Analysis of patterning in the occurrence of skeletal lesions used as indicators of vitamin D deficiency in subadult and adult skeletal remains

Investigating the association between intestinal parasite infection and cribra orbitalia in the medieval population of Cambridge, UK

OBJECTIVE

Cribra orbitalia is believed to be a skeletal indicator of chronic anaemia, scurvy, rickets or related metabolic diseases. It has been suggested that it may be used as a proxy indicator for intestinal parasite infection, as parasites often cause anaemia today. Our aim is to investigate this association in the medieval population of Cambridge, UK.

MATERIALS

Individuals excavated from the cemeteries of the Augustinian friary and All Saints by the Castle parish church, and aged from 7 to adulthood.

METHODS

We undertook parasite analysis of the pelvic sediment and control samples of 46 burials with intact orbital roofs.

RESULTS

Human roundworm (Ascaris lumbricoides) and/or whipworm (Trichuris trichiura) were identified in the pelvic sediment of 22 individuals, and cribra orbitalia noted in 11 individuals. Barnards test showed no association between parasite infection and cribra orbitalia (p = .882).

CONCLUSION

We found no association between infection and cribra orbitalia infection in this medieval adult population, calling into question this hypothesis, at least for adults.

SIGNIFICANCE

High or low cribra orbitalia prevalence in adults should not be used to infer rates of intestinal parasite infection.

LIMITATIONS

The individuals in the study were over the age of 7, with no younger children. It is possible that only parasites which cause marked anaemia (such as hookworm, schistosomiasis or malaria) may cause cribra orbitalia, while less marked anaemia from roundworm and whipworm may not do so.

SUGGESTIONS FOR FURTHER RESEARCH

Repeating this study in younger children, when most cribra orbitalia appears to form.

Investigating the "scapula sign" as an indicator of rickets

OBJECTIVE

In 1971, Weiss identified a "scapula sign" comprising a defect at the inferior angle of the scapula in juveniles with vitamin D deficiency rickets, but this has been little studied since. This study aimed to explore pathological variation of this defect in juveniles with other skeletal manifestations of vitamin D deficiency rickets.

MATERIALS AND METHODS

527 juveniles, aged from birth to 12 years, from two post-medieval British assemblages were macroscopically evaluated to document the range of pathological changes at the inferior angle. Scapula maximum lengths were recorded and supplementary radiographs were assessed.

RESULTS

Blunting, flattening or squaring of the inferior angle occurred in 34 of 155 (22%) juveniles with other indicators of rickets and occurred frequently in cases of severe active rickets. Coarsening of the border and cupping deformities were identified radiographically, as well as residual defects in healed cases. Scapula lengths in juveniles with active rickets did not consistently deviate from those expected in any age group.

CONCLUSIONS

The scapula sign is identifiable in some children with rickets. Differential diagnoses of scapula defects are important but the socio-cultural and environmental context of this sample suggests a link to vitamin D deficiency.

SIGNIFICANCE

This finding expands the range of pathological changes known to occur in rickets, helping to improve recognition of this condition in past groups.

LIMITATIONS

Small sample sizes prevented observation of the defect in adolescents with rickets. Defects can affect the positioning of standardised scapula length measures, complicating assessments of growth impacts.

SUGGESTIONS FOR FUTURE RESEARCH

Continued research into the range of skeletal changes that can develop in vitamin D deficiency to improve the identification of this deficiency in past groups.

Serum Vitamin D Concentration Is Lower in Patients with Tinnitus: A Meta-Analysis of Observational Studies

Background: Tinnitus is a highly prevalent and frequently disabling condition, such that the identification of possible causal mechanisms would yield significant clinical and social benefits. Since vitamin D (Vit D) is involved in the pathogenesis of several ear disturbances, we review here the current scientific literature addressing the relationship between Vit D status and tinnitus. Methods: An electronic search was conducted in PubMed, Scopus and Web of Science with the keywords “tinnitus” and “Vitamin D” or “Vit D” or “25OH-D” or “cholecalciferol” or “ergocalciferol” or “hydroxycholecalciferol”, without date (i.e., up to 8 February 2023) or language restrictions, in accordance with a protocol based on the transparent reporting of systematic reviews and meta-analysis (PRISMA) 2020 checklist, for identifying studies which assayed serum Vit D concentration in patients with or without tinnitus. Results: Three observational, case-control studies encompassing four cohorts and totaling 468 patients with (n = 268) or without tinnitus (n = 200) were included in this meta-analysis. Pooled analysis with quality effects models evidenced significantly reduced serum Vit D levels in patients with tinnitus compared to those without (weighted mean difference [WMD], −6.2 ng/mL; 95% CI, −10.3 to −2.1 ng/mL; I2, 56%). Serum Vit D was found to be 22% lower in patients with tinnitus compared to those without. Conclusions: Lower serum Vit D levels may be associated with tinnitus, thus paving the way to plan future trials aimed at exploring whether Vit D supplementation may aid in preventing and/or improving tinnitus.

Precarious adolescence: Adolescent rickets and anterior sacral angulation in two Dutch skeletal collections from the 18th-19th centuries

OBJECTIVE

This project aims to provide an objective approach to suggesting cases of adolescent rickets using the presence of anterior sacral angulation and interglobular dentine.

MATERIALS

Sacra from 49 individuals from Hattem and 150 individuals from Middenbeemster, and second and third molars from five individuals from Hattem were analyzed. Both sites date to the 17th to 19th centuries.

METHODS

The sacra were visually assessed for sacral angulation and measured to quantify anterior sacral angulation. The sampled molars were thin sectioned to look for the presence of interglobular dentine.

RESULTS

Metric analysis determined that seven individuals had significantly anteriorly angled sacra. Three of the five individuals with sampled molars had interglobular dentine formed during adolescence.

CONCLUSIONS

Adolescent rickets may be associated with anterior sacral angulation.

SIGNIFICANCE

Anterior sacral angulation may help identify possible cases of adolescent rickets in archaeological human remains.

LIMITATIONS

The small sample size for the molars prevented the identification of more individuals with interglobular dentine present during adolescence. Several individuals with visibly angled sacra were unmeasurable due to post-mortem damage and lacked molars.

SUGGESTIONS FOR FURTHER RESEARCH

Research on a larger sample would allow us to understand better the association between anterior sacral angulation and adolescent rickets.

Cribriotic lesions in archaeological human skeletal remains. Prevalence, co-occurrence, and association in medieval and early modern Netherlands

OBJECTIVE

This paper studies the prevalence, co-occurrence, and association of cribra orbitalia, cribra humeri, and cribra femora to contribute to the complex debate on cribriotic lesions and their relationship with one another.

MATERIALS

179 adults and 53 non-adults from the medieval/early modern Netherlands (800-1600 CE) for whom all three lesions could be observed are included in this study.

METHODS

Presence or absence of cribriotic lesions was studied macroscopically. Prevalence, co-occurrence, and association of lesions and their link to sex and age-at-death were assessed.

RESULTS

A clear link between prevalence of the lesions and age-at-death is found. Co-occurrence and association of all three lesions is uncommon. There is a significant moderate correlation for cribra humeri-femora in non-adults.

CONCLUSIONS

Lesion prevalence is connected to age-at-death. However, while a similar age distribution and associations between pairs of lesions are noted, due to limited co-occurrence of the three lesions, the presence of a 'cribrous syndrome' cannot supported.

SIGNIFICANCE

This is the first study investigating the prevalence, co-occurrence and association of cribra orbitalia, cribra humeri, and cribra femora in non-adults and adults contributing to discussions about the nature and the much-debated aetiology of these commonly encountered skeletal lesions.

LIMITATIONS

The number of non-adults in this study is limited, potentially obscuring meaningful patterns, as the cribrous lesions are significantly more common in younger individuals.

SUGGESTIONS FOR FURTHER RESEARCH

More research into the prevalence of the post-cranial lesions and their co-occurrence as well as into bone growth and remodelling is warranted.

Interglobular dentine attributed to vitamin D deficiency visible in cremated human teeth

Vitamin D deficiency has hugely impacted the health of past societies. Its identification in skeletal remains provides insights into the daily activities, cultural habits, and the disease load of past populations. However, up till now, this approach remained impossible in cremated bones, because temperatures reached during cremations destroyed all macroscopic evidence of vitamin D deficiency. This precluded the analyses of a large fraction of the archaeological record, as cremation was an important burial ritual from the Late Neolithic until the Early Medieval period in Europe. Here, the identification of interglobular dentine (IGD), a dental mineralisation defect attributed to vitamin D deficiency, in experimentally burnt teeth, demonstrates this deficiency to be observable in human teeth burned to temperatures as high as 900 °C. In most cases, it becomes even possible to assess the ages-of-occurrence as well as the severity of the IGD and possibly vitamin D deficiency intensity. This study represents a major step forward in the fields of biological anthropology, archaeology, and palaeopathology by opening up a variety of new possibilities for the study of health and activities related to sunlight exposure of numerous past populations that practiced cremation as their funerary ritual.

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.

A joint medico-historical and paleopathological perspective on vitamin D deficiency prevalence in post-Medieval Netherlands

OBJECTIVE

By applying a joint medico-historical and paleopathological perspective, this paper aims to improve our understanding of factors influencing past vitamin D deficiency in ten Dutch 17th to 19th-century communities of varying socioeconomic status and settlement type.

MATERIALS

Vitamin D deficiency is evaluated in 733 individuals of both sexes and all age groups: Silvolde (n = 16), Rotterdam (n = 23), Rhenen (n = 24), Noordwijkerhout (n = 27), Gouda1and 2 (n = 40; n = 59), Roosendaal (n = 51), Den Haag (n = 93), Hattem (n = 113), and Beemster (n = 287).

METHODS

Rickets and residual rickets are macroscopically assessed using established criteria. Hypotheses formulated based on medico-historical texts are investigated via multivariate statistical analysis of vitamin D deficiency prevalence.

RESULTS

Vitamin D deficiency prevalence ranges from 13.7 % (7/51) in Roosendaal to 48.1 % (13/27) in Noordwijkerhout, with an onset of < 4 years, and higher rates in cities, conforming to medico-historical texts. Patterns of child labor are likely key. In contrast, socioeconomic status did not statistically significantly influence vitamin D deficiency prevalence rates.

CONCLUSION

Systematically collected paleopathological data enabled evaluation of medico-historical texts and provided insights into the role that socioeconomic status and settlement type played on the prevalence of vitamin D deficiency.

SIGNIFICANCE

Combining medico-historical texts and large-scale paleopathological data enables disease patterning to be embedded in a comprehensive biocultural perspective.

LIMITATIONS

Comparisons may be limited by the small sample size of high socioeconomic status nonadults and some of the collections.

SUGGESTIONS FOR FUTURE RESEARCH

Analysis of more individuals and sites would improve our understanding of disease patterns.

Osteoporosis, osteomalacia, and hip fracture: A case study from the Terry collection

OBJECTIVE

This case study describes a perimortem hip fracture in a documented individual from the Robert J. Terry Skeletal Collection. The purpose of this paper is to comprehend how co-occurring conditions contributed to fracture risk and to understand the effect of the injury on this individual.

MATERIALS AND METHODS

A 73-year-old female from the Terry Collection with a fracture of the left proximal femur was assessed macroscopically, and images were taken with a Keyence VHX-2000 digital microscope. Documentation concerning the individual's history and contemporary treatment of hip fractures was explored.

RESULTS

Assessment demonstrated impaction of fractured elements occurred as a result of the inferior displacement of the femoral head into the femoral neck. Eburnation and hinge fractures are present on the fracture margins. Bending deformities of the sacrum, sternum, and ribs indicate underlying osteomalacia. No evidence of surgical intervention was observed.

CONCLUSIONS

Both osteomalacia and osteoporosis contributed to overall fracture risk in this case, which demonstrates how complex underlying factors can interact to increase the probability of fracture, and influence post-fracture mortality.

SIGNIFICANCE

This report is the first case study, to date, of a healing hip fracture in which the circumstances of the fracture and the medical history of the individual are known.

LIMITATIONS

To fully investigate osteoporosis, bone mineral density for this individual should be compared with others in the collection.

SUGGESTIONS FOR FURTHER RESEARCH

The effect of co-occurring conditions on fracture risk should be explored in the wider Terry Collection, and in other skeletal collections.

Micro-CT assessment of dental mineralization defects indicative of vitamin D deficiency in two 17th-19th century Dutch communities

OBJECTIVES

This study investigates vitamin D deficiency patterns in individuals from birth to the beginning of adolescence. Microscopic computed tomography (micro-CT) evaluation of interglobular dentine (IGD) in teeth provides information on the age of disease onset and the number of deficient periods per individual, which will increase our understanding of factors influencing vitamin D deficiency prevalence, including sociocultural practices and latitude.

MATERIALS AND METHODS

Beemster and Hattem, two Dutch 17th-19th century communities, yielded relatively high prevalences of rickets (15-24%) and residual rickets (15-24%). From the affected individuals, a subsample of 20 teeth were selected for micro-CT scanning. Thin sections were made of 17 teeth, consisting of 6 teeth with and 11 teeth without observable IGD on micro-CT that were included for method comparison.

RESULTS

About 19 out of 29 (65.5%) individuals (one tooth was deemed unobservable) presented with IGD on micro-CT. Eight of the 11 (72.7%) individuals without IGD on micro-CT demonstrated histologically visible IGD. In 40.7% (11/27) of the affected individuals (combined micro-CT and histology results), vitamin D deficiency was recurrent, and in four individuals, some episodes occurred at approximately annual intervals suggesting vitamin D deficiency was seasonal. In three individuals, IGD occurred in the dentine formed around birth, suggesting maternal vitamin D deficiency.

DISCUSSION

Micro-CT analysis of IGD is found to be a valuable non-destructive method that can improve our understanding of the influence of sociocultural practices and latitude on disease development within age and sex groups in past communities.

The rachitic tooth: Refining the use of interglobular dentine in diagnosing vitamin D deficiency

PURPOSE

This study provides guidelines on how IGD can be differentiated from other microstructures that naturally occur in dentine. Interglobular dentine (IGD) has recently been linked to disruption in vitamin D, calcium, and phosphorous pathways offering a valuable method to investigate vitamin D deficiency in archaeological individuals, but not all dentine defects are IGD.

METHODS

A detailed review of dental literature and dental histology cases gathered from known living and archaeological individuals were incorporated into interpretations.

RESULTS

Investigation of tooth dentine revealed that there can be instances where IGD is not linked to vitamin D deficiency. Information on how to differentiate different forms of defects in dentine were identified.

CONCLUSIONS

We conclude that caution is required when evaluating low-grade IGD, as it may be misidentified.

CONTRIBUTION TO KNOWLEDGE

Information reviewed and assimilated contributes to refining the role of IGD to act as a biological marker, particularly in less severe cases of vitamin D deficiency through provision of clear guidance.

LIMITATIONS OF THIS STUDY

Information from earlier experimental work is limited and until recently understanding of vitamin D and deficiency of this pro-hormone was restricted.

SUGGESTIONS FOR FURTHER RESEARCH

Further data could be gathered from living individuals with known biological/medical information.