Positive Cervical Artery Testing in a Patient with Chronic Whiplash Syndrome: Clinical Decision-Making in the Presence of Diagnostic Uncertainty

Abstract: This case report describes the diagnosis and management of a 43-year-old female patient who had sustained an injury to her neck in a motor-vehicle accident two years earlier. The major symptoms described by the patient included headache and neck pain, but history and examination also revealed signs and symptoms potentially indicative of cervical artery compromise. Physical therapy management initially consisted of soft tissue and non-thrust joint manipulation of the lower cervical and thoracic spine, specific exercise prescription, and superficial heat. Cervical vascular compromise was re-evaluated by way of the sustained extension-rotation test. When at the fifth visit this test no longer produced symptoms potentially indicative of vascular compromise, upper cervical diagnosis and management consisting of soft tissue and non-thrust joint manipulation was added. A positive outcome was achieved both at the impairment level and with regard to limitations in activities, the latter including increased performance at work, a return to previous reading activities, improved length and quality of sleep, and greater comfort while driving. At discharge, the patient reported only occasional pain and mild limitations in activities. This report describes the positive outcomes in a patient with chronic whiplash syndrome; however, its main emphasis lies in the discussion and critical evaluation of clinical reasoning in the presence of diagnostic uncertainty with regard to cervical artery compromise. Key Words: Whiplash Syndrome, Physical Therapy, Cervical Artery, Vertebral Artery, Diagnostic Uncertainty, Clinical Reasoning I n the United States alone, over one million people annually incur acceleration-deceleration or whiplash injuries to the cervical spine 1 . Cervical spine trauma is estimated to occur in 20% of motor-vehicle accidents 2 . Headache and neck pain are common complaints after a whiplash injury but symptoms may also include thoracic, temporomandibular, facial, and limb pain and stiffness, dizziness, nausea, visual disturbances, tinnitus, malaise, dysequilibrium, anxiety, and depression Neuromusculoskeletal lesions implicated in the etiology of chronic WAD include dysfunctions of the cervical zygapophyseal joints, disks, cartilaginous endplates, muscles, ligaments, vertebrae, and nervous systems structures including nerve roots, spinal cord, brain, and sympathetic nervous system, temporomandibular joints, acromioclavicular joints, the peripheral vestibular system, and-most importantly for this case report-the cervical arteries including the internal carotid and vertebral arteries There is an absence of data on the diagnostic or predictive validity for commonly used history items or physical tests or even clear criteria as to what constitutes positive history or physical examination findings indicative of cervical artery compromise. At the same time, because of the potential for traumatically induced cervical artery dysfunction, the clinician is faced with diagnostic uncertainty when dealing with patients with WAD who report symptoms potentially related to vertebral or internal carotid artery dysfunction. The goal for this case report was to describe and critically evaluate the physical therapy diagnosis and management of a patient with chronic post-whiplash complaints who presented with signs and symptoms potentially indicative of cervical artery compromise. Cervical artery in this case report is understood to include both vertebral and internal carotid arteries. Patient Examination The examination of this patient followed the format proposed by Paris and Loubert Pain Assessment For pain assessment, the body diagram, the McGill Pain Questionnaire (MPQ), and numeric pain rating scales (NPRS) were used. On the body diagram, the patient indicated pain in the superior, lateral, and posterior aspects of the head and the posterior cervical area bilaterally. On the MPQ, which has been demonstrated to be a reliable and valid method for measuring pain Average daily pain was rated as a 5 on a 0-10 NPRS. At its worst, the headache was rated as a 10 on the NPRS. The NPRS is simple to administer and has demonstrated good levels of reliability, validity, and responsiveness Initial Observation An initial observation was done when the patient was in the waiting area. A slightly endomorphic body type and medium height were observed, as was an overall kyphotic posture with a forward head posture when completing the insurance intake forms. History and Interview The patient was a 43-year-old female who had injured her neck in an MVA 2 years earlier. At the time of the accident, the patient was driving when her vehicle was impacted on the driver's side by a semi truck. Neck pain and headaches developed within minutes after the accident. A brief course of physical therapy was provided 2 weeks after the injury consisting of ultrasound, superficial heat, mechanical traction, and exercise. The patient was unsure of the frequency and duration of this treatment period, but she estimated having received a total of 8-10 visits over a period of 3 weeks. She reported temporary mild relief at the conclusion of this period of treatment but symptoms returned soon after. A gradual increase began for no apparent reason 5 months prior to the current course of treatment. Reported limitations in activities included being able to sleep only 4-5 hours per night, having to leave work early and missing work, all because of pain, and difficulty performing routine household chores. The patient was employed at a local factory on an assembly line and continued to work. Work activities were repetitive and required her to look down for long periods. Periodic rotation of her head was required to see other aspects of the assembly line. Small parts were handled routinely during work activities. Specific limitations involved sustained looking down and turning her neck at work, difficulty with turning her head to back up the car or to change lanes, and reading. In addition, occasional concentration and memory lapses were described including forgetting items that needed to be purchased at the grocery store, difficulty remembering the details of conversations with friends, and difficulty comprehending information during attempts at reading. The bilateral head and neck pain were described as vicelike. At times the patient also had knife-like temporal region headaches. The neck pain was constant, and headaches were present on a daily basis. Aggravating factors included activities requiring the patient to look down for long periods or to turn her head. The patient indicated no factors that provided relief. Pain behavior during a 24-hour period included stiffness and discomfort upon awakening in the morning, variable intensities by mid-day and late afternoon, depending on activity level, and increased intensity by the evening. Pain was at times present at night and might or might not be affected by changes in position. During the most painful episodes, the back of the head became so sensitive that it was hard to place it on a pillow. Severe headaches were associated with nausea, blurred vision, and tinnitus in the right ear, and occasional vomiting. The patient denied quadrilateral sensory changes or changes in bladder and bowel control. She also denied having problems of loss of balance, falling, sensation changes on the face, visual disturbances, lightheadedness, or quadrilateral weakness. Although commonly considered indicative of cervical artery and cervical cord compromise, no data on the diagnostic utility of these history items were found. With regard to the patient's report of occipital allodynia, Kerry and Taylor 25 mentioned scalp tenderness as a symptom of internal carotid artery ischaemia, but hypersensitivity of the head and neck has also been described in patients with chronic WAD 17 . However, absence of data on diagnostic utility and a patient report of intermittent rather than constant allodynia seemed to make this symptom less useful with regard to differential diagnosis. The patient's medical history included hypertension, three caesarean sections, appendectomy, hysterectomy, right carpal tunnel release, left wrist and hand fracture, and a cyst removal from the right palm. The patient reported depression and she attributed this to the pain, but she also related it to the passing of her father during the past year. The patient reported smoking one pack of cigarettes per day. Medications the patient was currently taking included the antidepressant Buproprion, the anti-hypertensive Inderal, and the anti-inflammatory medication Methylprednisone. Kerry and Taylor 25 implicated hypertension and smoking as risk factors for atherosclerotic cervical artery dysfunction. Palmer et al 34 found a small but consistent relationship between smoking and regional neck pain limiting activity (prevalence ratio 1.5; 95% confidence interval (CI) 1.3-1.6); other researchers have established a dose-response relationship between smoking and musculoskeletal pain Structural Inspection Structural inspection revealed a moderate forward head posture, a mild right mid-cervical and left upper-cervical sidebent position, hypertrophy of the right sternocleidomastoid muscle, and mildly increased lumbar lordosis and thoracic kyphosis. Cleland et al 37 reported 81% interrater agreement for identification of a forward head posture. Fedorak et al 38 reported fair mean intrarater reliability (κ=0.50) and poor mean interrater reliability (κ=0.16) for visual assessment of lordotic posture of the cervical and lumbar spine when using a 3-point rating scale (i.e., normal, increased, decreased). Active Movements Active range of motion (AROM) established by way of visual estimation demonstrated a moderate decrease for craniocervical flexion and left sidebending. Regional cervical AROM was moderately limited for flexion, right sidebending, and left rotation. Left sidebending and right rotation were only mildly restricted. Neurovascular Assessment As part of the normal screening examination-but all the more relevant with smoking implicated as a risk factor for hypertension and hypertension in turn implicated as a risk factor for (cervical) atherosclerotic disease, a cardiovascular screening was done: blood pressure was 134/90 (mmHg) and heart rate was 72 (BPM). The systolic value placed the patient in the high normal range and the diastolic value indicated mild hypertension as compared to an adult population not taking anti-hypertensive medication 47 . The upper-extremity neurovascular examination included a sensory examination including light touch and pinprick, deep tendon reflexes, and muscle-strength testing. Sensation and reflex testing was normal and neck and shoulder strength was grossly 4 on a 0-5 scale. Wainner et al 48 reported low sensitivity for upper-extremity deep tendon reflex testing and strength testing with values ranging from 3-24% and 12-29%, respectively; however, specificity was excellent with values of 93-95% and 66-86%, respectively, when compared to a reference standard of radiculopathy established by way of needle electromyography and nerve conduction studies. Interrater reliability was substantial for upper-extremity reflex testing (κ=0.73) and poor to substantial for upper-extremity strength (κ=0.23-0.69) and dermatomal sensation testing (κ=0.16-0.67) The sustained extension-rotation test was used for testing vertebrobasilar system functio

Long-term antidepressant use: a qualitative study on perspectives of patients and GPs in primary care

Background Antidepressant use is often prolonged in patients with anxiety and/or depressive disorder(s) compared with recommendations in treatment guidelines to discontinue after sustained remission. Aim To unravel the motivations of patients and GPs causing long-term antidepressant use and to gain insight into possibilities to prevent unnecessary long-term use. Design and setting Qualitative study using semi-structured, in-depth interviews with patients and GPs in the Netherlands. Method Patients with anxiety and/or depressive disorder(s) (n = 38) and GPs (n = 26) were interviewed. Innovatively, the interplay between patients and their GPs was also investigated by means of patient-GP dyads (n = 20). Results The motives and barriers of patients and GPs to continue or discontinue antidepressants were related to the availability of supportive guidance during discontinuation, the personal circumstances of the patient, and considerations of the patient or GP. Importantly, dyads indicated a large variation in policies of general practices around long-term use and continuation or discontinuation of antidepressants. Dyads further indicated that patients and GPs seemed unaware of each other's (mismatching) expectations regarding responsibility to initiate discussing continuation or discontinuation. Conclusion Although motives and barriers to antidepressant continuation or discontinuation were related to the same themes for patients and GPs, dyads indicated discrepancies between them. Discussion between patients and GPs about antidepressant use and continuation or discontinuation may help clarify mutual expectations and opinions. Agreements between a patient and their GP can be included in a patient-tailored treatment plan

What are sources of carbon lock-in in energy-intensive industry? A case study into Dutch chemicals production

Keeping global mean temperature rise well below 2 °C requires deep emission reductions in all industrial sectors, but several barriers inhibit such transitions. A special type of barrier is carbon lock-in, defined as a process whereby various forms of increasing returns to adoption inhibit innovation and the competitiveness of low-carbon alternatives, resulting in further path dependency. Here, we explore potential carbon lock-in in the Dutch chemical industry via semi-structured interviews with eleven key actors. We find that carbon lock-in may be the result of (i) technological incompatibility between deep emission reduction options over time, (ii) system integration in chemical clusters, (iii) increasing sunk costs as firms continue to invest in incremental improvements in incumbent installations, (iv) governmental policy inconsistency between targets for energy efficiency and deep emission reductions, and (v) existing safety routines and standards. We also identify barriers that do not have the self-reinforcing character of lock-in, but do inhibit deep emission reductions. Examples include high operating costs of low-carbon options and low risk acceptance by capital providers and shareholders. Rooted in the Dutch policy setting, we discuss policy responses for avoiding carbon lock-in and overcoming barriers based on the interviews, such as transition plans for individual industries and infrastructure subsidies

High Diet Quality Is Associated with a Lower Risk of Cardiovascular Disease and All-Cause Mortality in Older Men

Although diet quality is implicated in cardiovascular disease (CVD) risk, few studies have investigated the relation between diet quality and the risks of CVD and mortality in older adults. This study examined the prospective associations between dietary scores and risk of CVD and all-cause mortality in older British men. A total of 3328 men (aged 60–79 y) from the British Regional Heart Study, free from CVD at baseline, were followed up for 11.3 y for CVD and mortality. Baseline food-frequency questionnaire data were used to generate 2 dietary scores: the Healthy Diet Indicator (HDI), based on WHO dietary guidelines, and the Elderly Dietary Index (EDI), based on a Mediterranean-style dietary intake, with higher scores indicating greater compliance with dietary recommendations. Cox proportional hazards regression analyses assessed associations between quartiles of HDI and EDI and risk of all-cause mortality, CVD mortality, CVD events, and coronary heart disease (CHD) events. During follow-up, 933 deaths, 327 CVD deaths, 582 CVD events, and 307 CHD events occurred. Men in the highest compared with the lowest EDI quartile had significantly lower risks of all-cause mortality (HR:0.75; 95% CI: 0.60, 0.94; P-trend = 0.03), CVD mortality (HR: 0.63; 95% CI: 0.42, 0.94; P-trend = 0.03), and CHD events(HR: 0.66; 95% CI: 0.45,0.97; P-trend = 0.05) but not CVD events (HR: 0.79; 95% CI: 0.60, 1.05;P-trend = 0.16) after adjustment for sociodemographic, behavioral, and cardiovascular risk factors. The HDI was not significantly associated with any of the outcomes. The EDI appears to be more useful than the HDI for assessing diet quality in relation to CVD and morality risk in older men. Encouraging older adults to adhere to the guidelines inherent in the EDI criteria may have public health benefit

LC‐IMPACT: A regionalized life cycle damage assessment method

Life cycle impact assessment (LCIA) is a lively field of research, and data and models are continuously improved in terms of impact pathways covered, reliability, and spatial detail. However, many of these advancements are scattered throughout the scientific literature, making it difficult for practitioners to apply the new models. Here, we present the LC‐IMPACT method that provides characterization factors at the damage level for 11 impact categories related to three areas of protection (human health, ecosystem quality, natural resources). Human health damage is quantified as disability adjusted life years, damage to ecosystem quality as global species extinction equivalents (based on potentially disappeared fraction of species), and damage to mineral resources as kilogram of extra ore extracted. Seven of the impact categories include spatial differentiation at various levels of spatial scale. The influence of value choices related to the time horizon and the level of scientific evidence of the impacts considered is quantified with four distinct sets of characterization factors. We demonstrate the applicability of the proposed method with an illustrative life cycle assessment example of different fuel options in Europe (petrol or biofuel). Differences between generic and regionalized impacts vary up to two orders of magnitude for some of the selected impact categories, highlighting the importance of spatial detail in LCIA. This article met the requirements for a gold – gold JIE data openness badge described at http://jie.click/badges.info:eu-repo/semantics/publishedVersio

Neurocognitive outcome and mental health in children with tyrosinemia type 1 and phenylketonuria:A comparison between two genetic disorders affecting the same metabolic pathway

Tyrosinemia type 1 (TT1) and phenylketonuria (PKU) are both inborn errors of phenylalanine-tyrosine metabolism. Neurocognitive and behavioral outcomes have always featured in PKU research but received less attention in TT1 research. This study aimed to investigate and compare neurocognitive, behavioral, and social outcomes of treated TT1 and PKU patients. We included 33 TT1 patients (mean age 11.24 years; 16 male), 31 PKU patients (mean age 10.84; 14 male), and 58 age- and gender-matched healthy controls (mean age 10.82 years; 29 male). IQ (Wechsler-subtests), executive functioning (the Behavioral Rating Inventory of Executive Functioning), mental health (the Achenbach-scales), and social functioning (the Social Skills Rating System) were assessed. Results of TT1 patients, PKU patients, and healthy controls were compared using Kruskal-Wallis tests with post-hoc Mann-Whitney U tests. TT1 patients showed a lower IQ and poorer executive functioning, mental health, and social functioning compared to healthy controls and PKU patients. PKU patients did not differ from healthy controls regarding these outcome measures. Relatively poor outcomes for TT1 patients were particularly evident for verbal IQ, BRIEF dimensions "working memory", "plan and organize" and "monitor", ASEBA dimensions "social problems" and "attention problems", and for the SSRS "assertiveness" scale (all p value

Evaluating expert-based habitat suitability information of terrestrial mammals with GPS-tracking data

Aim Macroecological studies that require habitat suitability data for many species often derive this information from expert opinion. However, expert-based information is inherently subjective and thus prone to errors. The increasing availability of GPS tracking data offers opportunities to evaluate and supplement expert-based information with detailed empirical evidence. Here, we compared expert-based habitat suitability information from the International Union for Conservation of Nature (IUCN) with habitat suitability information derived from GPS-tracking data of 1,498 individuals from 49 mammal species. Location Worldwide. Time period 1998-2021. Major taxa studied Forty-nine terrestrial mammal species. Methods Using GPS data, we estimated two measures of habitat suitability for each individual animal: proportional habitat use (proportion of GPS locations within a habitat type), and selection ratio (habitat use relative to its availability). For each individual we then evaluated whether the GPS-based habitat suitability measures were in agreement with the IUCN data. To that end, we calculated the probability that the ranking of empirical habitat suitability measures was in agreement with IUCN's classification into suitable, marginal and unsuitable habitat types. Results IUCN habitat suitability data were in accordance with the GPS data (> 95% probability of agreement) for 33 out of 49 species based on proportional habitat use estimates and for 25 out of 49 species based on selection ratios. In addition, 37 and 34 species had a > 50% probability of agreement based on proportional habitat use and selection ratios, respectively. Main conclusions We show how GPS-tracking data can be used to evaluate IUCN habitat suitability data. Our findings indicate that for the majority of species included in this study, it is appropriate to use IUCN habitat suitability data in macroecological studies. Furthermore, we show that GPS-tracking data can be used to identify and prioritize species and habitat types for re-evaluation of IUCN habitat suitability data

Behavioral responses of terrestrial mammals to COVID-19 lockdowns

COVID-19 lockdowns in early 2020 reduced human mobility, providing an opportunity to disentangle its effects on animals from those of landscape modifications. Using GPS data, we compared movements and road avoidance of 2300 terrestrial mammals (43 species) during the lockdowns to the same period in 2019. Individual responses were variable with no change in average movements or road avoidance behavior, likely due to variable lockdown conditions. However, under strict lockdowns 10-day 95th percentile displacements increased by 73%, suggesting increased landscape permeability. Animals' 1-hour 95th percentile displacements declined by 12% and animals were 36% closer to roads in areas of high human footprint, indicating reduced avoidance during lockdowns. Overall, lockdowns rapidly altered some spatial behaviors, highlighting variable but substantial impacts of human mobility on wildlife worldwide.acceptedVersio

Behavioral responses of terrestrial mammals to COVID-19 lockdowns

DATA AND MATERIALS AVAILABILITY : The full dataset used in the final analyses (33) and associated code (34) are available at Dryad. A subset of the spatial coordinate datasets is available at Zenodo (35). Certain datasets of spatial coordinates will be available only through requests made to the authors due to conservation and Indigenous sovereignty concerns (see table S1 for more information on data use restrictions and contact information for data requests). These sensitive data will be made available upon request to qualified researchers for research purposes, provided that the data use will not threaten the study populations, such as by distribution or publication of the coordinates or detailed maps. Some datasets, such as those overseen by government agencies, have additional legal restrictions on data sharing, and researchers may need to formally apply for data access. Collaborations with data holders are generally encouraged, and in cases where data are held by Indigenous groups or institutions from regions that are under-represented in the global science community, collaboration may be required to ensure inclusion.COVID-19 lockdowns in early 2020 reduced human mobility, providing an opportunity to disentangle its effects on animals from those of landscape modifications. Using GPS data, we compared movements and road avoidance of 2300 terrestrial mammals (43 species) during the lockdowns to the same period in 2019. Individual responses were variable with no change in average movements or road avoidance behavior, likely due to variable lockdown conditions. However, under strict lockdowns 10-day 95th percentile displacements increased by 73%, suggesting increased landscape permeability. Animals’ 1-hour 95th percentile displacements declined by 12% and animals were 36% closer to roads in areas of high human footprint, indicating reduced avoidance during lockdowns. Overall, lockdowns rapidly altered some spatial behaviors, highlighting variable but substantial impacts of human mobility on wildlife worldwide.The Radboud Excellence Initiative, the German Federal Ministry of Education and Research, the National Science Foundation, Serbian Ministry of Education, Science and Technological Development, Dutch Research Council NWO program “Advanced Instrumentation for Wildlife Protection”, Fondation Segré, RZSS, IPE, Greensboro Science Center, Houston Zoo, Jacksonville Zoo and Gardens, Nashville Zoo, Naples Zoo, Reid Park Zoo, Miller Park, WWF, ZCOG, Zoo Miami, Zoo Miami Foundation, Beauval Nature, Greenville Zoo, Riverbanks zoo and garden, SAC Zoo, La Passarelle Conservation, Parc Animalier d’Auvergne, Disney Conservation Fund, Fresno Chaffee zoo, Play for nature, North Florida Wildlife Center, Abilene Zoo, a Liber Ero Fellowship, the Fish and Wildlife Compensation Program, Habitat Conservation Trust Foundation, Teck Coal, and the Grand Teton Association. The collection of Norwegian moose data was funded by the Norwegian Environment Agency, the German Ministry of Education and Research via the SPACES II project ORYCS, the Wyoming Game and Fish Department, Wyoming Game and Fish Commission, Bureau of Land Management, Muley Fanatic Foundation (including Southwest, Kemmerer, Upper Green, and Blue Ridge Chapters), Boone and Crockett Club, Wyoming Wildlife and Natural Resources Trust, Knobloch Family Foundation, Wyoming Animal Damage Management Board, Wyoming Governor’s Big Game License Coalition, Bowhunters of Wyoming, Wyoming Outfitters and Guides Association, Pope and Young Club, US Forest Service, US Fish and Wildlife Service, the Rocky Mountain Elk Foundation, Wyoming Wild Sheep Foundation, Wild Sheep Foundation, Wyoming Wildlife/Livestock Disease Research Partnership, the US National Science Foundation [IOS-1656642 and IOS-1656527, the Spanish Ministry of Economy, Industry and Competitiveness, and by a GRUPIN research grant from the Regional Government of Asturias, Sigrid Rausing Trust, Batubay Özkan, Barbara Watkins, NSERC Discovery Grant, the Federal Aid in Wildlife Restoration act under Pittman-Robertson project, the State University of New York, College of Environmental Science and Forestry, the Ministry of Education, Youth and Sport of the Czech Republic, the Ministry of Agriculture of the Czech Republic, Rufford Foundation, an American Society of Mammalogists African Graduate Student Research Fund, the German Science Foundation, the Israeli Science Foundation, the BSF-NSF, the Ministry of Agriculture, Forestry and Food and Slovenian Research Agency (CRP V1-1626), the Aage V. Jensen Naturfond (project: Kronvildt - viden, værdier og værktøjer), the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation) under Germany’s Excellence Strategy, National Centre for Research and Development in Poland, the Slovenian Research Agency, the David Shepherd Wildlife Foundation, Disney Conservation Fund, Whitley Fund for Nature, Acton Family Giving, Zoo Basel, Columbus, Bioparc de Doué-la-Fontaine, Zoo Dresden, Zoo Idaho, Kolmården Zoo, Korkeasaari Zoo, La Passarelle, Zoo New England, Tierpark Berlin, Tulsa Zoo, the Ministry of Environment and Tourism, Government of Mongolia, the Mongolian Academy of Sciences, the Federal Aid in Wildlife Restoration act and the Illinois Department of Natural Resources, the National Science Foundation, Parks Canada, Natural Sciences and Engineering Research Council, Alberta Environment and Parks, Rocky Mountain Elk Foundation, Safari Club International and Alberta Conservation Association, the Consejo Nacional de Ciencias y Tecnología (CONACYT) of Paraguay, the Norwegian Environment Agency and the Swedish Environmental Protection Agency, EU funded Interreg SI-HR 410 Carnivora Dinarica project, Paklenica and Plitvice Lakes National Parks, UK Wolf Conservation Trust, EURONATUR and Bernd Thies Foundation, the Messerli Foundation in Switzerland and WWF Germany, the European Union’s Horizon 2020 research and innovation program under the Marie Skłodowska-Curie Actions, NASA Ecological Forecasting Program, the Ecotone Telemetry company, the French National Research Agency, LANDTHIRST, grant REPOS awarded by the i-Site MUSE thanks to the “Investissements d’avenir” program, the ANR Mov-It project, the USDA Hatch Act Formula Funding, the Fondation Segre and North American and European Zoos listed at http://www.giantanteater.org/, the Utah Division of Wildlife Resources, the Yellowstone Forever and the National Park Service, Missouri Department of Conservation, Federal Aid in Wildlife Restoration Grant, and State University of New York, various donors to the Botswana Predator Conservation Program, data from collared caribou in the Northwest Territories were made available through funds from the Department of Environment and Natural Resources, Government of the Northwest Territories. The European Research Council Horizon2020, the British Ecological Society, the Paul Jones Family Trust, and the Lord Kelvin Adam Smith fund, the Tanzania Wildlife Research Institute and Tanzania National Parks. The Eastern Shoshone and Northern Arapahoe Fish and Game Department and the Wyoming State Veterinary Laboratory, the Alaska Department of Fish and Game, Kodiak Brown Bear Trust, Rocky Mountain Elk Foundation, Koniag Native Corporation, Old Harbor Native Corporation, Afognak Native Corporation, Ouzinkie Native Corporation, Natives of Kodiak Native Corporation and the State University of New York, College of Environmental Science and Forestry, and the Slovenia Hunters Association and Slovenia Forest Service. F.C. was partly supported by the Resident Visiting Researcher Fellowship, IMéRA/Aix-Marseille Université, Marseille. This work was partially funded by the Center of Advanced Systems Understanding (CASUS), which is financed by Germany’s Federal Ministry of Education and Research (BMBF) and by the Saxon Ministry for Science, Culture and Tourism (SMWK) with tax funds on the basis of the budget approved by the Saxon State Parliament. This article is a contribution of the COVID-19 Bio-Logging Initiative, which is funded in part by the Gordon and Betty Moore Foundation (GBMF9881) and the National Geographic Society.https://www.science.org/journal/sciencehj2023Mammal Research InstituteZoology and Entomolog