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.

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.

Pacific Islands Cohort on Cardiometabolic Health Study: rationale and design.

BACKGROUND: Pacific Islanders, including those residing in the US Affiliated Pacific Islands (USAPI), experience some of the highest mortality rates resulting from non-communicable diseases (NCDs) worldwide. The Pacific Island Health Officers' Association declared a Regional State of Health Emergency in 2010 due to the epidemic of NCDs in the USAPI. Obesity, a known risk factor for NCDs, has become an epidemic among both children and adults in Micronesia and other parts of the USAPI. There is some recent information about overweight and obesity (OWOB) among young children in the USAPI, but there is no data looking at the relationship between children and their biological parents. The Pacific Islands Cohort on Cardiometabolic Health (PICCAH) Study aims to collect data on NCD lifestyle factors from two generations of families (n = 600 child-parent dyads or 1,200 participants) living in Guam, Pohnpei, and Palau. METHODS: The PICCAH Study is an epidemiological study using community-based convenience sampling to recruit participants in USAPI of Guam, Palau, and Pohnpei. The goal is to recruit participant dyads consisting of 1 child plus their biological parent in Guam (500 dyads or 1,000 participants), Pohnpei (50 dyads or 100 participants), and Palau (50 dyads or 100 participants). All participants are having the following information collected: demographic, health, and lifestyle information; anthropometry; diet; physical activity; sleep; acanthosis nigricans; blood pressure; and serum levels of fasting plasma glucose, fasting insulin, glycated hemoglobin, total cholesterol, triglycerides, LDL, and HDL. DISCUSSION: The PICCAH Study is designed to establish the baseline of a generational epidemiologic cohort with an emphasis on cardiometabolic risk, and to better understand the extent of DM and CVD conditions and related risk factors of those living in the USAPI jurisdictions of Guam, Pohnpei, and Palau. This study also serves to further build research capacity in the underserved USAPI Region.

Holy Water.

Holy Water explores the infiltration of colonization on my home island, Belau, and the impact that it has had on our relationships to each other, our health, and our indigenous ways of knowing and being. I intentionally use baptism and Western Christianity as a metaphor for colonization to highlight the effect White supremacy has had on my people, while also challenging the ways in which we take part in continuing our colonial reality. I often run into contradictions about what Western culture deems we should be and who we actually are as Palauans-birthing this story of struggle into reclamation. This piece continually addresses the subject "unko," to highlight the tensions between myself, a queer femme diasporic micronesian, and the elder men in my community who have been forced into Westernization, and therefore enforce those same values and societal norms on my expression of self. I believe in radical self love and community care. I honor my ancestors and their fight for our liberation, and carry their legacy into my own journey. The health of my community depends on our ability to think critically about where we've been, who we are, and where we want to be. Holy Water is a testament to the reclamation of our stories, our history, and our collective power. To view the original version of this poem, see the supplemental material section of this article online.

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.

Determinants of alcohol consumption and marijuana use among young adults in the Republic of Palau.

BACKGROUND: This study aimed to describe the status of alcohol consumption and drug use among young adults as well as their determinants. METHODS: We conducted a cross-sectional study of 356 young adults (aged 18 to 24 years) living in Palau in 2013. The prevalence of self-reported alcohol and marijuana usage were compared within and between sexes, age groups, ethnicities, and education levels. RESULTS: The proportion of current drinking was higher in people aged 21-24 than in those aged 18-20 (73.2% vs. 60.9%, p = 0.09 in men and 48.3% vs. 30.0%, p = 0.02 in women), while that of marijuana use did not differ between the age groups. The proportions of current drinking and marijuana use were higher in Palauan than in other ethnicities (current drinking: 70.6% vs. 40.6%, p = 0.005 in men and 38.8% vs. 16.6%, p = 0.04 in women; lifetime marijuana use: 80.0% vs. 52.9%, p = 0.02 in men and 56.1% vs. 30.6%, p = 0.09 in women). The proportion of frequent (3 times or more) marijuana users was higher for the lower educated than for the higher educated (62.5% vs. 32.1%, p < 0.001 in men and 33.9% vs. 24.4%, p = 0.12 in women). CONCLUSIONS: Sex, age, ethnicity, and education were significant determinants of alcohol and marijuana use.

Prevalence and Correlates of Dyslipidemia Among Men and Women in Palau: Findings of the Palau STEPS Survey 2011-2013.

BACKGROUND: Epidemiological evidence of dyslipidemia in Pacific Island countries is limited despite the knowledge that non-communicable diseases have a high burden in the region. We aimed to examine the prevalence and correlates of dyslipidemia among residents of Palau. METHODS: The Palau STEPwise approach to Surveillance (STEPS), which was conducted from 2011 through 2013, comprised three parts: behavioral risk factors; physical measurements; and biochemical tests, covering areas such as blood lipids. We used STEPS-generated data to perform a cross-sectional study of 2,184 randomly selected Palau residents, comprising Palauans and non-Palauans aged 25-64 years. RESULTS: The age-adjusted mean BMI was 29.3 kg/m2 in men and 29.9 kg/m2 in women; age-adjusted mean triglycerides value was 182 mg/dL in men and 166 mg/dL in women; and age-adjusted mean cholesterol was 178 mg/dL in men and 183 mg/dL in women. The prevalence of overweight/obesity (BMI ≥25 kg/m2) was 75% in men and 76% in women, and those of hypertriglyceridemia (triglycerides ≥150 mg/dL) and hypercholesterolemia (total cholesterol ≥200 mg/dL) were 48% in men and 41% in women and 18% in men and 23% in women, respectively. Mean values of total cholesterol were 177 mg/dL in Palauan men and 182 mg/dL in non-Palauan men. Mean values of triglycerides were 171 mg/dL in Palauan women and 150 mg/dL in non-Palauan women. Women living in rural areas showed a higher mean value of total cholesterol than those in urban areas. CONCLUSION: We found a high mean BMI and high prevalence of overweight/obesity and hypertriglyceridemia, but low mean total cholesterol and a low prevalence of hypercholesterolemia in Palau. Lipid profiles varied by age, ethnicity, and living area.

Conservation Decision-Making in Palau: An Example of the Parallel Working of Scientific and Traditional Ecological Knowledge.

Despite unprecedented knowledge of conservation science, loss of biodiversity continues on a global scale. In this study, we investigate how choices are exercised where science, local and traditional knowledge come together for conservation decision-making. Our case study is the Palau Protected Areas Network, a program established to support conservation in the Pacific island nation of Palau. We apply a framework based on the concept of knowledge governance to explore the rules and norms that shape the relationships between knowledge and decision-making across both customary and Western-styled institutional lines. The major practical implications from this study are that: (1) there are internal and external audiences for Palauan conservation, (2) these audiences are associated with different expectations around what makes knowledge a legitimate basis for action, (3) the current conservation system operates in parallel, with science informing largely external audience and local and traditional knowledge speaking more directly to internal audiences and (4) this parallel system is likely to come under increasing pressure as the audiences for conservation change.

Assessment of Gestational Diabetes and Associated Risk Factors and Outcomes in the Pacific Island Nation of Palau.

Objective Gestational diabetes mellitus (GDM) in Palau and across the Pacific Islands is a serious public health issue that is currently understudied. Methods This study was a retrospective cohort study that included 1730 women with a single live birth in Palau between January 2007 and December 2014. Results The overall prevalence of GDM among women in Palau was 5.5%. Women who were older (≥30 years) or obese (BMI ≥30) were more likely to have GDM than women who were younger (<30 years) or non-obese (BMI <30), respectively. When adverse birth outcomes were assessed, women with GDM were found to have significantly higher prevalence of high birth weight infants, cesarean sections, and neonatal deaths when compared to women without GDM. In fact, women with GDM were five times more likely to have a neonatal death than women without GDM (p = 0.008). Conclusion Reducing overall rates of obesity in the population could help reduce rates of diabetes and GDM in Palau. Based on this work, current practices for the identification, monitoring and treatment of women with GDM should be evaluated and strengthened in order to reduce neonatal mortality rates in Palau.

Mass spawning aggregation of the giant bumphead parrotfish Bolbometopon muricatum.

The present study reports a previously undocumented mass spawning aggregation and group spawning phenomena of c. 1200 individual bumphead parrotfish Bolbometopon muricatum in Palau, Micronesia. Although B. muricatum are protected in Palau, it is further recommended that management strategies should consider establishment of no-take zones at B. muricatum spawning aggregations and concomitant sleeping grounds elsewhere.

The Effects of Chewing Betel Nut with Tobacco and Pre-pregnancy Obesity on Adverse Birth Outcomes Among Palauan Women.

The small Pacific Island nation of Palau has alarmingly high rates of betel nut with tobacco use and obesity among the entire population including pregnant women. This study aimed to determine the effects of betel nut with tobacco use and pre-pregnancy obesity on adverse birth outcomes. This study used retrospective cohort data on 1171 Palauan women who gave birth in Belau National Hospital in Meyuns, Republic of Palau between 2007 and 2013. The exposures of interest were pre-pregnancy obesity and reported betel nut with tobacco use during pregnancy. The primary outcomes measured were preterm birth and low birth weight among full-term infants. A significantly increased risk for low birth weight among full-term infants was demonstrated among those women who chewed betel nut with tobacco during pregnancy when other known risk factors were controlled for. Additionally, pre-pregnancy obesity was associated with a significantly increased risk for preterm birth when other known risk factors were controlled for. Both betel nut with tobacco use and pre-pregnancy obesity were associated with higher risks for adverse birth outcomes. These findings should be used to drive public health efforts in Palau, as well as in other Pacific Island nations where these studies are currently lacking.

Prevalence and predictors of prediabetes and diabetes among adults in Palau: population-based national STEPS survey.

We aimed to investigate the prevalence and predictors of diabetes and prediabetes among adults in Palau. We used data of 1915 adults, aged 25 to 64 years, who participated in the World Health Organization's (WHO) STEPwise Approach to Risk Factor Surveillance (STEPS) study in Palau. Information on behavioral risk factors of NCDs and physical and biochemical measurements were obtained using standard methods of the WHO. The diagnosis of diabetes and prediabetes was based on the recent American Diabetes Association criteria. Predictors of the prevalence of diabetes and prediabetes were identified using multinomial logistic regression analysis. The overall age-standardized prevalence of prediabetes and diabetes were 40.4% (43.6% for men, 37.4% for women) and 17.7% (18.6% for men, 17% for women), respectively. Old age, overall obesity (high BMI), central obesity (large waist circumference or waist-hip ratio), hypertension and hypertriglyceridemia were significant predictors of prediabetes and/or diabetes. Diabetes occurred at a younger age in "obese" individuals than that of their "non-obese" counterparts. We confirmed that prediabetes and diabetes are highly prevalent in Palau affecting 40% and 18% adults, respectively. Introducing public health interventions to reduce and prevent obesity as early as possible could prove useful to curb the problem.

Characterizing runs of homozygosity and their impact on risk for psychosis in a population isolate.

An increased abundance of runs of homozygosity (ROH) has been associated with risk for various diseases, including schizophrenia. Here we investigate the characteristics of ROH in Palau, an Oceanic population, evaluating whether these characteristics are related to risk for psychotic disorders and the nature of this association. To accomplish these aims we evaluate a sample of 203 cases with schizophrenia and related psychotic disorders-representing almost complete ascertainment of affected individuals in the population-and contrast their ROH to that of 125 subjects chosen to function as controls. While Palauan diagnosed with psychotic disorders tend to have slightly more ROH regions than controls, the distinguishing features are that they have longer ROH regions, greater total length of ROH, and their ROH tends to co-occur more often at the same locus. The nature of the sample allows us to investigate whether rare, highly penetrant recessive variants generate such case-control differences in ROH. Neither rare, highly penetrant recessive variants nor individual common variants of large effect account for a substantial proportion of risk for psychosis in Palau. These results suggest a more nuanced model for risk is required to explain patterns of ROH for this population.

Cistus, Acacia, and Lemon verbena Valorization through Response Surface Methodology: Optimization Studies and Potential Application in the Pharmaceutical and Nutraceutical Industries.

Cistus ladanifer L., Acacia dealbata L., and Aloysia citrodora Paláu were subject to an optimization procedure for two extraction techniques (heat-assisted extraction (HAE) and ultrasound-assisted extraction (UAE)). The extracts were then analyzed by HPLC-DAD-ESI/MS for their phenolic profile (cistus-15 compounds, acacia-21 compounds, and lemon verbena-9 compounds). The response surface methodology was applied, considering four varying factors: ethanol percentage; extraction time; temperature/power; and S/L ratio, generating two responses (the major phenolic compound, or family of compounds, and the extraction yield). For cistus, both techniques optimized the extraction yield of punicalagins, with UAE proving to be the most efficient extraction method (3.22% ethanol, 22 min, 171 W, and 35 g/L). For acacia, HAE maximized the extraction of procyanidin (74% ethanol, 86 min, 24 °C, and 50 g/L), and UAE maximized the content of myricetin (65% ethanol, 8 min, 50 W, and 50 g/L). For lemon verbena, HAE favored the extraction of martynoside (13% ethanol, 96 min, 49 °C and 17 g/L) and forsythiaside UAE (94% ethanol, 25 min, 399 W, and 29 g/L). The optimal conditions for the extraction of compounds with high added value and potential for use in pharmaceuticals and nutraceuticals were defined.

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.

Small-scale genetic structure of coral populations in Palau based on whole mitochondrial genomes: Implications for future coral resilience.

The ability of local populations to adapt to future climate conditions is facilitated by a balance between short range dispersal allowing local buildup of adaptively beneficial alleles, and longer dispersal moving these alleles throughout the species range. Reef building corals have relatively low dispersal larvae, but most population genetic studies show differentiation only over 100s of km. Here, we report full mitochondrial genome sequences from 284 tabletop corals (Acropora hyacinthus) from 39 patch reefs in Palau, and show two signals of genetic structure across reef scales from 1 to 55 km. First, divergent mitochondrial DNA haplotypes exist in different proportions from reef to reef, causing PhiST values of 0.02 (p = 0.02). Second, closely related sequences of mitochondrial Haplogroups are more likely to be co-located on the same reefs than expected by chance alone. We also compared these sequences to prior data on 155 colonies from American Samoa. In these comparisons, many Haplogroups in Palau were disproportionately represented or absent in American Samoa, and inter-regional PhiST = 0.259. However, we saw three instances of identical mitochondrial genomes between locations. Together, these data sets suggest two features of coral dispersal revealed by occurrence patterns in highly similar mitochondrial genomes. First, the Palau-American Samoa data suggest that long distance dispersal in corals is rare, as expected, but that it is common enough to deliver identical mitochondrial genomes across the Pacific. Second, higher than expected co-occurrence of Haplogroups on the same Palau reefs suggests greater retention of coral larvae on local reefs than predicted by many current oceanographic models of larval movement. Increased attention to local scales of coral genetic structure, dispersal, and selection may help increase the accuracy of models of future adaptation of corals and of assisted migration as a reef resilience intervention.

Effects of the aroma of lemone verbena (Aloysia citriodora Paláu) essential oil on anxiety and the hemodynamic profile before cesarean section: A randomized clinical trial.

Background: Aromatherapy is a noninvasive method used for alleviating anxiety. Lemon verbena (Aloysia citriodora Paláu, LV) has been frequently used in traditional medicine as an anxiolytic agent due to its pharmacological ingredients. Objective: This randomized controlled trial aimed to assess the effects of inhaling essential oil of LV on the level of anxiety and subsequent hemodynamic changes before cesarean section. Methods: The recent study was a randomized single-blind trial. Participants (n = 84) were randomly divided into two groups: LV essential oil (group A) and placebo (group B). The intervention group underwent aromatherapy using three drops of LV essential oil at a distance of 10 cm for 30 min. The placebo group received aromatherapy in a similar fashion. The State-Trait Anxiety Inventory of Spielberger questionnaire was administered before and 5 min after aroma inhalation. Vital signs were recorded before and after aromatherapy. Likewise, pain severity was assessed using the Numeric Rating Scale and vital signs were recorded. Data were analyzed using t-test, χ 2, and the Kolmogrov-Smirnov test through SPSS21 software. Results: Anxiety level was significantly attenuated in group A after aromatherapy. Heart rate, respiratory rate, and blood pressure decreased after inhalation; but no significant variation of pain scores was observed after inhalation in both groups. Conclusion: We concluded that LV decreased preoperative anxiety in this recent study, therefore, aromatherapy with LV essential oil as a preemptive adjuvant to relieve anxiety before cesarean section is recommended by us; although more studies are required to endorse the results.

Cancer Disparities among Pacific Islanders: A Review of Sociocultural Determinants of Health in the Micronesian Region.

It is well appreciated that the social determinants of health are intimately related with health outcomes. However, there is a paucity of literature that explores these themes comprehensively for the indigenous people within Micronesia. Certain Micronesia-specific factors, such as transitions from traditional diets, the consumption of betel nut, and exposure to radiation from the nuclear bomb testing in the Marshall Islands, have predisposed certain Micronesian populations to an increased risk of developing a variety of malignancies. Furthermore, severe weather events and rising sea levels attributed to climate change threaten to compromise cancer care resources and displace entire Micronesian populations. The consequences of these risks are expected to increase the strain on the already challenged, disjointed, and burdened healthcare infrastructure in Micronesia, likely leading to more expenses in off-island referrals. A general shortage of Pacific Islander physicians within the workforce reduces the number of patients that can be seen, as well as the quality of culturally competent care that is delivered. In this narrative review, we comprehensively underscore the health disparities and cancer inequities faced by the underserved communities within Micronesia.

First records of three Nematocarcinus species (Crustacea, Decapoda, Nematocarcinidae) in the deep-waters of the north-western Pacific.

Background: During two scientific expeditions in the South China Sea and the Kyushu-Palau Ridge area, several specimens of thread-leg shrimp were collected from deep waters. Amongst them, three species, Nematocarcinusevansi Burukovsky, 2000, N.exilis (Spence Bate, 1888) and N.machaerophorus Burukovsky, 2003 were newly recorded from the north-western Pacific. The morphological features of these specimens are in concordance with the original description. New information: Nematocarcinusevansi and N.machaerophorus were recorded for the second time since their original descriptions and newly found from the South China Sea. Nematocarcinusexilis, collected from the Kyushu-Palau Ridge area, represents a great distribution expansion from the eastern Atlantic and the Mediterranean to the Pacific, making it the fourth Atlantic-Pacific distributed Nematocarcinus species. Their detailed morphological characteristics, colour patterns and partial sequences of the COI and 16S rRNA genes are provided, respectively.