Accounting for unobserved population dynamics and aging error in close-kin mark-recapture assessments.

Obtaining robust estimates of population abundance is a central challenge hindering the conservation and management of many threatened and exploited species. Close-kin mark-recapture (CKMR) is a genetics-based approach that has strong potential to improve the monitoring of data-limited species by enabling estimates of abundance, survival, and other parameters for populations that are challenging to assess. However, CKMR models have received limited sensitivity testing under realistic population dynamics and sampling scenarios, impeding the application of the method in population monitoring programs and stock assessments. Here, we use individual-based simulation to examine how unmodeled population dynamics and aging uncertainty affect the accuracy and precision of CKMR parameter estimates under different sampling strategies. We then present adapted models that correct the biases that arise from model misspecification. Our results demonstrate that a simple base-case CKMR model produces robust estimates of population abundance with stable populations that breed annually; however, if a population trend or non-annual breeding dynamics are present, or if year-specific estimates of abundance are desired, a more complex CKMR model must be constructed. In addition, we show that CKMR can generate reliable abundance estimates for adults from a variety of sampling strategies, including juvenile-focused sampling where adults are never directly observed (and aging error is minimal). Finally, we apply a CKMR model that has been adapted for population growth and intermittent breeding to two decades of genetic data from juvenile lemon sharks (Negaprion brevirostris) in Bimini, Bahamas, to demonstrate how application of CKMR to samples drawn solely from juveniles can contribute to monitoring efforts for highly mobile populations. Overall, this study expands our understanding of the biological factors and sampling decisions that cause bias in CKMR models, identifies key areas for future inquiry, and provides recommendations that can aid biologists in planning and implementing an effective CKMR study, particularly for long-lived data-limited species.

Impact of group medical visits on patient engagement and quality of life.

BACKGROUND: Group medical visits (GMV) effectively improve patient care and outcomes through interactive education, increased patient contact, and facilitated social support. This quality improvement research examined if patient activation and quality of life correlate with weight, blood pressure (BP), and hemoglobin A1c (A1C) through GMV interventions. METHODS: Participants were enrolled in GMV Lighten Up for weight management or GMV Diabetes. At pre- and post-intervention, patients completed the Patient Activation Measure (PAM) and the health-related quality of life measure, the SF-12; and were assessed for weight, blood pressure (BP), and hemoglobin A1c (A1C). RESULTS: Weight and PAM scores significantly improved regardless of group. For patients in GMV Diabetes, A1C significantly decreased. GMV Lighten Up participants had statistically significant declines in diastolic BP. Both groups improved patient activation, but statistically significantly so only in GMV Diabetes participants. SF-12 scores did not statistically significantly improve. There were no predictors of A1C and PAM score change for the Diabetes GMV. However, age, SBP and SF-12 scores predicted PAM score changes in GMV Lighten up participants. CONCLUSIONS: Participants in this study showed overall improvement in biomarkers and patient activation. Thus, GMV continue to be a viable method for healthcare delivery.

High-dose tramadol conversion to buprenorphine-naloxone.

Buprenorphine-naloxone is a combination medication of an opioid partial agonist and opioid antagonist that is proven to be effective in outpatient management of opioid use disorder (OUD). Tramadol is a centrally acting analgesic. This commonly used pain medication inhibits serotonin and noradrenaline reuptake by acting as a selective agonist on opioid µ receptors. Transition and tapering high-dose tramadol to buprenorphine-naloxone is not well described in the literature. We report a case of a patient who was taking 1,000-1,250 mg of tramadol daily upon presentation to the clinic. She was originally prescribed 150 mg daily with escalation in dose and frequency over a 10-year period. The patient was converted to bupren-orphine-naloxone and has been successful in treatment of OUD for 1 year.

Utility of the group medical visit model for medication-assisted therapy.

OBJECTIVE: To describe a group medical visit (GMV) model to facilitate medication assisted therapy. DESIGN: Retrospective cohort analysis. PARTICIPANTS: Adult patients over 18 years of age desiring to receive medication assisted therapy (MAT). METHODS: We describe the MAT GMV model including the clinical flow and group facilitation processes. The key elements for documentation and the medical portion of the visit are discussed. Using descriptive methods, we report the characteristics of our patient population entailing demographics, co-occurring mental health diagnosis, and medication use. RESULTS: A total of 32 patients have participated in our MAT GMV over the past 2 years with nine active patients. Age range of participants is 20-65, with about half of them between 31 and 54; race and ethnicity have been primarily White (87 percent) with equal distribution of male and female patients. Most patients had one or more co-occurring mental health disorder. The majority of patients had a prescription of buprenorphine-naloxone 8-2 mg twice a day (62 percent). Many of our patients had repeated co-occurring illegal substance use on urine testing resulting in program dismissal. CONCLUSIONS: MAT GMV is a straightforward and innovative way to deliver care to patients affected by opioid use disorder who are in a maintenance state. One of the biggest obstacles to successful participation in this program is repeated co-occurring illegal substance use. When remission is achieved via MAT GMV, provider efficiency is also increased and patients accomplish a sense of wellbeing via therapy, self-management, and medication assistance.

Shifting trends: Detecting changes in cetacean population dynamics in shifting habitat.

The ability to monitor population dynamics and detect major changes in population trend is essential for wildlife conservation and management. However, this is often challenging for cetaceans as surveys typically cover only a portion of a population's range and conventional stock assessment methods cannot then distinguish whether apparent changes in abundance reflect real changes in population size or shifts in distribution. We developed and tested methods for estimating population size and trend and detecting changes in population trend in the context of shifting habitat by integrating additional data into distance-sampling analysis. Previous research has shown that incorporating habitat information can improve population size estimates for highly mobile species with dynamic spatial distributions. Here, using simulated datasets representative of a large whale population, we demonstrate that incorporating individual mark-recapture data can increase the accuracy and precision of trend estimation and the power to distinguish whether apparent changes in abundance reflect changes in population trend or distribution shifts. We recommend that similar simulation studies are conducted for specific cetacean populations to assess the potential for detecting changes in population dynamics given available data. This approach is especially important wherever population change may be confounded with long-term change in distribution patterns associated with regime shifts or climate change.

Launching a Medication-Assisted Treatment in an Outpatient Office-Based Practice.

Background: Opioid use and overdose are escalating in the United States. Primary care providers are in a strategic position to assess patients for medication-assisted treatment (MAT). Objectives: To describe the implementation of MAT in an integrated primary care residency clinic and assess provider comfort levels with evaluating patients for high-risk opioid use, conduct crucial conversations about MAT treatment options and referral to MAT for evaluation and treatment. Methods: As part of a Primary Care Training and Enhancement grant through Health Resources and Services Administration, we used an implementation process to allow for optimal clinic flow. The process included assessment of patient populations, identifying a provider champion, organizing multidisciplinary team, engaging a practice facilitator, designing clinic model and infrastructure, creating the electronic health record order sets along with provider and staff training. Providers responded to brief questions to evaluate comfort levels in 3 domains: identifying high-risk opioid use, conducting crucial conversations about treatment options and referral to MAT for evaluation and treatment. Discussion: Incorporating MAT within an integrated primary care clinic and residency program with waiver training for residents was a successful and innovative program. The availability of MAT provided a solution for patients that could benefit from this type of treatment. MAT presence gave providers the opportunity to refer these patients for treatment that had not previously been as accessible. Conclusion: An integrated primary care practice with an embedded MAT can be successful with an organized structure to optimize clinic flow.

Assessing cetacean populations using integrated population models: an example with Cook Inlet beluga whales.

Effective conservation and management of animal populations requires knowledge of abundance and trends. For many species, these quantities are estimated using systematic visual surveys. Additional individual-level data are available for some species. Integrated population modeling (IPM) offers a mechanism for leveraging these data sets into a single estimation framework. IPMs that incorporate both population- and individual-level data have previously been developed for birds, but have rarely been applied to cetaceans. Here, we explore how IPMs can be used to improve the assessment of cetacean populations. We combined three types of data that are typically available for cetaceans of conservation concern: population-level visual survey data, individual-level capture-recapture data, and data on anthropogenic mortality. We used this IPM to estimate the population dynamics of the Cook Inlet population of beluga whales (CIBW; Delphinapterus leucas) as a case study. Our state-space IPM included a population process model and three observational submodels: (1) a group detection model to describe group size estimates from aerial survey data; (2) a capture-recapture model to describe individual photographic capture-recapture data; and (3) a Poisson regression model to describe historical hunting data. The IPM produces biologically plausible estimates of population trajectories consistent with all three data sets. The estimated population growth rate since 2000 is less than expected for a recovering population. The estimated juvenile/adult survival rate is also low compared to other cetacean populations, indicating that low survival may be impeding recovery. This work demonstrates the value of integrating various data sources to assess cetacean populations and serves as an example of how multiple, imperfect data sets can be combined to improve our understanding of a population of interest. The model framework is applicable to other cetacean populations and to other taxa for which similar data types are available.

Group Medical Visits: experiences with patient and resident implementation.

Objective: Patients with diabetes must navigate multiple components of care to self-manage their disease. Group Medical Visits (GMVs) are a forum for patients to see a provider as well as actively participate in education and care management with other patients with diabetes. The objective is to describe GMV implementation and resident involvement in a primary care setting.Methods: We adapted and implemented a GMV model into a primary care practice with a residency program. Residents attend GMV sessions that provide a continuity experience in addition to their regular clinic schedules. A cohort of patients enroll in a series of eight GMVs occurring over of 4 months. Each patient and resident complete surveys evaluating the visits.Results: There have been 14 GMV groups totaling 70 participants. GMV groups (N = 67) mean A1C for reduction was 0.53 ± 1.60 from baseline to 3- to 6-month post-GMV follow-up. Resident and patient feedback show an overall positive experience.Conclusion: The GMV model offers patients the setting to interact and exchange experiences with each other as well as to receive feedback from providers and the health-care team.  The incorporation of the GMV program into residency training provides a continuity group care experience and an alternative practice model.

Predictive modelling of habitat selection by marine predators with respect to the abundance and depth distribution of pelagic prey.

Understanding the ecological processes that underpin species distribution patterns is a fundamental goal in spatial ecology. However, developing predictive models of habitat use is challenging for species that forage in marine environments, as both predators and prey are often highly mobile and difficult to monitor. Consequently, few studies have developed resource selection functions for marine predators based directly on the abundance and distribution of their prey. We analysed contemporaneous data on the diving locations of two seabird species, the shallow-diving Peruvian Booby (Sula variegata) and deeper diving Guanay Cormorant (Phalacrocorax bougainvilliorum), and the abundance and depth distribution of their main prey, Peruvian anchoveta (Engraulis ringens). Based on this unique data set, we developed resource selection functions to test the hypothesis that the probability of seabird diving behaviour at a given location is a function of the relative abundance of prey in the upper water column. For both species, we show that the probability of diving behaviour is mostly explained by the distribution of prey at shallow depths. While the probability of diving behaviour increases sharply with prey abundance at relatively low levels of abundance, support for including abundance in addition to the depth distribution of prey is weak, suggesting that prey abundance was not a major factor determining the location of diving behaviour during the study period. The study thus highlights the importance of the depth distribution of prey for two species of seabird with different diving capabilities. The results complement previous research that points towards the importance of oceanographic processes that enhance the accessibility of prey to seabirds. The implications are that locations where prey is predictably found at accessible depths may be more important for surface foragers, such as seabirds, than locations where prey is predictably abundant. Analysis of the relative importance of abundance and accessibility is essential for the design and evaluation of effective management responses to reduced prey availability for seabirds and other top predators in marine systems.

Pro-poor tourism: putting poverty at the heart of mass tourism

How does tourism affect the lives of the poor and what is the relevance of tourism to the poverty agenda? What are the impacts (positive and negative) and how can they be better understood? What factors encourage or constrain economic participation of the poor in the tourist industry? Can tourism be pro-poor?