Differential diagnosis of metabolic disease in a commingled sample from 19th century Hisban, Jordan.

OBJECTIVE: This research attempts a differential diagnosis of skeletal lesions in a commingled sample from Hisban, Jordan, focusing on non-adults in the assemblage. MATERIALS: 2,883 well-preserved skeletal elements and 9 relatively complete skulls representing an MNI of 32 non-adults (<18 years old). METHODS: All skeletal elements were observed macroscopically and pathophysiological processes underlying any lesions or other anomalies were assessed, followed by a comparative approach to rule out potential diagnoses. RESULTS: The skeletal lesions observed were caused by inflammation due to chronic hemorrhaging, marrow hyperplasia due to an increase in hemopoiesis, rapid bone growth, and the impact of biomechanical strain on poorly mineralized elements. Rickets, scurvy, and acquired anemias best fit this pattern of lesions, although inflammation from other sources such as trauma or infection could not be definitively ruled out. CONCLUSIONS: The in utero and postnatal environments at Hisban were conducive to the development of vitamin C and D deficiencies from birth until 2 years of age. The analysis of commingled remains requires an ontological shift in the importance of the individual to the population in paleopathology. SIGNIFICANCE: This investigation demonstrates the efficacy of a combined biological and comparative approach in differential diagnosis in complicated commingled collections. In addition, it emphasizes the importance of the mother-infant dyad in understanding metabolic disease. LIMITATIONS: Histological and radiographic analyses were not included in this diagnostic study due to COVID-19 travel restrictions. SUGGESTIONS FOR FURTHER RESEARCH: Isotopic analysis to investigate childhood diet and histological and radiographic analyses to assess survival of deficiencies.

Decreased Mortality of falciparum Malaria in Anemic Prisoners of War?

Modern clinical trials have suggested that anemia protects against malaria mortality. Military records of the Second World War in Asia were examined to see if there was support for this hypothesis. When relatively well-nourished Imperial Japanese Navy sailors captured on Nauru (n = 799) were imprisoned on the Fauro Islands, 26% died from falciparum malaria. Similarly treated but very malnourished colocated Imperial Army soldiers experienced low stable malaria mortality. One-fifth of previously healthy Australian Army soldiers (n = 252) retreating from New Britain died largely because of malaria in April 1942. Malnourished prisoners of war, who were as a group very anemic, both Australian Army soldiers in Thailand and Japanese Army soldiers in Papua New Guinea, had high malaria rates but very low (< 3%) mortality rates. Malaria immunity does not adequately explain this dichotomy, suggesting that severe nutritional deprivation may be protective against malaria mortality possibly because of iron-deficiency anemia.

Ancient Egyptian health: the prevalence of anemia at the origins of agriculture and state level society.

Ancient Egyptians experienced a vast increase in population size following the Neolithic Revolution. Nomadic hunter-gatherer groups gradually adopted agriculture as their primary food subsistence strategy. Analyses of human societies shifting from foragers to farmers have provided evidence which suggests this transition is linked with an increase in disease and allostatic load. This paper presents an examination of cribra orbitalia and porotic hyperostosis prevalence in Predynastic and Dynastic Egyptians using public health evidence as a means to interpret the skeletal findings. The sample included 219 individuals from the regions of Naga-ed-Dêr, Mesheikh, Giza, and potentially El-Ahaiwah. The aim of this study was to identify significant differences of cribra orbitalia and porotic hyperostosis across time and sex. Application of a Fisher-Freeman-Halton's test indicated there were no differences in prevalence of cribra orbitalia or porotic hyperostosis between the Predynastic and Dynastic, nor were there differences between the sexes. The results of this study did not produce any evidence for an epidemiological shift to have occurred in post-agricultural Egypt. Further, the most likely explanation of the pattern of disease stems from a parasitic model of infection.

Paleopathological rigor and differential diagnosis: Case studies involving terminology, description, and diagnostic frameworks for scurvy in skeletal remains.

Diverse pathological processes can produce overlapping or even indistinguishable patterns of abnormal bone formation or destruction, representing a fundamental challenge in the understanding of ancient diseases. This paper discusses increasing rigor in differential diagnosis through the paleopathological study of scurvy. First, paleopathology's use of descriptive terminology can strive to more thoroughly incorporate international standards of anatomical terminology. Second, improved observation and description of abnormal skeletal features can help distinguish between anemia or vitamin C deficiency. Third, use of a structured rubric can assist in establishing a more systematic, replicable, and precise decision-making process in differential diagnosis. These issues are illustrated in the study of two new cases of suspected scurvy from northern Peru. From this, it appears possible that ectocranial vascular impressions may further examined as a morphological marker of scurvy in the skeleton. Also, increased paleopathological attention to pellagra is long overdue, especially as it may produce generally comparable lesions to scurvy. This paper reflexively speaks to the process of paleopathological problem solving and the epistemology of our discipline-particularly regarding the ways in which we can continuously improve description and the construction of diagnostic arguments.

Erythrokinetics: quantitative measurements of red cell production and destruction in normal subjects and patients with anemia.

To study erythropoiesis and anemia, one must have a firm foundation of indices that accurately measure red blood cell production and destruction. This paper, authored by hematology legends Arno G. Motulsky and Clement A. Finch, provides that foundation. Using methods that would not be approved in today's environment, the authors studied a cohort of normal healthy patients and an equal number of patients with different forms of anemia. The results confirm a reciprocal model of red cell production and destruction, show that anemia can be the result of either underproduction (a regenerative anemia or ineffective erythropoiesis) or increased destruction, and define parameters for distinguishing these 2 possibilities that are still widely used today.

Dental health and alimentation among the Quintana Roo Mayas: coastal and inland sites of the classic-postclassic periods.

OBJECTIVES: The goal of this study is to compare both dental and skeletal stress indicators of the Classic and Postclassic coastal and inland sites of the State of Quintana Roo, Mexico. The hypothesis is that coastal populations will show osteo and dental pathologies characteristic of a primarily marine food source combined with a diet of horticultural resources. This kind of alimentation provides people with less environmental stress and therefore a better health status. However, over time, in the Postclassic period, the health conditions deteriorated among both coastal and inland inhabitants, according to the hierarchization of the society, militarization, and commercial activities of all the coastal sites. METHODS: The sample was drawn from 19 sites (196 individuals of both sexes) from the east coast of the Yucatan Peninsula, as well as from inland localities within the boundaries of Quintana Roo. Both dental and osteological stress indicators were analyzed, and crosstabs were applied for absolute and relative frequencies and their corresponding χ(2) and F Fisher analyses. The osteopathological index of the coastal and inland sites of the Classic period were compared over time between the Classic coastal inhabitants and the Postclassic coastal inhabitants so as to understand how life conditions changed over time. The Mantel-Haenszel odds ratio, with the crosstabs controlling for sex (males and females), was also carried out. RESULTS: There are low frequencies of dental pathologies and anemia present in both the coastal and inland populations of Quintana Roo in the Classic and Postclassic times. Only the presence of periostitis is highly common in both types of site, and this is the only indicator with significant differences. The dental pathologies, anemia and periostitis, in general, present a slight upward trend in both the coastal and inland populations over time. The coastal populations have fewer frequencies of the above than the inland sites whilst, in the Postclassic period, both the coastal and inland sites register increased frequencies of all the indicators. Linear enamel hypoplasia (LEH) is the only indicator that does not follow this tendency. CONCLUSIONS: The analyzed indicators are in accord with the general tendency reported in the literature. The results revealed a general trend whereby the Classic inland sites display poorer life conditions than the Classic coastal sites. In the Postclassic period, this pattern changed because the frequencies of all stress indicators increased. The explanations regarding this tendency are related to the differential access to food resources between regions; coastal people had a varied diet and better sources of protein, taking into account the culture of alimentation, the type, and the sources (in general, fish) that have an important impact on the absorption of micronutrients and therefore greater impact on local health conditions. Also, it is plausible that they were able to access imported food through commerce (such as meat and vegetables/corn). The decline in health of the coastal people in the Postclassic period was probably associated with social stratification, increasing militarism, changes in the economic corpus, new pathogens, and the decline of the power structures prevailing throughout the Classic period.

Making birth defects 'preventable': pre-conceptional vitamin supplements and the politics of risk reduction.

Since the mid-1990s, governments and health organizations around the world have adopted policies designed to increase women's intake of the B-vitamin 'folic acid' before and during the first weeks of pregnancy. Building on initial clinical research in the United Kingdom, folic acid supplementation has been shown to lower the incidence of neural tube defects (NTDs). Recent debate has focused principally on the need for mandatory fortification of grain products with this vitamin. This article takes a longer view, tracing the transformation of folic acid from a routine prenatal supplement to reduce the risk of anaemia to a routine 'pre-conceptional' supplement to 'prevent' birth defects. Understood in the 1950s in relation to social problems of poverty and malnutrition, NTDs were by the end of the century more likely to be attributed to individual failings. This transition was closely associated with a second. Folic acid supplements were initially prescribed to 'high-risk' women who had previously borne a child with a NTD. By the mid-1990s, they were recommended for all women of childbearing age. The acceptance of folic acid as a 'risk-reducing drug' both relied upon and helped to advance the development of preventive and clinical practices concerned with women's health before pregnancy.

History of patient blood management.

This article traces the development of modern patient blood management (PBM) from its origins in 17th-century transfusion to the present day.

Health status among prehistoric Eskimos from Point Hope, Alaska.

Using the protocol outlined in The Backbone of History: Health and Nutrition in the Western Hemisphere (BBH) (Steckel and Rose. 2002a. The backbone of history: health and nutrition in the Western Hemisphere. Cambridge: Cambridge University Press), this project compares the Mark I Health Index (MIHI) scores of the Ipiutak (n = 76; 100BCE-500CE) and Tigara (n = 298; 1200-1700CE), two samples of North American Arctic Eskimos excavated from Point Hope, Alaska. Macroscopic examination of skeletal remains for evidence of anemia, linear enamel hypoplasias (LEH), infection, trauma, dental health, and degenerative joint disease (DJD) was conducted to assess differences in health status resulting from a major economic shift at Point Hope. These data demonstrate that despite differences in settlement pattern, economic system, and dietary composition, the MIHI scores for the Ipiutak (82.1) and Tigara (84.6) are essentially equal. However, their component scores differ considerably. The Ipiutak component scores are suggestive of increased prevalence of chronic metabolic and biomechanical stresses, represented by high prevalence of nonspecific infection and high frequencies of DJD in the hip/knee, thoracic vertebrae, and wrists. The Tigara experienced more acute stress, evidenced by higher prevalence of LEH and trauma. Comparison of overall health index scores with those published in BBH shows the MIHI score for the Ipiutak and Tigara falling just above the average for sites in the Western Hemisphere, adding support to the argument that the human capacity for cultural amelioration of environmental hardships is quite significant.

2009: a requiem for rHuEPOs--but should we nail down the coffin in 2010?

The recombinant human erythropoietins and allied proteins (epoetin alfa, attempted copies and biosimilar variants of epoetin alfa, epoetin beta, epoetin delta, epoetin zeta, epoetin theta, epoetin omega, darbepoetin alfa, and methoxy-polyethylene glycol-epoetin beta) are among the most successful and earliest examples of biotechnologically manufactured products to be used in clinical medicine. This article charts a brief history of their use in clinical medicine, mainly dealing with chronic kidney disease, paying special attention to how these agents were introduced into clinical medicine and what has happened subsequently; in 2009, there were several developments that could be regarded as a "perfect storm" in terms of the long-term use of these compounds in chronic kidney disease and oncology and, likely, elsewhere. We are now very much at a "crossroads," where mature reflection is required, because with the latest trials and meta-analyses, these therapies seem not only expensive but also very much a clinical tradeoff (increased risk of adverse effects versus a small gain in fatigue scores). How we arrived at this crossroads is a useful illustration of how easy it is, without properly designed randomized, controlled trials, to assume that clinical benefit must follow therapeutic interventions.

Lucy Wills (1888-1964): the life and research of an adventurous independent woman.

Lucy Wills was one of a pioneering generation of women in medicine and medical research in England. After a double first honours degree in botany and geology from Cambridge in 1911, she travelled to South Africa, where she worked as a nurse during the First World War. Wills then gained a medical degree in London in 1920. By the late 1920s she had developed an interest in haematology and began travelling to India to investigate pernicious anaemia in pregnancy. There she identified a substance often called 'the Wills' factor', which was later recognised as folic acid. Wills undertook a placebo trial of routine iron supplementation in pregnant women during the Second World War, hampered, but not stopped, by bombing. In retirement, she continued to study nutritional effects on health in South Africa and Fiji.