Tuberculosis (TB) is a bacterial infection that is well-known in the palaeopathological record because it can affect the skeleton and consequently leaves readily identifiable macroscopic alterations. Palaeopathological case studies provide invaluable information about the spatio-temporal distribution of TB in the past. This is true for those archaeological periods and geographical regions from when and where no or very few TB cases have been published until now-as in the Sarmatian period (1st-5th centuries CE) in the Barbaricum of the Carpathian Basin. The aim of our paper is to discuss five newly discovered TB cases (HK199, HK201, HK225, HK253, and HK309) from the Sarmatian-period archaeological site of Hódmezővásárhely-Kenyere-ér, Bereczki-tanya (Csongrád-Csanád county, Hungary). Detailed macromorphological evaluation of the skeletons focused on the detection of bony changes likely associated with different forms of TB. In all five cases, the presence of endocranial alterations (especially TB-specific granular impressions) suggests that these individuals suffered from TB meningitis. Furthermore, the skeletal lesions observed in the spine and both hip joints of HK225 indicate that this juvenile also had multifocal osteoarticular TB. Thanks to the discovery of HK199, HK201, HK225, HK253, and HK309, the number of TB cases known from the Sarmatian-period Carpathian Basin doubled, implying that the disease was likely more frequent in the Barbaricum than previously thought. Without the application of granular impressions, the diagnosis of TB could not have been established in these five cases. Thus, the identification of TB in these individuals highlights the importance of diagnostics development, especially the refinement of diagnostic criteria. Based on the above, the systematic macromorphological (re-)evaluation of osteoarchaeological series from the Sarmatian-period Carpathian Basin would be advantageous to provide a more accurate picture of how TB may have impacted the ancestral human communities of the Barbaricum.

During research conducted in 2019 regarding pelvic shape in population groups and its effects on successful delivery, one of the individuals studied was a Late Dynastic/Coptic Egyptian female mummy approximately 14-17 years old (USNM catalogue number 258601). She had an associated fetus that was wrapped and placed between her legs during mummification (USNM 258602). In 1908, the mother and child were excavated and autopsied for analysis. Field notes from 1908 said she had died from obstetric complications. For our 2019 study, the mummy was CT scanned to acquire the measurements of her pelvis and determine if cephalopelvic disproportion played a role in her death. While examining the CT images, elements of what was believed to be the fetus were identified in the mother. However, there were repetitions of elements, and a second fetus was discovered in the chest cavity of the mummy. The mother was carrying twins. For this study, re-scanning by CT and plain film radiography of the torso were performed on the mother as well as plain film radiography on the external fetus. Additionally, records and photographs from the 1908 expedition were reviewed to gather additional information on the mummy. Results note this mummy was pregnant with twins and in the middle of the birthing process at the time of her death.

Although knee measurements yield high classification rates in metric sex estimation, there is a paucity of studies exploring the knee in artificial intelligence-based sexing. This proof-of-concept study aimed to develop deep learning algorithms for sex estimation from radiographs of reconstructed cadaver knee joints belonging to the Terry Anatomical Collection. A total of 199 knee radiographs were obtained from 100 skeletons (46 male and 54 female cadavers; mean age at death 64.2 years, range 50-102 years) whose tibiofemoral joints were recon-structed in standard anatomical position. The AIDeveloper software was used to train, validate, and test neural network architectures in sex estimation based on image classification. Of the explored algorithms, an MhNet-based model reached the highest overall testing accuracy of 90.3%. The model was able to classify all females (100.0%) and most males (78.6%) correctly. These preliminary findings encourage further research on artificial intelligence-based methods in sex estimation from the knee joint. Combining radiographic data with automated and externally validated algorithms may establish valuable tools to be utilized in forensic anthropology.

BACKGROUND: Hospitals with high mortality and readmission rates for patients with heart failure (HF) might also perform poorly in other quality concepts. We sought to evaluate the association between hospital performance on mortality and readmission with hospital performance rates of safety adverse events. METHODS: This cross-sectional study linked the 2009 to 2019 patient-level adverse events data from the Medicare Patient Safety Monitoring System, a randomly selected medical records-abstracted patient safety database, to the 2005 to 2016 hospital-level HF-specific 30-day all-cause mortality and readmissions data from the United States Centers for Medicare & Medicaid Services. Hospitals were classified to one of 3 performance categories based on their risk-standardized 30-day all-cause mortality and readmission rates: better (both in <25th percentile), worse (both >75th percentile), and average (otherwise). Our main outcome was the occurrence (yes/no) of one or more adverse events during hospitalization. A mixed-effect model was fit to assess the relationship between a patient's risk of having adverse events and hospital performance categories, adjusted for patient and hospital characteristics. RESULTS: The study included 39 597 patients with HF from 3108 hospitals, of which 252 hospitals (8.1%) and 215 (6.9%) were in the better and worse categories, respectively. The rate of patients with one or more adverse events during a hospitalization was 12.5% (95% CI, 12.1–12.8). Compared with patients admitted to better hospitals, patients admitted to worse hospitals had a higher risk of one or more hospital-acquired adverse events (adjusted risk ratio, 1.24 [95% CI, 1.06–1.44]). CONCLUSIONS: Patients admitted with HF to hospitals with high 30-day all-cause mortality and readmission rates had a higher risk of in-hospital adverse events. There may be common quality issues among these 3 measure concepts in these hospitals that produce poor performance for patients with HF.

OBJECTIVES This study compares humeral diaphyseal robusticity and asymmetry between Late Holocene hunter-gatherers from Alaska with the goal of reconstructing habitual activity in relation to culture and environment. MATERIALS AND METHODS Ancestral remains from four geographic regions of Alaska were divided into five site groups defined by subsistence strategies and technology: Aleutian Islands, Coastal Bay, Far North Coastal, Inland/Riverine, and Tikeraq. Mid-distal humeral diaphyseal robusticity was quantified using cross-sectional geometric properties standardized by estimated body mass and bone length. RESULTS Humeral strength and bilateral asymmetry were greatest in Aleutian Island males, moderate in Far North Coastal and Tikeraq males, and reduced in Inland/Riverine males. Left-biased directional asymmetry and reduced humeral strength were found in Coastal Bay males. Aleutian Island males had relatively mediolaterally strengthened humeri compared with other groups. Aleutian Island females had elevated humeral strength, while humeral asymmetry among females was moderate and did not vary between groups. Humeri were relatively round among Aleutian Island and Tikeraq females and anteroposteriorly (A-P) strengthened among Coastal Bay, Far North Coastal, and Inland/Riverine females. CONCLUSIONS These results suggest elevated humeral strength and asymmetry in males that engaged in rowing and unimanual projectile hunting, while reduced humeral strength and asymmetry may reflect bow-and-arrow or ensnarement technologies. Left-biased humeral asymmetry may be associated with net-fishing. Humeral strength and asymmetry are consistent with select instances of unimanual projectile hunting in females, while differences in humeral A-P/mediolateral strength may reflect variation in butchery and processing of prey versus rowing and throwing behaviors.

The macromorphological examination of identified human osteological collections from the pre-antibiotic era (e.g., Terry Collection) can provide invaluable information about the skeletal manifestations of tuberculosis (TB) in individuals who did not receive pharmaceutical therapy. With analysis of such collections, new diagnostic criteria for TB can be recognised which can be used in palaeopathological interpretation. The aim of our paper is to provide a reference and aid for the identification of TB in past populations by demonstrating and discussing in detail the vertebral alterations indicative of one of its rare skeletal manifestations, lumbosacral TB. These changes were detected in two individuals from the Terry Collection (Terry No. 760 and Terry No. 1093). These two case studies furnish palaeopathologists with a stronger basis for diagnosing lumbosacral TB in skeletons which exhibit similar vertebral lesions from osteoarchaeological series. To illustrate this, an archaeological case from Hungary (KK146) is also presented, displaying vertebral alterations resembling that of the two cases from the Terry Collection. Through the demonstrated case studies, we can derive a better insight into the disease experience of people who lived in the past and suffered from TB.

ImportancePatient safety is a US national priority, yet lacks a comprehensive assessment of progress over the past decade.ObjectiveTo determine the change in the rate of adverse events in hospitalized patients.Design, Setting, and ParticipantsThis serial cross-sectional study used data from the Medicare Patient Safety Monitoring System from 2010 to 2019 to assess in-hospital adverse events in patients. The study included 244 542 adult patients hospitalized in 3156 US acute care hospitals across 4 condition groups from 2010 through 2019: acute myocardial infarction (17%), heart failure (17%), pneumonia (21%), and major surgical procedures (22%); and patients hospitalized from 2012 through 2019 for all other conditions (22%).ExposuresAdults aged 18 years or older hospitalized during each included calendar year.Main Outcomes and MeasuresInformation on adverse events (abstracted from medical records) included 21 measures across 4 adverse event domains: adverse drug events, hospital-acquired infections, adverse events after a procedure, and general adverse events (hospital-acquired pressure ulcers and falls). The outcomes were the total change over time for the observed and risk-adjusted adverse event rates in the subpopulations.ResultsThe study sample included 190 286 hospital discharges combined in the 4 condition-based groups of acute myocardial infarction, heart failure, pneumonia, and major surgical procedures (mean age, 68.0 [SD, 15.9] years; 52.6% were female) and 54 256 hospital discharges for the group including all other conditions (mean age, 57.7 [SD, 20.7] years; 59.8% were female) from 3156 acute care hospitals across the US. From 2010 to 2019, the total change was from 218 to 139 adverse events per 1000 discharges for acute myocardial infarction, from 168 to 116 adverse events per 1000 discharges for heart failure, from 195 to 119 adverse events per 1000 discharges for pneumonia, and from 204 to 130 adverse events per 1000 discharges for major surgical procedures. From 2012 to 2019, the rate of adverse events for all other conditions remained unchanged at 70 adverse events per 1000 discharges. After adjustment for patient and hospital characteristics, the annual change represented by relative risk in all adverse events per 1000 discharges was 0.94 (95% CI, 0.93-0.94) for acute myocardial infarction, 0.95 (95% CI, 0.94-0.96) for heart failure, 0.94 (95% CI, 0.93-0.95) for pneumonia, 0.93 (95% CI, 0.92-0.94) for major surgical procedures, and 0.97 (95% CI, 0.96-0.99) for all other conditions. The risk-adjusted adverse event rates declined significantly in all patient groups for adverse drug events, hospital-acquired infections, and general adverse events. For patients in the major surgical procedures group, the risk-adjusted rates of events after a procedure declined significantly.Conclusions and RelevanceIn the US between 2010 and 2019, there was a significant decrease in the rates of adverse events abstracted from medical records for patients admitted for acute myocardial infarction, heart failure, pneumonia, and major surgical procedures and there was a significant decrease in the adjusted rates of adverse events between 2012 and 2019 for all other conditions. Further research is needed to understand the extent to which these trends represent a change in patient safety.

Recently, the combined macroscopic and statistical evaluation of 427 identified pre-antibiotic era skeletons from the Terry Collection (Washington, DC, USA) revealed that there is a positive association between tuberculous meningitis (TBM) and four endocranial alteration types, namely, granular impressions (GIs), abnormal blood vessel impressions (ABVIs), periosteal appositions (PAs), and abnormally pronounced digital impressions (APDIs). Although all the four lesion types can be used as diagnostic criteria for TBM in the paleopathological practice, they do not have the same diagnostic value. The first aim of the current paper is to further highlight the diagnostic value of GIs, ABVIs, PAs, and APDIs by calculating and discussing their diagnostic sensitivity and specificity estimate values, as well as their association with each other from the 427 identified pre-antibiotic era skeletons of the Terry Collection. The second aim is to demonstrate three example cases from the Terry Collection, who exhibit bony changes on the inner skull surface that are representative of the macromorphological appearance and co-occurrence of GIs, ABVIs, PAs, and APDIs (in different combinations). Based on the generated sensitivity and specificity estimate values, GIs are sufficient enough on their own to make a definitive diagnosis of TBM, whereas ABVIs, PAs, and APDIs are not specific to the disease but can be of tuberculous origin. The chi(2) test results regarding the association of ABVIs, PAs, and APDIs revealed that their co-occurrence with each other (in any possible combination) is significantly more common in individuals who died of TB than in those who died of non-TB causes-it implies that the chance of them being tuberculous in origin is higher when they simultaneously occur with each other. The three cases demonstrated in detail in the paper provide paleopathologists with a stronger basis for identifying TBM in ancient human remains that reveal endocranial alterations resembling that of the presented cases.

Abnormally pronounced digital impressions (APDIs) on the endocranial surface develop secondary to a prolonged rise in the intracranial pressure. This can result from a number of pathological conditions, including hydrocephalus due to tuberculous meningitis (TBM). APDIs have been described with relation to TBM not only in the modern medical literature but also in several paleopathological studies. However, APDIs are not pathognomonic for TBM and their diagnostic value for identifying TBM in past human populations has not been evaluated in identified pre-antibiotic era skeletons. To assess the diagnostic value of APDIs for the first time, a macroscopic investigation was performed on skeletons from the Terry Collection (Smithsonian Institution, Washington, DC, USA). Our material consisted of 234 skeletons with tuberculosis (TB) as the cause of death (TB group) and 193 skeletons with non-tuberculous (NTB) causes of death (NTB group). The macroscopic examination focused on the stage of the prominence and frequency of APDIs in the TB group and NTB group. To determine the significance of difference (if any) in the frequency of APDIs between the two groups, χ 2 testing of our data was conducted. We found that APDIs were twice as common in the TB group than in the NTB group. The χ 2 comparison of the frequencies of APDIs revealed a statistically significant difference between the two groups. In addition, APDIs with more pronounced stages were recorded more frequently in the TB group. Our results indicate that APDIs can be considered as diagnostic criteria for TBM in the paleopathological practice. With suitable circumspection, their utilization provides paleopathologists with a stronger basis for identifying TB and consequently, with a more sensitive means of assessing TB frequency in past human populations.

Objectives: This study was performed to determine the values of the articular eminence inclination (AEI), the articular eminence height (AEH), and the length of the articular eminence curved line (AEL) among American prehistoric and contemporary populations. Materials and methods: The study was carried out on 120 human dry skulls divided into 4 groups: Illinois group (IP), Kentucky group (KP), African Americans group (AAP) and American Caucasians group (ACP). Each group comprised 30 human dry skulls. Measurements of AEI (by two methods), AEH and AEL were performed using computer software on 5 sagittal sections through silicone molds of the articular eminence. The obtained results were statistically analyzed at significance level of p < 0.05. Results: No statistically significant differences of AEI, AEH and AEL values were obtained among American populations (IP, KP, AAP, ACP) neither by body side, sex and age (p > 0.05). The mean AEI M1 values ranged from 31.56° to 38.72°, the mean AEI M2 values ranged from 44.14° to 58.37°, the mean AEH ranged from 5.82 to 6.86 mm, and the mean AEL values ranged from 11.57 to 12.73 mm. Conclusions: AEI, AEH, AEL values are variables, but they did not differ significantly among American populations. Left-right differences as the result of natural body asymmetry were not statistically significant. Sex and age did not significantly affect the articular eminence morphology.

OBJECTIVE:The current study evaluates the feasibility of using clinical cranial computed tomography (CT) scans for assessing the presence and morphology of porous cranial lesions (cribra orbitalia, porotic hyperostosis).METHODS:Observers (n = 4) conducted three independent evaluations of porous cranial lesions based on photographs, 2-D CT, and 3-D CT scans of archaeological crania. Evaluations of the crania from each viewing scenario were compared to findings from direct macroscopic observation.MATERIALS:Twenty-two complete adult crania from the Peruvian sites of Pachacamac and Chicama.RESULTS:We found that lesion visibility differed by location: vault lesions with porosity larger than the resolution of the CT scan were identifiable across all viewing scenarios, but orbital lesions were identifiable only when extensive porosity was accompanied by widening of the inter-trabecular spaces. Lesions in stages of advanced remodeling were not visible on CT.CONCLUSIONS:Paleopathological criteria applied to head CTs from clinical cases of suspected cranial fracture can reliably identify moderate to severe porous cranial lesions in living individuals.SIGNIFICANCE:This validation study opens the door to broader study of porous cranial lesions in living individuals that can address open questions about the causes and consequences of these commonly reported skeletal indicators of stress.LIMITATIONS:Performance of all viewing scenarios was evaluated relative to assessment data from direct observation of skeletal remains, but direct observation is itself subject to error.SUGGESTIONS FOR FURTHER RESEARCH:The increasing resolution of routine CTs makes it increasingly possible to explore skeletal lesions in clinical contexts.

Abstract The explicit declaration in the landmark 1999 Institute of Medicine report “To Err Is Human” that, in the United States, 44,000 to 98,000 patients die each year as a consequence of “medical errors” gave widespread validation to the magnitude of the patient safety problem and catalyzed a number of U.S. federal government programs to measure and improve the safety of the national healthcare system. After more than 10 years, one of those federal programs, the Medicare Patient Safety Monitoring System (MPSMS), has reached a level of maturity and stability that has made it useful for the consistent measurement of the safety of inpatient care. The MPSMS is a chart review–based national patient safety surveillance system that provides rates of 21 specific hospital inpatient adverse event measures, which have been divided into 4 clinical domains (general, hospital-acquired infections, postprocedure adverse events, and adverse drug events) for analysis. The 2014 MPSMS national sample was drawn from 1109 hospitals and includes approximately 20,000 medical records of patients admitted to the hospital (all payors) for at least 1 of the 4 conditions of congestive heart failure, acute myocardial infarction, pneumonia, and major surgical procedures as defined by the Centers for Medicare and Medicaid Services Surgical Care Improvement Project. The MPSMS is now going through a major transformation to capture additional types of adverse events and is being redeveloped as the Quality and Safety Review System (QSRS). As an example of this transformation, QSRS will electronically import electronic data, which are standardized according to the Centers for Medicare and Medicaid Services billing definitions and will be updated and evolve over time to incorporate expanded standardized data available from electronic health records. This article reviews the development of MPSMS, the strengths and limitations of MPSMS, and expected future directions in patient safety measurement, focusing on those issues that are informing the development and implementation of QSRS.

Paleopathological diagnosis of tuberculosis (TB) essentially relies on the identification of macroscopic lesions in the skeleton that can be related to different manifestations of TB. Among these alterations, granular impressions (GIs) on the inner skull surface have been considered as pathognomonic features of tuberculous meningitis (TBM). GIs may be established by pressure atrophy of the tubercles formed on the outermost meningeal layer during later stages of TBM. Although GIs were used as diagnostic criteria for TBM in the paleopathological practice since the late 20th century, their diagnostic value has been questioned. To contribute to strengthening the diagnostic value of GIs, a macroscopic investigation-focusing on the macromorphological characteristics and frequency of GIs-was performed on skeletons of known cause of death from the Terry Collection. The χ2 analysis of our data revealed that GIs were significantly more common in individuals who died of TB than in individuals who died of non-TB causes. Furthermore, GIs were localized on the inner surface of the skull base and of the lower lateral skull vault. The localization pattern and distribution of GIs on the endocranial surface resemble that of the tubercles observed in the affected meninges during the pathogenesis of TBM. Our results strengthen the tuberculous origin of GIs and imply that they can be considered as specific signs of TBM. Therefore, GIs can be used as diagnostic criteria for TBM in the paleopathological practice, and the diagnosis of TBM can be established with a high certainty when GIs are present in ancient human bone remains.

OBJECTIVES:Common wisdom in paleoanthropology is that Neandertals had bigger brains than recent humans. Here we tested the hypothesis that there is no difference in brain size between Neandertals and recent humans while accounting for methodological variation and the makeup of both the Neandertal and recent human samples.MATERIALS AND METHODS:We examined endocranial volume (ECV) derived from virtually reconstructed endocasts of 11 Neandertals, six of which had associated femoral head diameters (FHD). Our recent human comparative dataset consisted of virtually measured ECV and associated FHD from 94 recent humans from the Robert J. Terry Anatomical Collection (63 male, 31 female). ECV of Neandertals and recent humans was compared using bootstrap resampling, repeating the analysis for two groupings of Neandertals (all and classic) and for three groupings of recent humans (all, males, and females). To examine brain size scaling, we completed an ordinary least squares regression of log (ECV) against log (FHD) for Neandertals and recent humans.RESULTS:The results of the bootstrap resampling analyses indicated that Neandertals only had significantly larger ECV when compared with recent human females. The regression between ECV and FHD suggested that Neandertals fall within the range of variation for larger humans.DISCUSSION:Our results demonstrate that Neandertals do not have uniquely large brains when compared with recent humans. Their brain size falls in the large end of the recent human range of variation, but does not exceed it. These results have implications for future research on Neandertal encephalization.

OBJECTIVES:Due to the indelible nature of enamel, bioarchaeologists use linear enamel hypoplasia (LEH) to detect early investments in surviving stress and have identified an association between LEH presence and constraints in growth and maintenance as well as an increased susceptibility to future stress events. This study evaluates heterogenous frailty and susceptibility to death in relation to episodes of early life stress, as reflected by LEH presence, in the Ancestral Pueblo Southwest. This study hypothesizes that LEH presence will be associated with decreased survivorship and an increased likelihood of mortality in both samples.MATERIALS AND METHODS:This study uses two samples, one from Pueblo Bonito (A.D. 800-1200; n = 28) and the second from Hawikku (A.D. 1300-1680; n = 103). Kaplan-Meier survival analysis with a log-rank test was used to evaluate the effect of LEH presence on survivorship for the two samples.RESULTS:Survival analysis reveals statistically significant differences in mortality risk between individuals with and without LEH for the Hawikku sample, but no significant differences for the Pueblo Bonito sample.CONCLUSION:The results demonstrate differences in the response to early life stress at the Hawikku and Pueblo Bonito sites, likely reflecting context. The Pueblo Bonito sample represents a high-status group, and survival following LEH may be the result of cultural buffering. Hawikku dates to a period associated with increased levels of disease and malnutrition as well as Spanish colonization. This environment may have exacerbated mortality risk for individuals in the region who survived early life stress and signifies the consequences of European colonialism in the New World.

Although endocranial abnormal blood vessel impressions (ABVIs) and periosteal appositions (PAs) have been considered as paleopathological diagnostic criteria for tuberculous meningitis (TBM) based on findings of previous studies, they are not pathognomonic for tuberculosis (TB). Therefore, their utilization in the paleopathological practice can be questioned, especially in consideration that most of the previous studies were not performed on identified skeletal collections but on osteoarchaeological material and did not include statistical data analysis. To fill the aforementioned research gap, for the first time, a macroscopic investigation was conducted on identified pre-antibiotic era skeletons from the Terry Collection. A sample set of 234 individuals who died of TB (TB group) and 193 individuals who died of non-tuberculous causes (NTB group) were examined. The frequency of ABVIs and PAs, as well as other probable TB-related lesions was recorded. To determine the significance of difference (if any) in the frequencies of ABVIs and PAs between the two groups, χ2 testing of our data was performed. We found that ABVIs, PAs, and their co-occurrence with each other and with other probable TB-related lesions were more common in the TB group than in the NTB group. In addition, the χ2 comparative frequencies of ABVIs and PAs revealed a statistically significant difference between individuals who died of TB and individuals who died of NTB causes. Our findings strengthen those of previous studies that ABVIs and PAs are not specific to TBM but can be of tuberculous origin. Therefore, they do have a diagnostic value in the identification of TB in human osteoarchaeological material, especially when they simultaneously occur with other probable TB-related lesions. Their prudent utilization provides paleopathologists with a stronger basis for diagnosing TB and consequently, a more sensitive means of assessing TB frequency in past human populations.