Back-to-back: The co-occurrence of DISH and ankylosing spondylitis from early modern Poland.

OBJECTIVE: This case study evaluates an individual with skeletal changes consistent with DISH and ankylosing spondylitis. We present here an evaluation of the individual's pathological skeletal changes and a review of the potential diagnoses. Finally, we offer a differential diagnosis of co-morbidity infrequently found in the paleopathological record. MATERIALS: The skeletal remains of a male, aged 50 + years from the early modern Polish (17th-18th century CE) site of Drawsko 1. METHODS: Skeletal remains were examined for the presence of spondyloarthropathies. RESULTS: The individual presented with anterolateral fusion of the vertebral bodies of T6-T10 with a "dripping candle wax" appearance, fusion of the right costovertebral joint at rib 8, fusion of the left apophyseal joints of T8-T10, and the calcification of the supraspinous ligament at T3-T4. The left sacroiliac joint shows intra-articular and para-articular fusion; the right has bony changes consistent with ongoing fusion. Entheseal reactions were noted on the left clavicle, scapulae, first metacarpals, ulnae, and humerii. Diffuse idiopathic skeletal hyperostosis (DISH), ankylosing spondylitis (AS), reactive arthritis (RA), psoriatic arthritis (PA), and enteropathic arthritis (EA) are considered as differential diagnoses. CONCLUSIONS: Based on the skeletal pattern of involvement, the individual suffered from both DISH and AS, which has previously been reported once in the paleopathological literature since 1950. The clinical literature indicates that co-occurrence of these two conditions is possible, with approximately 40 individuals affected. SIGNIFICANCE: This case study is significant for demonstrating the co-occurrence of DISH and AS in the paleopathological record. Additionally, this case contributes to the understanding of heterogenous frailty and syndemics. LIMITATIONS: No radiographs were taken to confirm the differential diagnosis. No aDNA analysis was conducted. SUGGESTIONS FOR FURTHER RESEARCH: The remains have been reburied; no further analysis is possible.

Deviant burials and social identity in a postmedieval Polish cemetery: An analysis of stable oxygen and carbon isotopes from the "vampires" of Drawsko.

OBJECTIVES: Deviant burials can reveal important information about both social and individual identity, particularly when the mortuary record is supplemented by an examination of skeletal remains. At the postmedieval (17th to 18th c. AD) cemetery of Drawsko (Site 1), Poland, six individuals (of n = 285) received deviant, anti-vampiristic mortuary treatment. A previous study using radiogenic strontium isotope ratios ( x¯= 0.7112 ± 0.0006, 1σ, n = 60) found that these "vampires" were in fact locals, not migrants to the region targeted for deviant burial due to their status as immigrant outsiders. However, considerable geologic overlap in strontium isotope ratios across the North European Plain may have masked the identification of at least some nonlocal individuals. This study further contextualizes strontium isotope ratios using additional biogeochemical data to test the hypothesis that additional nonlocals were present in the Drawsko cemetery. METHODS: Stable oxygen and carbon isotopes from the dental enamel of 58 individuals interred in both normative and atypical burials at Drawsko were analyzed. RESULTS: Both δ18 Oc(VPDB) ( x¯= -4.5 ± 0.7‰) and δ13 Cap isotope values ( x¯= -13.6 ± 0.8‰) displayed little variability and were not significantly different between vampire and normative burials, supporting prior strontium results of a largely local population. Nevertheless, homogeneity in oxygen isotope values across other northern European sites makes it difficult to speculate about isotopic regional diversity, leaving open the possibility that additional migrants to the region remain undetected. Additionally, carbon isotope values point to a locally sourced diet dominated by C3 resources but with some supplementation by C4 goods that likely included millet, fitting with historic descriptions of postmedieval diet in Poland. CONCLUSIONS: Those interred as vampires appear local to the region and thus likely underwent deviant funerary treatment due to some other social stigma not apparent from the skeleton.

A re-evaluation of the impact of radiographic orientation on the identification and interpretation of Harris lines.

The identification of Harris lines through radiographic analysis has been well-established since their discovery in the late nineteenth century. Most commonly associated with stress, the study of Harris lines has been fraught with inconsistent identification standards, high levels of intra- and interobserver error, and the inevitability of skeletal remodelling. Despite these methodological challenges, the use of Harris lines remains an important contributor to studies of health in archaeological populations. This research explores the radiographic process, specifically orientation and how Harris lines are initially captured for study. Using the Black Friars (13th-mid 17th centuries) skeletal sample from Denmark, 157 individuals (134 adults; 23 subadults) were radiographically analyzed in both an anterior-posterior (A-P) and medial-lateral (M-L) view for the left and right radii and tibiae. Based on the current methodological standards within the literature, it was hypothesized that the A-P view would provide the best resolution and visualization of Harris lines. The results, however, show that the number of lines visible in the M-L view were significantly higher than those visible in the A-P view; inferring that the M-L view is superior for the study of Harris lines.

Apotropaic practices and the undead: a biogeochemical assessment of deviant burials in post-medieval poland.

Apotropaic observances-traditional practices intended to prevent evil-were not uncommon in post-medieval Poland, and included specific treatment of the dead for those considered at risk for becoming vampires. Excavations at the Drawsko 1 cemetery (17th-18th c. AD) have revealed multiple examples (n = 6) of such deviant burials amidst hundreds of normative interments. While historic records describe the many potential reasons why some were more susceptible to vampirism than others, no study has attempted to discern differences in social identity between individuals within standard and deviant burials using biogeochemical analyses of human skeletal remains. The hypothesis that the individuals selected for apotropaic burial rites were non-local immigrants whose geographic origins differed from the local community was tested using radiogenic strontium isotope ratios from archaeological dental enamel. 87Sr/86Sr ratios ( = 0.7112±0.0006, 1σ) from the permanent molars of 60 individuals reflect a predominantly local population, with all individuals interred as potential vampires exhibiting local strontium isotope ratios. These data indicate that those targeted for apotropaic practices were not migrants to the region, but instead, represented local individuals whose social identity or manner of death marked them with suspicion in some other way. Cholera epidemics that swept across much of Eastern Europe during the 17th century may provide one alternate explanation as to the reason behind these apotropaic mortuary customs, as the first person to die from an infectious disease outbreak was presumed more likely to return from the dead as a vampire.

Engaging providers in medication adherence: a health plan case study.

BACKGROUND: Nonadherence to treatment regimens is a common, costly, and complex problem that is often overlooked in a busy primary care setting. OBJECTIVE: The goals of this study were to raise providers' awareness of nonadherence among their patients, to identify the reasons for lack of adherence, and engage physicians in addressing these barriers. METHOD: Five primary care practices agreed to participate. The project began in the fall of 2008 with a therapy gap analysis, using prescription drug data from the previous 18 months to identify nonadherent patients. Initially, 237 members were identified as potential nonadherent patients. Each practice was presented with the data related to its patients; the group then narrowed its sample using a chart review and/or patient outreach. Each practice had to determine the barriers to adherence, and was then asked to create action steps to improve patient adherence based on the group's unique results and the specific patient population. RESULTS: Barriers to adherence identified included prescription drug cost, multiple medications and dosing schedules, and patient as well as family level of understanding and acceptance of disease state. Each group gained an awareness of nonadherence as it related to their patients. For example, in the internal medicine practice, 33% (n = 17) of the patients reported stopping their medication because of cost. A common reason for poor adherence in the pediatric groups was that parents decided to stop their child's medication on weekends and in the summer, without a physician's recommendation. Using such feedback, each practice then developed its own methods to improve medication adherence within its patient population. CONCLUSION: Although the final numbers in this case study were small, the providers gained valuable insights regarding nonadherence in their practice. This study shows the importance of engaging providers in medication adherence as a way to improve this common problem. Making this universal issue a personal problem for providers is key to overcoming many of the adherence barriers.

Effects of a physician office generic drug sampling system on generic dispensing ratios and drug costs in a large managed care organization.

BACKGROUND: Greater use of generic drugs, particularly as measured by the generic utilization or dispensing ratio (GDR), is an effective means of managing care by attaining the same clinical outcome as brand drugs but at lower cost. Health plans encourage members to use generic drugs through copayments that are lower than for brand drugs. Encouraging physicians to prescribe generic drugs in therapeutic selection continues to be an opportunity for health plans to produce drug cost savings without compromising safety or efficacy. OBJECTIVE: To determine if the addition of an automated generic drug sampling system in primary care physician offices would increase (1) the GDR of the sampled therapeutic categories and (2) the overall GDR. METHODS: To encourage prescribers to increase their use of generic pharmaceuticals, this managed care organization of 2.3 million members with pharmacy benefits, who represent about two thirds of approximately 3.5 million total health plan members, collaborated with a vendor that developed an automated generic medication sampling intervention that takes place in the physician's office at the point of care. The generic sampling system (kiosk) included 21 distinct generic drugs in 36 variations of dose and strength. To isolate the effect of the generic sampling intervention from the general trend of greater generic drug use, we compared physicians participating in the generic sampling program with all other network physicians. Because formal statistical testing of program outcomes was precluded by incomplete physician data, we performed a descriptive, business-case analysis of the program. RESULTS: Before implementation of the generic sampling program, the physicians in the intervention group and the comparison group had the same GDR of 47.8%. In the first full year of the intervention in 2005, the 301 physicians participating in the generic sampling program had a GDR of 55.3% compared with 54.1% for all of the other approximately 33,000 network physicians. This absolute 1.2 percentage point difference narrowed to 0.8 points in 2006 (59.9% vs. 59.1%). After subtraction of payments made to the vendor of the generic samples, including all administrative costs, the direct drug cost savings were estimated to be $397,486 in 2005 and $453,545 in 2006. The direct drug cost savings per physician participating in the generic sampling program were estimated at $1,321 in 2005 and $719 in 2006. Members paid no copayment for the generic samples and paid lower copayments throughout the continued use of the generic drugs for chronic conditions such as hypertension. CONCLUSIONS: Physician practices that participated in the generic sampling program demonstrated an increase in the average GDR that was slightly greater than the increase in the comparison group of all other network physicians in each of the 2 measurement years, 2005 and 2006. Direct drug cost savings after subtraction of all administrative costs associated with the generic sampling program were estimated at $1,321 per participating physician in 2005 and $719 per participating physician in 2006. Members benefited from no copayment for the generic drug samples and from lower copayments for continued use of the generic drugs.