hydrodistillation (CHD), with little information available on alternative extraction methodologies or the biological properties of the oil. Therefore, this work aimed to compare the volatile composition, antioxidant activity, cytotoxicity, anti-inflammatory and antibacterial activities of the essential oil extracted by conventional hydrodistillation by Clevenger (CHD) and Microwave-Assisted Hydrodistillation (MAHD). Significant differences (p < 0.05) were observed for some compounds, including the two major ones, geranial (18.7-21.1%) and neral (15.3-16.2%). Better antioxidant activity was exhibited by the MAHD essential oil in DPPH radical scavenging and reducing power assays, while no differences were observed in the cellular antioxidant assay. The MADH essential oil also presented higher inhibition against four tumoral cell lines and exhibited lower cytotoxicity in non-tumoral cells as compared with Clevenger-extracted essential oil. In contrast, the latter showed higher anti-inflammatory activity. Both essential oils were able to inhibit the growth of eleven out of the fifteen bacterial strains tested.

Palau's warmest reefs harbor thermally tolerant corals that thrive across different habitats.

Ocean warming is killing corals, but heat-tolerant populations exist; if protected, they could replenish affected reefs naturally or through restoration. Palau's Rock Islands experience consistently higher temperatures and extreme heatwaves, yet their diverse coral communities bleach less than those on Palau's cooler outer reefs. Here, we combined genetic analyses, bleaching histories and growth rates of Porites cf. lobata colonies to identify thermally tolerant genotypes, map their distribution, and investigate potential growth trade-offs. We identified four genetic lineages of P. cf. lobata. On Palau's outer reefs, a thermally sensitive lineage dominates. The Rock Islands harbor two lineages with enhanced thermal tolerance; one of which shows no consistent growth trade-off and also occurs on several outer reefs. This suggests that the Rock Islands provide naturally tolerant larvae to neighboring areas. Finding and protecting such sources of thermally-tolerant corals is key to reef survival under 21st century climate change.

Plastics are a new threat to Palau's coral reefs.

Plastic pollution of the oceans has long been an ongoing and growing problem. Single-use plastic (plastic bags and microbeads) is responsible for most of this pollution. In recent years, studies have highlighted the importance of the size of plastic particles, and the impact of this pollution source on the environment. We determined the concentration of small marine plastics in seawater, sediments and beach sand around a pristine reef area (Republic of Palau) using very simple tools (plankton net, sieves, organic matter degradation, density separation, Nile red fluorochrome). In this study, we succeeded in detecting microplastic (MPs) particles and microplastic fibers, but also nanoplastic (NPs). These three types of particles were found in all samples with a large heterogeneity, from 0.01 to 0.09 particles L-1 and 0.17 to 32.13 particles g-1 DW for MPs in seawater, sediments and sand, respectively. Even when NPs were identified, the amounts of NPs were underestimated and varied from 0.09 to 0.43 particles L-1 in seawater and from 1.08 to 71.02 particles g-1 DW in sediment and sand, respectively. These variations could be attributed to the environmental characteristics of the different sites. This study shows that plastic pollution must be considered in environmental studies even in the most pristine locations. It also shows that NPs pollution is related to the amount of MPs found at the sites. To understand the effects of this plastic pollution, it is necessary that the next toxicological studies take into account the effects of this fraction that makes up the NPs.

The Current Status of Telehealth and Distance Learning in Palau.

In 2017 the Republic of Palau installed fiber optic cables, allowing access to high speed internet for the first time and the capacity for growth in telehealth. Given Palau's poor access to specialists and resources, telehealth has the potential to radically change health care delivery. Currently, the status of telehealth in Palau is unknown. This study describes telehealth resources utilized at the Ministry of Health in Palau and potential future directions for telehealth. Thirty-four people, mostly health professionals at the Belau National Hospital in Palau were interviewed, including physicians, information technology personnel, public health department staff, department managers of allied health, and telehealth experts in the Pacific. Standardized questions and surveys were conducted in-person during July 2019. All departments utilized some form of telehealth. Common needs for the advancement of telehealth included: a telehealth champion, a resource facilitator, successful distance learning for auxiliary staff, dedicated telehealth space, technological help, and better telehealth communication with rural clinics. Survey respondents indicated that they would like to use some sort of distance learning, most commonly for professional betterment (86%) and upskilling of staff (86%). There are numerous distance learning and telehealth opportunities available, yet recurrent barriers to these opportunities were noted across all departments. The barriers identified in the current study and recommendations to overcome them may be applicable to other Pacific nations who face similar challenges.

A new species of Trimma (Pisces: Gobiidae) from the deep reefs of Palau, western Pacific Ocean.

A new species of Trimma is described from three specimens from deep reefs (91.4 m) at Uchelbeluu Reef, Palau, western Pacific Ocean. Trimma panemorfum n. sp. is characterized by a live colouration of a yellow to orange body with two light blue stripes, each with a ventral bar of the same colour from the anterior origin. The predorsal midline is scaled, opercular and cheek scales are absent, the middle 1213 pectoral-fin rays are branched, the fifth pelvic-fin ray has two dichotomous branch points (total of four branch tips), the bony interorbital is 3442% pupil width and does not extend ventrolaterally beyond the fifth papilla of row p, where the posterior interorbital trench is present as a slight groove or absent.

Epidemiology of dermatologic disease in Palau: a cross-sectional study in the national public and community health service.

BACKGROUND: Dermatologic disease is a neglected public health challenge that disproportionately affects resource-poor settings. Globally, dermatologic disease contributes the fourth highest burden of nonfatal disability with the most acute impact in the Oceanic region, including the Republic of Palau. Efforts to address the dermatologic health inequality are hindered without the necessary epidemiologic evidence to guide health policy in the resource-poor setting of Palau. METHODS: We conducted a 4-year cross-sectional study of all Dermatology Service patients in the Belau National Hospital and outreach community health centers from 2015 to 2018. No other specialized dermatology service was available. Skin disease was classified by both diagnosis and Global Burden of Disease criteria and analyzed by age, gender, region, and surrounding Oceanic nations. RESULTS: The study enrolled 494 patients comprising 179 males and 315 females between 2015 and 2018. The most prevalent diseases were eczema (48.8%), superficial fungal infection (24.5%), and pruritus (22.7%). The neglected tropical disease of scabies was detected in four patients. Males were significantly more likely to present with cellulitis, keratinocyte carcinoma, stasis dermatitis, wounds, marine-related dermatitis, viral skin disease, tinea faciei, verruca, and xerosis and females with melasma and hyperpigmentation. CONCLUSION: This study presents the first primary epidemiologic data describing the prevalence of dermatologic disease in the Palauan adult population. The significant burden of disease in Palau compared with other Oceanic nations validates ongoing dermatology services and informs public health implications for resource allocation and disease management to achieve health equality in the resource-poor nation.

Essential oil of Aloysia citriodora Paláu and citral: sedative and anesthetic efficacy and safety in Rhamdia quelen and Ctenopharyngodon idella.

OBJECTIVE: To verify the efficacy of citral in inducing sedation and anesthesia in silver catfish (Rhamdia quelen) and grass carp (Ctenopharyngodon idella) and to assess the safety of essential oil (EO) of Aloysia citriodora and citral in inducing and maintaining anesthesia in silver catfish. STUDY DESIGN: Clinical study, randomized, parallel, multi-arm with control group in target species. ANIMALS: A total of 96 juvenile and 72 adult silver catfish and 80 juvenile grass carp were used. METHODS: Silver catfish and grass carp were exposed to different concentrations of citral, 15-675 and 15-600 µL L-1, respectively, during the maximum period of 30 minutes to verify sedation and anesthesia induction and recovery times. In addition, for anesthetic induction, silver catfish were exposed to the EO of A. citriodora and citral at 225 µL L-1 for 3.5 minutes. Then, fish were transferred to an anesthesia maintenance solution at 50 µL L-1 for 10 minutes to assess hematologic and biochemical variables at 60 minutes, 2 and 6 days after treatment. RESULTS: Citral only induced sedation from 15, 25 and 40 µLL-1 in both species. Anesthesia without mortality was induced in silver catfish at 50-600 µL L-1 and grass carp at 75-450 µL L-1. At 675 and 600 µL L-1, mortality was recorded in silver catfish and grass carp, respectively. The EO of A. citriodora and citral were safe in inducing and maintaining anesthesia in silver catfish, with mean corpuscular hemoglobin concentration being the only variable that varied in relation to time and treatments. CONCLUSIONS AND CLINICAL RELEVANCE: Citral was effective in inducing sedation and anesthesia in both species. In addition, A. citriodora EO and citral were safe in inducing and maintaining anesthesia in silver catfish. Both agents are promising substances for the development of new drugs for fish.

An overview of the genus Aloysia Paláu (Verbenaceae): Essential oil composition, ethnobotany and biological activities.

Aloysia Paláu is an important herbal genus from the Verbenaceae family and possesses numerous remedial properties in the folk medicine of Asian, European, and, in particular, South American countries. Only a few reports have discussed some phytochemical characteristics associated with Aloysia species. Right the lack of an exhaustive report prompted us to organize this review article. Accordingly, besides the ethnobotanical knowledge of Aloysia species, their essential oil profiles, phytochemistry of the polar isolated fractions, and the relevant biological activities are discussed in detail.[Formula: see text].

Caught between Worlds: Assessing Generational Change in Palauan Foodways Post-Independence.

Palauan foodways have changed significantly over the last 100 years. Current nutritional norms in Palau have led to increased prevalence of nutrition-based noncommunicable disease. While generational change in Palauan foodways in the decades immediately following World War II has been documented, less attention has been paid to change since national independence. Parents, teachers, and students at Palauan elementary schools participated in focus groups designed to advance understanding of the current state of Palauan nutrition across generations at home, school, and elsewhere (including after-school snacks and ritual events). We document these perspectives and share Palauan ideas for improving local nutrition.

Confirmation of Oryctes rhinoceros nudivirus infections in G-haplotype coconut rhinoceros beetles (Oryctes rhinoceros) from Palauan PCR-positive populations.

Coconut rhinoceros beetle (CRB), Oryctes rhinoceros, is a pest of palm trees in the Pacific. Recently, a remarkable degree of palm damage reported in Guam, Hawaii, Papua New Guinea and Solomon Islands has been associated with a particular haplotype (clade I), known as "CRB-G". In the Palau Archipelago, both CRB-G and another haplotype (clade IV) belonging to the CRB-S cluster coexist in the field. In this study, more than 75% of pheromone trap-captured adults of both haplotypes were Oryctes rhinoceros nudivirus (OrNV)-positive by PCR. No significant difference in OrNV prevalence between the haplotypes was detected. In PCR-positive CRB-G tissue specimens from Palau, viral particles were observed by electron microscopy. Hemocoel injection of CRB larvae with crude virus homogenates from these tissues resulted in viral infection and mortality. OrNV isolated from Palauan-sourced CRB was designated as OrNV-Palau1. Both OrNV-Palau1 and OrNV-X2B, a CRB biological control isolate released in the Pacific, were propagated using the FRI-AnCu-35 cell line for production of inoculum. However, the OrNV-Palau1 isolate exhibited lower viral production levels and longer larval survival times compared to OrNV-X2B in O. rhinoceros larvae. Full genome sequences of the OrNV-Palau1 and -X2B isolates were determined and found to be closely related to each other. Altogether these results suggest CRB adults in Palau are infected with a less virulent virus, which may affect the nature and extent of OrNV-induced pathology in Palauan populations of CRB.

Widespread variation in heat tolerance and symbiont load are associated with growth tradeoffs in the coral Acropora hyacinthus in Palau.

Climate change is dramatically changing ecosystem composition and productivity, leading scientists to consider the best approaches to map natural resistance and foster ecosystem resilience in the face of these changes. Here, we present results from a large-scale experimental assessment of coral bleaching resistance, a critical trait for coral population persistence as oceans warm, in 221 colonies of the coral Acropora hyacinthus across 37 reefs in Palau. We find that bleaching-resistant individuals inhabit most reefs but are found more often in warmer microhabitats. Our survey also found wide variation in symbiont concentration among colonies, and that colonies with lower symbiont load tended to be more bleaching-resistant. By contrast, our data show that low symbiont load comes at the cost of lower growth rate, a tradeoff that may operate widely among corals across environments. Corals with high bleaching resistance have been suggested as a source for habitat restoration or selective breeding in order to increase coral reef resilience to climate change. Our maps show where these resistant corals can be found, but the existence of tradeoffs with heat resistance may suggest caution in unilateral use of this one trait in restoration.

Perceptions and behaviors related to noncommunicable diseases in Palau: a qualitative study.

The increasing burden of noncommunicable diseases (NCDs) is a major public health concern in Palau. This study aims to identify social and psychological factors related to NCDs among Palauan people using a qualitative approach. We conducted eight key informant interviews and eight focus group discussions, which were audio-recorded, transcribed and translated into English. Ideas of the respondents were extracted and labeled, and the labels were analyzed using an inductive multistage approach referred to as qualitative content analysis. Three themes emerged: (1) home education, (2) traditional local community, and (3) modernization and westernization of lifestyle. Respondents believed that the influence of the family on lifestyle was significant, but that disciplining children at home had become difficult. They considered that the traditional lifestyle was mostly healthy, and were reluctant to abandon certain unhealthy customs, such as serving abundant food to guests as a sign of fraternity. They also thought that they overate because of their stressful modernized lifestyle. This is the first qualitative study to analyze perception and behavior of the Palauan people in relation to NCDs. We found that the increase in NCDs was related to two concurrent trends: preserving certain traditional customs unfavorable to good health, and abandoning time-consuming healthy traditional lifestyle to adopt a modernized one. We also found that Palauan people were not confident in their ability to prevent NCDs. Therefore, health promotion activities should be designed to empower people to make positive changes.