Consistent Risk Management in a Changing World: Risk Equivalence in Fisheries and Other Human Activities Affecting Marine Resources and Ecosystems

A changing climate makes the evaluation of human impacts on natural systems increasingly uncertain and affects the risk associated with management decisions. This influences both the achievability and meaning of marine conservation and resource management objectives. A risk-based framework that includes a risk equivalence approach in the evaluation of the potential consequences from human activity, can be a powerful tool for timely and consistent handling of environmental considerations in management advice. Risk equivalence permits a formal treatment of all sources of uncertainty, such that objectives-based management decisions can be maintained within acceptable risk levels and deliver outcomes consistent with expectations. There are two pathways to risk equivalence that can be used to account for the short-term and longer-term impacts of a changing environment: adjusting the degree of exposure to human pressure and adjusting the reference levels used to measure the risk. The first uses existing data and knowledge to derive risk conditioning factors applied to condition management advice on environmental departures from baseline conditions. The second is used to formalise the review and update of management objectives, reference levels and risk tolerances, so they remain consistent with potential consequences from human activity under new biological, ecological and socio-economic realities. A risk equivalence approach is about adapting existing practice to frame environmental considerations within objectives-based risk frameworks, systematically exploring alternative scenarios and assumptions, and conditioning management advice on environmental status. It is applicable to the management of all human activities impacting biological and ecological systems. Concepts of risk, risk conditioning factors, and incremental changes in risk, provide a common currency for the inclusion and communication of environmental effects into advice. Risk equivalence can ensure timely delivery of robust management advice accounting for demonstrated, anticipated or projected environmental effects. This can guide management decisions in a changing world, and greatly facilitate the implementation of an ecosystem approach for the management of human activities.

Modeling Discards in Stock Assessments: Red Grouper Epinephelus morio in the U.S. Gulf of Mexico

To be as accurate as possible, stock assessments should account for discard mortality in fisheries if it occurs. Three common approaches to modeling discards in assessments are to lump dead discards with landings, treat dead discards as their own fleet, or link them conversely with landings through use of a retention function. The first approach (lumping) implicitly assumes that the selectivity of landings applies also to discards. In many cases, that assumption is false, for example, if discards comprise smaller fish than do landings. The latter two approaches avoid the assumption by modeling discards explicitly with their own selectivity pattern. Here, we examine these approaches to modeling discards. Using a simulation study, we demonstrate that the two approaches to modeling discards explicitly can provide identical results under both static and time-varying conditions. Then, using a stock assessment case study of red grouper Epinephelus morio in the U.S. Gulf of Mexico, we demonstrate that in practice the approaches to modeling discards can provide different outcomes, with implications for the resultant management advice. We conclude by comparing and contrasting the different approaches, calling for more research to elucidate which approach is most suitable under various sources of error typically encountered in discard data.

Remote Skin Cancer Diagnosis: Adding Images to Electronic Referrals Is More Efficient Than Wait-Listing for a Nurse-Led Imaging Clinic

We undertook a retrospective comparison of two teledermatology pathways that provide diagnostic and management advice for suspected skin cancers, to evaluate the time from referral to diagnosis and its concordance with histology. Primary Care doctors could refer patients to either the Virtual Lesion Clinic (VLC), a nurse-led community teledermoscopy clinic or, more recently, to the Suspected Skin Cancer (SSC) pathway, which requires them to attach regional, close-up, and dermoscopic images. The primary objective of this study was to determine the comparative time course between the SSC pathway and VLC. Secondary objectives included comparative diagnostic concordance, skin lesion classification, and evaluation of missed skin lesions during subsequent follow-up. VLC referrals from July to December 2016 and 2020 were compared to SSC referrals from July to December 2020. 408 patients with 682 lesions in the VLC cohort were compared with 480 patients with 548 lesions from the 2020 SSC cohort, matched for age, sex, and ethnicity, including histology where available. Median time (SD) from referral to receipt of teledermatology advice was four (2.8) days and 50 (43.0) days for the SSC and VLC cohorts, respectively (p < 0.001). Diagnostic concordance between teledermatologist and histopathologist for benign versus malignant lesions was 70% for 114 lesions in the SSC cohort, comparable to the VLC cohort (71% of 122 lesions). Referrals from primary care, where skin lesions were imaged with variable devices and quality resulted in faster specialist advice with similar diagnostic performance compared to high-quality imaging at nurse-led specialist dermoscopy clinics.

A randomised controlled trial of the 5:2 diet

Objective The 5:2 diet is a popular intermittent energy restriction method of weight management that awaits further evaluation. We compared the effects of one-off 5:2 instructions with the effects of one-off standard multicomponent weight-management advice; and also examined whether additional behavioural support enhances 5:2 adherence and efficacy compared to one-off instructions. Methods Three hundred adults with obesity were randomised to receive a Standard Brief Advice (SBA) covering diet and physical activity (N = 100); 5:2 self-help instructions (5:2SH) (N = 100); or 5:2SH plus six once-weekly group support sessions (N = 100). Participants were followed up for one year. Results Adherence to 5:2SH was initially high (74% at 6 weeks), but it declined over time (31% at 6 months and 22% at one year). 5:2SH and SBA achieved similar weight-loss at six months (-1.8kg (SD = 3.5) vs -1.7kg (SD = 4.4); b = 0.23, 95%CI:-0.79–1.27, p = 0.7) and at one year (-1.9kg (SD = 4.9) vs -1.8kg (SD = 5.7), b = 0.20, 95%CI:-1.21–1.60, p = 0.79), with 18% vs 15% participants losing ≥5% of their body weight with 5:2SH and SBA, respectively at one year (RR = 0.83, 95%CI:0.44–1.54, p = 0.55). Both interventions received positive ratings, but 5:2SH ratings were significantly higher. 5:2SH had no negative effect on fat and fiber intake and physical activity compared to SBA. Compared to 5:2SH, 5:2G generated a greater weight loss at 6 weeks (-2.3kg vs -1.5kg; b = 0.74, 95%CI:1.37–0.11, p = 0.02), but by one year, the difference was no longer significant (-2.6kg vs -1.9kg, p = 0.37; ≥5% body weight loss 28% vs 18%, p = 0.10). Conclusions Simple 5:2 advice and multicomponent weight management advice generated similar modest results. The 5:2 diet did not undermine other health behaviours, and it received more favourable ratings. Adding initial group support enhanced 5:2 adherence and effects, but the impact diminished over time. Health professionals who provide brief weight management advice may consider including the 5:2 advice as an option. Trial registration ISRCTN registry (ISRCTN79408248).

“Left in limbo”: Exploring how patients with colorectal cancer interpret and respond to a suspected Lynch syndrome diagnosis

Background A diagnosis of suspected Lynch syndrome (SLS) is given when a tumour displays characteristics consistent with Lynch syndrome (LS), but no germline pathogenic variant is identified. This inconclusive diagnosis results in uncertainty around appropriate cancer risk management. This qualitative study explored how patients with CRC interpret and respond to an SLS diagnosis. Methods Semi-structured telephone interviews were conducted with 15 patients with CRC who received an SLS diagnosis, recruited from cancer genetics services across Australia. Interviews were transcribed verbatim and analysed using thematic analysis. Participant responses were compared with appointment summary letters from cancer genetics services. Results Participants’ interpretations of genetic test results were found to vary widely. While this variation often aligned with variation in interpretations by cancer genetics services, participants also had difficulties with the complexity and recall of genetic test results. Participants had a range of psychological responses to the uncertainty that their results presented, from relief to disappointment and doubt. Cancer risk perceptions also varied widely, with participants’ interpretations of their genetic test results just one of several influencing factors. Despite this variability, almost all participants adhered to cancer risk management advice, although different participants received different advice. All participants also communicated any cancer risk management advice to first-degree relatives, motivated by protecting them, but information communicated was not always consistent with advice received. Conclusions Our study findings highlight the variability in patients’ interpretations of their diagnosis, cancer risk management and family communication when a diagnosis of SLS is received, and provide novel insights into how healthcare professionals can better support patients with SLS.

Consistent risk management in a changing world: risk equivalence in fisheries and other human activities affecting marine resources and ecosystems

This manuscript addresses the need to account for climate change in the management of human activities affecting marine resources and ecosystems. A changing climate makes the evaluation of human impacts on natural systems increasingly uncertain, and affects the risks associated with management decisions. A flexible approach is proposed that involves routine formulation of alternative hypotheses for climate effects and exploration of risk equivalent management options that allow human activities to continue within acceptable risk levels despite shifting or novel conditions. The approach fits within existing risk frameworks and is applicable in all data and knowledge situations where management objectives are specified. Risk equivalence can be achieved either by conditioning the exposure to human pressures on demonstrated, anticipated or projected environmental change, or by conditioning the objectives themselves on a new environmental reality. We exemplify risk equivalence in fisheries management and discuss its applicability to the management of other human activities. Concepts of risk and risk conditioning factors provide a common language and understanding for the inclusion and communication of environmental considerations in management advice. The approach can guide robust and accountable decision-making in a changing world, and facilitate the implementation of ecosystem-based management.

Quality of life in women with urinary incontinence seeking care using e-health

Background Quality of life (QoL) in women with urinary incontinence (UI) is mainly affected by UI severity, but it is also affected by the UI subtype, comorbidities, age, and socioeconomic status. e-Health is a new method for providing UI treatment. This study aimed to identify factors with the highest impact on QoL in women that turned to e-health for UI self-management. Methods We analysed data from three randomized controlled trials (RCTs) that evaluated e-health treatments for UI. We included baseline data for 373 women with stress urinary incontinence (SUI) and 123 women with urgency/mixed UI (UUI/MUI). All participants were recruited online, with no face-to-face contact. Participants completed two questionnaires: the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF, range: 0–21 points), for assessing UI severity, and the ICIQ Lower Urinary Tract Symptoms Quality of Life (ICIQ-LUTSqol, range: 19–76 points), for assessing condition-specific quality of life (QoL). To identify factors that impacted QoL, we constructed a linear regression model. Results The mean ICIQ-LUTSqol score was 34.9 (SD 7.6). UI severity significantly affected QoL; the adjusted mean ICIQ-LUTSqol score increased by 1.5 points for each 1.0-point increase in the overall ICIQ-UI SF score (p < 0.001). The UI type also significantly affected QoL; the adjusted mean ICIQ-LUTSqol score was 2.5 points higher in women with UUI/MUI compared to those with SUI (p < 0.001). Conclusions We found that women that turned to e-health for UI self-management advice had a reduced QoL, as shown previously among women seeking UI care through conventional avenues, and that the severity of leakage had a greater impact on QoL than the type of UI. Condition-specific factors impacted the QoL slightly less among women that turned to e-health, compared to women that sought help in ordinary care. Thus, e-health might have reached a new group of women in need of UI treatment.

Identifying Métiers Using Landings Profiles: An Octopus-Driven Multi-Gear Coastal Fleet

The multi-gear coastal vessels in the Algarve (South Portugal) own licenses for various fishing gears. However, it is generally uncertain what gears they use, which is problematic as each individual gear is responsible for unique impacts on the resources and the environment. In this study, landing profiles identified for the multi-gear coastal fleet (2012–2016) were used as support in defining potential métiers using k-mean clustering analysis (CLARA) along with information from past studies on métiers. The results showed that more than 50% of the vessels were engaged in the octopus fishery year-round, using traps, while a small percentage (~13%) were entirely dedicated to clam dredging. In general, gillnets (21%) were used to target monkfish, hake and bastard soles, while trammel nets (6%) were used to target cuttlefish, with some vessels alternating the fishing gears (either seasonally or annually) according to target species. The method for the initial characterization of this fleet’s métiers and its efficiency with limited data is discussed, as well as the utility of this segmentation in support of management advice.

The long and winding road: perspectives of people and parents of children with mitochondrial conditions negotiating management after diagnosis

Background The diagnostic odyssey for people with a rare disease is well known, but difficulties do not stop at diagnosis. Here we investigate the experience of people, or parents of children with a diagnosed mitochondrial respiratory chain disorder (MRCD) in the management of their disease. The work complements ongoing projects around implementation of consensus recommendations for management of people with MRCD. People with or caring for a child with a formally diagnosed MRCD were invited to take part in an hour-long focus group held via videoconference. Questions elicited experiences of receiving management advice or information specific to their MRCD in four areas drawn from the consensus recommendations: diet and supplements, exercise, access to social services, and mental health. Sessions were audio-recorded, transcribed and analysed using a combination of inductive and deductive coding. Results Focus groups were conducted with 20 participants from five Australian states in June–September 2020. Fourteen adults with a MRCD (three of whom also had a child with a MRCD), and six who cared for a child with a MRCD took part. The overarching finding was that of the need for ongoing negotiation to access the advice and service required to manage their condition. The nature of these negotiations varied across contexts but mostly related to joint decision-making, and more commonly, the need to advocate for their care with non-specialist services (e.g., dieticians, schools). The effort required for this self-advocacy was a prominent theme. While most participants reported receiving adequate advice around supplements, and to a lesser extent diet and exercise, the majority reported no formal advice around mental health or practical assistance accessing social services. Conclusion These focus groups have revealed several gaps in the system for people with a MRCD, interacting with care providers after diagnosis. Focus group participants had to negotiate with a range of different stakeholders in order to secure appropriate advice or services. Notable was the gap in appropriate generalist services (e.g., dieticians) with sufficient knowledge of MRCD to support people with their day-to-day challenges.