bluuebunny/crossref_metadata_2025 huggingface dataset:
Commerce and the Agrarian Empires: Northern India
Authors: Sahu Bhairabi Prasad
Published: November 2021

This article focuses on the shifts in the ways of seeing the history and historiography of the emergence of agrarian landscapes, manufacture of crafts, and trade and commerce in north India, during the mid-first millennium bce to the 13th century. Continued manifestation of settled agrarian localities, or janapadas, with its attendant concomitant processes, is visibly more noticeable from the middle of the first millennium ce onward, though their early beginnings can be traced back to the later Vedic times. The study of the janapadas or localities and regions, as distinguished from earlier regional studies, focusing on the trajectory of sociopolitical developments through time is a development dating to around the turn of the 21st century. It has much to do with the recognition of the fact that historical or cultural regions and modern state boundaries, which are the result of administrative decision-making, do not necessarily converge. Simultaneously, instead of engaging in macro-generalizations, historians have moved on to acknowledge that spaces in the past, as in the present, were differentiated, and there were uneven patterns of growth across regions and junctures. Consequently, since 1990 denser and richer narratives of the regions have been available. These constructions in terms of the patterns for early India have moved away from the earlier accounts of wider generalizations in time and space, colonization by Gangetic north India, and crisis. Alternatively, they look for change through continuities and try to problematize issues that were earlier subsumed under broader generalizations, and provide local and regional societies with the necessary agency. Rural settlements and rural society through the regions are receiving their due, and so are their networks of linkages with artisanal production, markets, merchants, and trade. The grades of peasants, markets, and merchants as well as their changing forms have attracted the notice of the historian. This in turn has compelled a shift in focus from being mostly absorbed with subcontinental history to situating it in its Asiatic and Indian Ocean background.
Regional Organizations and Geopolitics in the Indian Ocean
Authors: McDougall Derek
Published: November 2021

Regional organizations in the Indian Ocean need to be understood in their geopolitical context. The sense of “regionness” in the Indian Ocean is weak. There is some focus on the oceanic region as a whole, but also on the various sectors of the ocean: northwest, northeast, southwest, and southeast. India, China, and the United States are the most important of the major powers involved, with their interests and engagement extending across the whole ocean. Other extraregional powers include Japan, Russia, and the European Union (EU). Among the middle powers, the most important are France (especially in the southwest sector), Australia (southeast), South Africa (southwest), and Indonesia (northeast), with the United Kingdom also playing a role. Some Middle Eastern states (especially Iran, Saudi Arabia, Turkey, and the United Arab Emirates [UAE]) are involved in the Indian Ocean because the northwest sector has a strategic significance for issues in the Middle East and Southwest Asia. Then there is the “rest,” the range of Indian Ocean littoral and island states that are affected by developments in the Indian Ocean, especially in areas adjacent to their own territories.

There is only one comprehensive regional organization based on the whole Indian Ocean: the Indian Ocean Rim Association (IORA). There is also a comprehensive regional organization for the southwest sector: the Indian Ocean Commission (IOC). Most of the other Indian Ocean organizations focus on different kinds of maritime activities. The more significant regional organizations affecting the Indian Ocean are those relating to the adjoining regions but with some Indian Ocean involvement. These are the organizations relating to southern and eastern Africa, the Persian/Arabian Gulf, South Asia, and Southeast Asia.
Women in Southern African History
Authors: Becker Heike
Published: November 2021

Women have played complex roles in the history of Southern Africa, a vast region that comprises diverse local histories as well as social and cultural forms. The diversity of the region has been both integrated and fragmented through historical connections, which have centered on South Africa as a subimperial power.

Prior to colonial conquest and the impact of Christian missions and European trade, gender relations varied, partly due to an array of social and kinship systems. Overall, however, the position of women in southern African societies deteriorated after colonization. Economic, political, and cultural dynamics impacted on gender relations through the interaction of European and indigenous patriarchy, colonial rule, and capitalist modes of production, which reinforced and transformed one another, evolving into new structures and forms of domination.

The paradox of similarities due to settler colonialism and differences in respect of timing and pathways to decolonization impacted upon the trajectories of postcolonial gender politics and the representation of women in the postcolonial political structures of southern Africa.

Despite initial differences regarding legal gender equality, everywhere that liberation movements in power established themselves in the region, discourses of “African culture and tradition” became pertinent. Colonial customary laws and powers given to traditional leaders remain at the heart of contemporary battles over gender equality and social justice.
Trade Finance and Payment Methods in International Trade
Authors: Ahn JaeBin
Published: November 2021

International transactions are riskier than domestic transactions for several reasons, including, but not limited to, geographical distance, longer shipping times, greater informational frictions, contract enforcement, and dispute resolution problems. Such risks stem, fundamentally, from a timing mismatch between payment and delivery in business transactions. Trade finance plays a critical role in bridging the gap, thereby overcoming greater risks inherent in international trade. It is thus even described as the lifeline of international trade, because more than 90% of international transactions involve some form of credit, insurance, or guarantee. Despite its importance in international trade, however, it was not until the great trade collapse in 2008–2009 that trade finance came to the attention of academic researchers.

An emerging literature on trade finance has contributed to providing answers to questions such as: Who is responsible for financing transactions, and, hence, who would need liquidity support most to sustain international trade? This is particularly relevant in developing countries, where the lack of trade finance is often identified as the main hindrance to trade, and in times of financial crisis, when the overall drying up of trade finance could lead to a global collapse in trade.
The Role of Wage Formation in Empirical Macroeconometric Models
Authors: Nymoen Ragnar
Published: November 2021

The specification of model equations for nominal wage setting has important implications for the properties of macroeconometric models and requires system thinking and multiple equation modeling. The main models classes are the Phillips curve model (PCM), the wage–price equilibrium correction model (WP-ECM), and the New Keynesian Phillips curve (NKPCM). The PCM was included in the macroeconometric models of the 1960s. The WP‑ECM arrived in the late 1980s. The NKPCM is central in dynamic stochastic general equilibrium models (DSGEs). The three model classes can be interpreted as different specifications of the system of stochastic difference equations that define the supply side of a medium-term macroeconometric model. This calls for an appraisal of the different wage models, in particular in relation to the concept of the non-accelerating inflation rate of unemployment (NAIRU, or natural rate of unemployment), and of the methods and research strategies used. The construction of macroeconomic model used to be based on the combination of theoretical and practical skills in economic modeling. Wage formation was viewed as being forged between the forces of markets and national institutions. In the age of DSGE models, macroeconomics has become more of a theoretical discipline. Nevertheless, producers of DSGE models make use of hybrid forms if an initial theoretical specification fails to meet a benchmark for acceptable data fit. A common ground therefore exists between the NKPC, WP‑ECM, and PCM, and it is feasible to compare the model types empirically.
Aterian
Authors: Garcea Elena A.A.
Published: November 2021

The Aterian is a North African late Middle Stone Age techno-complex. It is spread from the Atlantic coast in Morocco to the Middle Nile Valley in Sudan and from the Mediterranean hinterland to the Southern Sahara. Chronologically, it covers the period between c. 145,000 years bp and 29,000 bp, spanning across discontinuous, alternating dry (end of MIS 6 and MIS 4) and humid (MIS 5 and MIS 3) climatic phases. Few, but significant human remains indicate that the makers of the Aterian complex belong to early Homo sapiens. Their osteological features show affinities with the early anatomically modern human record in the Levant (Skhul and Qafzeh), suggesting that Aterian groups may have taken part in the initial dispersals out of Africa by Homo sapiens. Toolkits consist of a variety of implements not only made of stone but also of bone (points, spatulas, knives, and retouchers). They include tools that were lacking in earlier or other North African contemporary contexts, namely bifacial foliates, blades, perforators, burins, endscrapers, and particularly tanged pieces. Overemphasis on tanged tools often obscured the complexity of the Aterian, which instead displays a wide range of cultural and behavioral innovations. New mobility patterns and intra-site organization, as well as early symbolism with the use of Nassariidae shells and ochre, corroborate early fully complex behavior by these populations. Given the broad geographic and chronological extension of the Aterian, differences are evident at both local and regional scales. They suggest the development of a flexible and variable techno-complex mirroring considerable adaptive cognitive and behavioral plasticity derived from nonlinear processes. Such diversified behavioral experiments result from multiple and noncumulative trajectories due to different internal and external stimuli but are still part of a single cultural entity.
Judeo-Spanish (Judezmo, Ladino)
Authors: Bunis David M.
Published: November 2021

The Ibero-Romance-speaking Jews of medieval Christian Iberia were linguistically distinct from their non-Jewish neighbors primarily as a result of their language’s unique Hebrew-Aramaic component; preservations from older Jewish Greek, Latin, and Arabic; a tradition of translating sacred Hebrew and Aramaic texts into their language using archaisms and Hebrew-Aramaic rather than Hispanic syntax; and their Hebrew-letter writing system. With the expulsions from Iberia in the late 15th century, most of the Sephardim who continued to maintain their Iberian-origin language resettled in the Ottoman Empire, with smaller numbers in North Africa and Italy. Their forced migration, and perhaps a conscious choice, essentially disconnected the Sephardim from the Spanish language as it developed in Iberia and Latin America, causing their language—which they came to call laðino ‘Romance’, ʤuðezmo or ʤuðjó ‘Jewish, Judezmo’, and more recently (ʤudeo)espaɲol ‘Judeo-Spanish’—to appear archaic when compared with modern Spanish. In their new locales the Sephardim developed the Hispanic component of their language along independent lines, resulting in further differentiation from Spanish. Divergence was intensified through borrowing from contact languages of the Ottoman Empire such as Turkish, Greek, and South Slavic. Especially from the late 18th century, factors such as the colonializing interests of France, Italy, and Austro-Hungary in the region led to considerable influence of their languages on Judezmo. In the 19th century, the dismemberment of the Ottoman and Austro-Hungarian empires and their replacement by highly nationalistic states resulted in a massive language shift to the local languages; that factor, followed by large speech-population losses during World War II and immigration to countries stressing linguistic homogeneity, have in recent years made Judezmo an endangered language.
Verbal Plurality in the Romance Languages
Authors: Cabredo Hofherr Patricia
Published: November 2021

Verbal plurality is commonly defined as a morphological means of marking event plurality on verbs. However, the definition of verbal plurality in terms of discrete event plurality hides a number of complexities. Firstly, many verbal markers that may mark discrete event multiplicities do not intrinsically mark discrete events, as they also allow durative, intensive, and attenuative readings. This suggests that discrete event multiplicity may emerge from quantity expressions that do not themselves impose discreteness. Secondly, markers of discrete event multiplicities fall into different classes. Additive markers in particular have to be treated as a separate type of event plurality, as they include presupposed and asserted events in the event plurality.
Urban Planning and Social Work
Authors: Walker Laurie A.
Published: November 2021

Urban neighborhood disinvestment in the United States resulted in deferred maintenance of buildings and common social problems experienced by residents. Strategies to redevelop neighborhoods include collaboration among many subsystems seeking to collectively invest in places and people. Contemporary federal initiatives focus on incentivizing coordinated investments between existing local community-based organizations, local and federal government, and private investors. Public–private partnerships include anchor institutions with commitments to the long-term success of place-based initiatives who invest their financial, intellectual, social, and political capital. Social workers are embedded in local community-based organizations and relationships with residents in neighborhoods experiencing redevelopment. Social workers can help guide top-down and bottom-up approaches to neighborhood revitalization toward more equitable and inclusive processes and outcomes. Resident engagement in redeveloping neighborhoods takes many forms and requires differing skill sets for social workers. Urban redevelopment is a global trend with common critiques regarding relying on gentrification and market-driven strategies with private investors.
Gentrification
Authors: Thurber Amie , Krings Amy
Published: November 2021

Gentrification can be understood as the process through which geographical areas become increasingly exclusive, which disproportionately harms people living in poverty and people of color, as well as the elderly, families, and youth. As such, this article argues that macro social work practitioners should view gentrification as a key concern. Thus, to help guide macro interventions, the article begins by first defining gentrification and describing ways to measure it, while emphasizing its difference from revitalization. Second, the article explores causes of gentrification, including its relationship to systemic racism. Third, the article explores the consequences of gentrification on individuals’ and communities’ well-being, considering how these consequences can influence macro practice. Finally, the article provides insight into ways that macro practitioners can strategically with others to prevent gentrification, mitigate its harms, and proactively support community well-being in areas threatened by gentrification.
DeepCEL0 for 2D single-molecule localization in fluorescence microscopy
Authors: Cascarano Pasquale , Comes Maria Colomba , Sebastiani Andrea , Mencattini Arianna , Loli Piccolomini Elena , Martinelli Eugenio
Published: November 2021

Motivation

In fluorescence microscopy, single-molecule localization microscopy (SMLM) techniques aim at localizing with high-precision high-density fluorescent molecules by stochastically activating and imaging small subsets of blinking emitters. Super resolution plays an important role in this field since it allows to go beyond the intrinsic light diffraction limit.

Results

In this work, we propose a deep learning-based algorithm for precise molecule localization of high-density frames acquired by SMLM techniques whose ℓ2-based loss function is regularized by non-negative and ℓ0-based constraints. The ℓ0 is relaxed through its continuous exact ℓ0 (CEL0) counterpart. The arising approach, named DeepCEL0, is parameter-free, more flexible, faster and provides more precise molecule localization maps if compared to the other state-of-the-art methods. We validate our approach on both simulated and real fluorescence microscopy data.

Availability and implementation

DeepCEL0 code is freely accessible at https://github.com/sedaboni/DeepCEL0.
RCandy: an R package for visualizing homologous recombinations in bacterial genomes
Authors: Chaguza Chrispin , Tonkin-Hill Gerry , Lo Stephanie W , Hadfield James , Croucher Nicholas J , Harris Simon R , Bentley Stephen D
Published: November 2021

Homologous recombination is an important evolutionary process in bacteria and other prokaryotes, which increases genomic sequence diversity and can facilitate adaptation. Several methods and tools have been developed to detect genomic regions recently affected by recombination. Exploration and visualization of such recombination events can reveal valuable biological insights, but it remains challenging. Here, we present RCandy, a platform-independent R package for rapid, simple and flexible visualization of recombination events in bacterial genomes.

Availability and implementation

RCandy is an R package freely available for use under the MIT license. It is platform-independent and has been tested on Windows, Linux and MacOSX. The source code comes together with a detailed vignette available on GitHub at https://github.com/ChrispinChaguza/RCandy.

Supplementary information

Supplementary data are available at Bioinformatics online.
Graphical Gaussian process models for highly multivariate spatial data
Authors: Dey Debangan , Datta Abhirup , Banerjee Sudipto
Published: November 2021

For multivariate spatial Gaussian process models, customary specifications of cross-covariance functions do not exploit relational inter-variable graphs to ensure process-level conditional independence between the variables. This is undesirable, especially in highly multivariate settings, where popular cross-covariance functions, such as multivariate Matérn functions, suffer from a curse of dimensionality as the numbers of parameters and floating-point operations scale up in quadratic and cubic order, respectively, with the number of variables. We propose a class of multivariate graphical Gaussian processes using a general construction called stitching that crafts cross-covariance functions from graphs and ensures process-level conditional independence between variables. For the Matérn family of functions, stitching yields a multivariate Gaussian process whose univariate components are Matérn Gaussian processes, and which conforms to process-level conditional independence as specified by the graphical model. For highly multivariate settings and decomposable graphical models, stitching offers massive computational gains and parameter dimension reduction. We demonstrate the utility of the graphical Matérn Gaussian process to jointly model highly multivariate spatial data using simulation examples and an application to air-pollution modelling.
Lesion covariance networks reveal proposed origins and pathways of diffuse gliomas
Authors: Mandal Ayan S , Romero-Garcia Rafael , Seidlitz Jakob , Hart Michael G , Alexander-Bloch Aaron F , Suckling John
Published: November 2021

Diffuse gliomas have been hypothesized to originate from neural stem cells in the subventricular zone and develop along previously healthy brain networks. Here, we evaluated these hypotheses by mapping independent sources of glioma localization and determining their relationships with neurogenic niches, genetic markers and large-scale connectivity networks. By applying independent component analysis to lesion data from 242 adult patients with high- and low-grade glioma, we identified three lesion covariance networks, which reflect clusters of frequent glioma localization. Replicability of the lesion covariance networks was assessed in an independent sample of 168 glioma patients. We related the lesion covariance networks to important clinical variables, including tumour grade and patient survival, as well as genomic information such as molecular genetic subtype and bulk transcriptomic profiles. Finally, we systematically cross-correlated the lesion covariance networks with structural and functional connectivity networks derived from neuroimaging data of over 4000 healthy UK BioBank participants to uncover intrinsic brain networks that may that underlie tumour development. The three lesion covariance networks overlapped with the anterior, posterior and inferior horns of the lateral ventricles respectively, extending into the frontal, parietal and temporal cortices. These locations were independently replicated. The first lesion covariance network, which overlapped with the anterior horn, was associated with low-grade, isocitrate dehydrogenase -mutated/1p19q-codeleted tumours, as well as a neural transcriptomic signature and improved overall survival. Each lesion covariance network significantly coincided with multiple structural and functional connectivity networks, with the first bearing an especially strong relationship with brain connectivity, consistent with its neural transcriptomic profile. Finally, we identified subcortical, periventricular structures with functional connectivity patterns to the cortex that significantly matched each lesion covariance network. In conclusion, we demonstrated replicable patterns of glioma localization with clinical relevance and spatial correspondence with large-scale functional and structural connectivity networks. These results are consistent with prior reports of glioma growth along white matter pathways, as well as evidence for the coordination of glioma stem cell proliferation by neuronal activity. Our findings describe how the locations of gliomas relate to their proposed subventricular origins, suggesting a model wherein periventricular brain connectivity guides tumour development.
The Devastating Economic Impact of COVID-19 on Older Black and Latinx Adults: Implications for Health and Well-Being
Authors: Garcia Marc A , Thierry Amy D , Pendergrast Claire B
Published: November 2021

Objectives

While disparities in coronavirus disease 2019 (COVID-19) infections and mortality have been documented for older Black and Latinx populations, pandemic-related economic impacts have been less studied for these groups. Minoritized older adults may be particularly vulnerable to financial hardships given their precarious socioeconomic positions. Thus, we aim to highlight the devastating economic impact of the ongoing COVID-19 pandemic and subsequent economic recession on older Black and Latinx adults, with a particular focus on the foreign-born population.

Methods

This study used data from the 2020 COVID-19 module of the Health and Retirement Study. The sample included adults older than 50 years of age who were U.S.-born non-Latinx White and Black, U.S.-born Latinx, and foreign-born Latinx (n = 2,803). We estimated age-standardized prevalence and means of variables indicating financial impact and economic hardship during the pandemic. We further examined differences in these measures across racial/ethnic and nativity groups.

Results

Our findings document stark racial/ethnic inequalities in the pandemic’s economic impact on older adults. Results show the pandemic has negatively affected older Black and Latinx adults across a host of economic factors (e.g., paying bills, affording health-related needs, or purchasing food), with foreign-born Latinx experiencing greater economic hardships relative to other groups.

Discussion

During the COVID-19 pandemic, older Black and Latinx adults are experiencing disparate economic effects, including lacking money to cover basic needs, compared to older White adults. The implications of the economic shocks of the pandemic for the health and well-being of older Black and Latinx adults warrant policy-oriented action toward promoting equity.
Testing length-based reference points in a management strategy evaluation for cuckoo ray (Leucoraja naevus) and thornback ray (Raja clavata)
Authors: Miethe Tanja , Dobby Helen
Published: November 2021

Elasmobranchs grow relatively slowly and mature at a relatively high age, leading to longer generation time. Due to low fecundity of these stocks, sufficient numbers of mature individuals are important to ensure a viable recruitment level and sustainable management. Length-based indicators (LBIs), such as the mean length and the mean length of the largest 5% in the catch, can be used to characterize the length distribution of exploited stocks and aid a data-limited assessment. Reference points for these indicators are calculated using basic life history parameters. Using cuckoo ray, Leucoraja naevus, and thornback ray, Raja clavata, as example species, we apply management strategy evaluations to test the performance of LBI-based harvest control rules (HCRs) in their ability to recover overexploited stocks. We illustrate the importance of the stock–recruitment relationship for the management outcome. If immature individuals are targeted by the fishery, HCRs perform better in terms of stock recovery when coupled with reference points, which account for the maturation schedule of the stock. The sensitivity of reference points to parameter misspecification means that elasmobranchs stocks in which immature individuals are exploited by the fishery may require more precautionary reference points, with consideration of the trade-off between biomass recovery and yield.
Optimal convergence of arbitrary Lagrangian–Eulerian iso-parametric finite element methods for parabolic equations in an evolving domain
Authors: Li Buyang , Xia Yinhua , Yang Zongze
Published: November 2021

An optimal-order error estimate is presented for the arbitrary Lagrangian–Eulerian (ALE) finite element method for a parabolic equation in an evolving domain, using high-order iso-parametric finite elements with flat simplices in the interior of the domain. The mesh velocity can be a linear approximation of a given bulk velocity field or a numerical solution of the Laplace equation with specified boundary value matching the velocity of the boundary. The optimal order of convergence is obtained by comparing the numerical solution with the ALE-Ritz projection of the exact solution, and by establishing an optimal-order estimate for the material derivative of the ALE-Ritz projection error.
Effect of Aging on Three Lures Used for MonitoringCeratitis capitata(Diptera: Tephritidae): Release Rate, Volatile Composition, and Fly Recaptures
Authors: Gómez-Escobar Enoc , Alavez-Rosas David , Castellanos David , Quintero-Fong Luis , Liedo Pablo , Malo Edi A
Published: November 2021

Prevention and control programs for Ceratitis capitata require a large supply of lures and traps for use in established trapping networks and mass-trapping suppression measures. The main lures currently used are: Trimedure (TML), three-component Biolure (BL), and Ceratrap (CT). The aim of this study was to determine the release rates of these lures, the chemical composition of their volatiles, and how these parameters change with exposure time. Tests were conducted under field conditions at three different elevations (25, 500, and 1,300 masl) during the dry and rainy seasons in Chiapas, Mexico. We found that for TML and BL, the release rate was similar in both seasons and at all three elevations. In the case of CT, the release rate was greater during the dry season and at the lowest elevation during the rainy season. With the caveat of using solid-phase microextraction technique for identification of lure compounds in this study, we found that the volatile compounds of TML were maintained throughout the rainy season, however, in the dry season, some compounds could not be detected. The volatile compounds emitted by BL were trimethylamine, ammonium acetate, and acetamide. Among volatile compounds of CT, acetic acid was the most abundant in the rainy season, while minor compounds were only detected during the first five weeks. Recapture rates were affected by elevation in the three lures tested and there was a significant interaction between elevation in exposure time for TML and BL.
Mitochondrial capture and subsequent genetic divergence generates a novel haplogroup: evidence from ancient and ongoing hybridization in mule and white-tailed deer
Authors: Wright Emily A , Roberts Emma K , Platt Roy N , Bayouth Jacob V , Conway Warren C , Bradley Robert D
Published: November 2021

Odocoileus virginianus (white-tailed deer) and O. hemionus (mule deer) are sympatric across much of North America. Molecular evidence suggests that up to 24% of individuals in some populations are a product of hybrid ancestry. Several studies have alluded to ancient and recent introgression between Odocoileus spp.; however, no divergence dates were proposed. Herein, phylogenetic analyses of DNA sequences obtained from the mitochondrial Cytochrome b gene in 690 individuals identified three clades corresponding to black-tailed deer, white-tailed deer, or a unique combination of both white-tailed deer and mule deer. White-tailed deer and mule deer diverged from a common ancestor of approximately 3.13 mya followed by an ancient hybridization event of approximately 1.32 mya, in which the white-tailed deer mitochondrial genome was “captured” by mule deer. This hybridization event produced a novel haplogroup for white-tailed deer and mule deer located west of the Appalachian Mountains and east of the Cascade Range, south to Veracruz, Mexico, and north to the Yukon Territory, Canada. The ancestral mule deer-like mitochondrial genome appears to be restricted to black-tailed deer distributed along the western portion of the Cascade and Sierra Nevada Ranges of the United States and Canada, whereas the ancestral white-tailed deer-like mitochondrial genome is restricted to the eastern United States and portions of Latin America and Caribbean regions. The “captured mitochondrial genome” has continued on an independent evolutionary trajectory and represents a unique and broadly distributed haplogroup that is 7.25% and 2.84% different from the ancestral mule deer and ancestral white-tailed deer haplogroups, respectively.
Telehealth Cybersecurity
Authors: Hood Colton D.
Published: November 2021

Clinical information systems are becoming increasingly complex, and telehealth is no exception. Threats to information systems are far and wide including phishing, malware, ransomware and even advanced persistent threats. Maintaining good security practices is necessary in order to secure telehealth and other clinical information systems. Compliance with the HIPAA Security Rule is mandatory, while providing a practical framework for good security practices and self-guidance that ensure basic compliance to all covered entities regardless of their level of IT support. Good security practices are essential to build trust in the telehealth system for both providers, and clinicians, as well as patients.
Role of Telemedicine in Guiding Rural Emergent Neurosurgical Care
Authors: Chohan M. Omar , Stippler Martina , Wendt Susy Salvo , Yonas Howard
Published: November 2021

Teleneurosurgery can play a vital role in the care of patients in hospitals and community health settings where neurosurgical expertise is not available. The combination of audiovisual interaction of a neurosurgeon with the emergency physician, the patient and the patient’s family, combined with an intense education program delivered to the originating site care team, has greatly enhanced the appropriate triage of patients in community hospitals. The result is better patient care, improved patient and family satisfaction, cost savings, and the retention of patients within the local community care system, as well as the improved sustainability of the wider health delivery system. To succeed, start-up financial support is often needed to provide the required technical elements and 24/7 neurosurgical availability.
Medical Subspecialty Telehealth Consults
Authors: Lew Susie Q. , Sharma Shailendra , Siegel Marc O. , Akselrod Hana , Kaur Simranjit , Kumar Anita , Borum Marie L. , Gross Hartmut
Published: November 2021

Health care reforms are advancing new care models that emphasize population-based outcomes. Emergency clinicians are challenged to provide coordinated care with limited resources. Emerging value-based models create the incentives for emergency clinicians to collaborate with specialists to provide high-quality care while lowering cost by reducing admissions when possible. Subspecialty consultation may be difficult to obtain in regions where the population does not support a subspecialist or where there is a workforce shortage. However, obtaining a telehealth subspecialist consult from a remote pool, local network, or established patient–physician relationship can provide such a service. Several use-cases are presented to illustrate how telehealth subspecialty consultation from the emergency department can change patient care and outcomes.
Weakness With Neck Flexion
Authors: Weinshenker Brian G.
Published: November 2021

A 51-year-old woman sought care for difficulty “picking up” her right foot after walking for 30 minutes; with rest, the symptoms would subside. A few months later, she reported a “zinging” sensation in her right 4th and 5th fingers and down her right side with neck flexion. Brain magnetic resonance imaging showed tiny nonspecific lesions not suggestive of demyelinating disease and a single T2 hyperintensity at the cervicomedullary junction that did not enhance with gadolinium administration. Cerebrospinal fluid analysis showed 10 oligoclonal bands on isoelectric focusing electrophoresis and a mildly increased immunoglobulin G index of 0.73. The patient was diagnosed with solitary sclerosis, suspected to be a form of central nervous system demyelinating disease strongly related to multiple sclerosis. Treatment was based on a diagnosis of “primary progressive multiple sclerosis,” although the patient did not satisfy the criterion of dissemination in space. The patient was being treated with glatiramer acetate 40 mg 3 times weekly for a presumptive diagnosis of multiple sclerosis before evaluation at Mayo Clinic. After our evaluation, she was advised that no treatments at that time were efficacious to prevent deterioration in patients with primary progressive multiple sclerosis. The mainstay of treatment is physical medicine modalities, including principles of energy conservation and, when necessary, mobility aids, such as braces and canes. The presentation of disease in this patient suggested a chronic myelopathy. Her symptoms did not develop acutely and manifested only after she walked a distance. Symptoms involving the upper and lower extremities and precipitation of Lhermitte sign with neck flexion also suggested a spinal cord lesion, typically a demyelinating lesion. However, a single spinal cord lesion present at the cervicomedullary junction. Oligoclonal bands are detected in patients with central nervous system infections or paraneoplastic disorders that might be associated with myelopathy.
Progressive Spasticity With a Single Magnetic Resonance Imaging Lesion
Authors: Banks Samantha A. , Flanagan Eoin P.
Published: November 2021

A 59-year-old White man with a history of excised basal and squamous cell skin cancers was evaluated for gait difficulties. He had erectile dysfunction but no bowel or bladder dysfunction. He also reported fatigue. He began using a cane for ambulation 2 weeks before evaluation at our facility. His medications included vitamin D and sildenafil. He was a lifelong nonsmoker and had no family history of multiple sclerosis. Neurologic examination at the time of our evaluation 3 years after onset was notable for a positive Hoffman sign on the right and mild weakness of the right triceps but preserved strength elsewhere. He had a spastic gait with moderate spasticity in both lower extremities, hyperreflexic patellar and ankle jerks bilaterally, and bilateral positive Babinski sign. The remainder of the examination was essentially normal.

Magnetic resonance imaging of the brain showed a single lesion at the cervicomedullary junction and medullary pyramids, more prominent on the right. There was also some accompanying atrophy that was also visible on cervical spine magnetic resonance imaging. Results of cerebrospinal fluid analysis showed a normal white blood cell count, increased protein concentration (108 mg/dL), and positive oligoclonal bands.

The progressive nature of his symptoms, spinal fluid results, and lesion appearance were all consistent with a diagnosis of progressive solitary sclerosis.

At the time this patient was seen, no immunomodulatory medications for progressive solitary sclerosis were approved, so no immunomodulatory medication was tried. Ongoing symptomatic management was recommended.

Progressive solitary sclerosis is a rare variant of multiple sclerosis in which patients have a single central nervous system demyelinating lesion and development of motor progression attributable to that lesion. Patients can initially have a clinical episode followed by progression or can have a progressive course without an initial relapse.
Encephalopathy and Quadriparesis After an Upper Respiratory Tract Infection
Authors: Chiriboga A. Sebastian Lopez
Published: November 2021

A 23-year-old woman with no pertinent medical history sought care at the emergency department after having difficulties with ambulation, with bilateral leg weakness and incoordination. Her coworkers reported that she was acting erratically during the previous 24 hours. Two weeks before the onset of the neurologic symptoms, the patient had a fever, productive cough, and generalized myalgias and was diagnosed with influenza type B based on a positive nasopharyngeal swab. The family history was noncontributory, and the patient did not use illicit drugs or have relevant occupational exposures.

Brain magnetic resonance imaging demonstrated large confluent white matter hyperintensities, without restricted diffusion or enhancement, and a longitudinally extensive lesion in the cervical spine extending from C3 to C7. Cerebrospinal fluid analysis revealed increased protein concentration, glucose level, red blood cell count, and white blood cell count with 78% lymphocytes.

On the basis of the preceding infection, imaging findings, and negative infectious investigations, there was a high suspicion for a diagnosis of acute disseminated encephalomyelitis.

Because of the suspicion for acute disseminated encephalomyelitis and before the confirmation of seropositivity for myelin oligodendrocyte glycoprotein-immunoglobulin G1, the patient was treated with intravenous methylprednisolone and courses of plasma exchange. After administration of immunotherapy, the encephalopathy improved substantially, which allowed for extubation and improvement of her quadriplegia and urinary retention. The patient was discharged from the hospital on oral prednisone therapy. The patient has had no further episodes as of the last follow-up (5 years after the initial event).

Acute disseminated encephalomyelitis is a monophasic idiopathic inflammatory demyelinating disease that predominantly affects the white matter of the brain and spinal cord. Acute disseminated encephalomyelitis typically follows an infection or, rarely, immunization.
Multiple Sclerosis and Cognitive Impairment
Authors: Valencia-Sanchez Cristina , Carter Jonathan L.
Published: November 2021

A 60-year-old woman with a history of multiple sclerosis was evaluated for cognitive concerns. At age 30 years she had an episode of optic neuritis, followed by an episode of bilateral lower extremity numbness at age 35 years. In the following years, she had at least 6 further multiple sclerosis relapses, the last one approximately 3 years before the current presentation. She was initially treated with interferon, but she did not tolerate it. She had been taking glatiramer acetate for the past 3 years. She had noticed progressive deterioration of her gait for the past 3 years, having to use a cane on occasions.

Magnetic resonance imaging of the brain showed multiple demyelinating lesions), and magnetic resonance imaging of the cervical spine showed 1 small demyelinating lesion at C6. Vitamin B12 level and thyroid function were normal. Comprehensive neuropsychological testing showed multidomain cognitive impairment, mainly impairment of speed of information processing, spatial discrimination skills, and attention/concentration.

The patient’s multiple sclerosis phenotype was consistent with secondary progressive multiple sclerosis. Her cognitive impairment profile, mainly affecting information processing speed and disinhibition suggestive of frontal dysfunction, was consistent with multiple sclerosis.

The patient began a cognitive rehabilitation program, and learning and memory aids were recommended. Lifestyle changes were also recommended, including weight loss and physical exercise. She was given recommendations for sleep hygiene and began taking gabapentin for neuropathic pain and restless legs.

Cognitive impairment is common in patients with multiple sclerosis. Slowed cognitive processing speed and episodic memory decline are the most common cognitive deficits in MS, with additional difficulties in executive function, verbal fluency, and visuospatial analysis.
New-Onset Gait Difficulty With Kappa Free Light Chains in Cerebrospinal Fluid
Authors: Willrich Maria Alice V. , Saadeh Ruba S.
Published: November 2021

A 49-year-old woman sought care for a 9-month history of gait difficulty. She was dragging her right foot when walking and could not walk more than 3 blocks because of right leg weakness. Physical examination showed right-sided weakness of hip flexion and foot dorsiflexion and symmetrical hyperreflexia at the knees and ankles.

Magnetic resonance imaging of the brain showed multiple foci of T2 hyperintensity throughout the white matter in both cerebral and cerebellar hemispheres, predominantly in a periventricular distribution. Several small enhancing lesions and mild generalized cerebral volume loss were seen. The appearance and distribution were consistent with a demyelinating process such as multiple sclerosis. Magnetic resonance imaging of the cervical and thoracic spine showed multiple small T2 hyperintensities, including 1 enhancing lesion in the cervical spinal cord. Oligoclonal bands were positive, with 11 unique bands in the cerebrospinal fluid. The concentration of cerebrospinal fluid kappa free light chains was increased, at 0.314 mg/dL.

The patient was diagnosed with relapsing-remitting multiple sclerosis.

A 5-day course of intravenous corticosteroids was started, after which she noted clinical improvement. At her last follow-up 2 years after initial evaluation, the patient has been stable with no new clinical multiple sclerosis episodes and stable magnetic resonance imaging disease burden with no new lesions.

The diagnosis of multiple sclerosis incorporates clinical, imaging, and laboratory evidence. The 2017 revised McDonald criteria state that a finding of cerebrospinal fluid -specific oligoclonal bands can replace the criterion for dissemination in time to make a diagnosis of definitive multiple sclerosis. The standard test for oligoclonal bands is performed using isoelectric focusing electrophoresis and takes more than 3 hours to complete. The case patient had 11 unique cerebrospinal fluid bands. The number of bands is not correlated with disease severity or prognosis.
Highly Active Multiple Sclerosis
Authors: Kassa Roman , Tobin W. Oliver
Published: November 2021

A 16-year-old girl was evaluated for symptoms of thoracic myelitis with sensory loss below T12, gait difficulty, constipation, and incomplete bladder emptying. On evaluation, she had a flat affect, normal cranial nerve function, and normal motor examination findings. Deep tendon reflexes were symmetric, and plantar responses were flexor. She had a sensory level at T12 with diminished vibratory sense distal to the knees and normal coordination and gait.

Magnetic resonance imaging of the brain, cervical spine, and thoracic spine showed a high burden of disease, with multiple enhancing lesions indicative of highly active disease. Spinal fluid analysis showed 16 white blood cells/µL with 95% lymphocytes; protein, 70 mg/dL; 7 unique oligoclonal bands; and immunoglobulin G index, 0.87. Neurocognitive testing showed normal scores overall, and psychiatric evaluation indicated major depressive disorder.

She was given a diagnosis of relapsing-remitting multiple sclerosis, highly active.

On initial evaluation for thoracic myelitis, intravenous methylprednisolone was given, with resolution of bladder and bowel symptoms and 75% recovery of sensory loss. High-dose interferon beta-1a was then initiated. At age 28 years, she had worsening left hemiparesis of 1 month’s duration. Neurologic examination showed word-finding difficulty, gaze-evoked horizontal nystagmus, moderate left-sided spastic hemiparesis in a pyramidal distribution, brisk reflexes with an extensor plantar response on the left, sensory ataxia in the left leg, and a hemiparetic gait. Intravenous methylprednisolone was given, with minimal improvement. She then received plasmapheresis with about 50% recovery of power. The patient was seropositive for antibodies to JC polyoma virus.

Despite the increased risk of progressive multifocal leukoencephalopathy, natalizumab was reinitiated considering the even higher risk of long-term disability due to continued active disease (highly active multiple sclerosis). Her therapy was transitioned to teriflunomide. Six months later she returned with new right leg weakness and received high-dose intravenous corticosteroids for 5 days, followed by rituximab infusion. On follow-up neuroimaging, breakthrough disease activity was noted, and her therapy was switched to alemtuzumab.

Highly active multiple sclerosis is characterized by frequent clinical episodes, with or without high disease activity on neuroimaging as evidenced by multiple enhancing lesions or interval new lesion formation, and disability accrual. It includes a spectrum of patients with clinical and radiologic evidence of ongoing disease activity who have no response to adequate treatment with multiple sclerosis disease-modifying therapy.