Investigation into childhood origins of coronary heart disease

1. Introduction

Post-mortem studies of children killed in road accidents have shown evidence of early degenerative changes in their arteries (Sanders, 1987). Post-mortem examination of Korean War casualties showed that 77% of U.S servicemen had some degree of atherosclerosis, with some 15% having considerable coronary narrowing (Enos, 1953). USA casualties in Vietnam showed 45% with some degree of atherosclerosis (McNamara, 1971).

The Coronary Prevention Group has stated that “the physiological conditions that predispose adults to CHD can occur during childhood: children can have raised blood pressure, raised cholesterol levels or be overweight.” and, say the American Health Foundation (1983), middle-aged atherosclerosis is related to the extent of fatty streaking in childhood, whilst other population studies have shown that levels of blood cholesterol in youth correlate with adult levels of cholesterol and incidence of CHD (American Health Foundation, 1983).

Figure 1.  Comparison of adult and childhood ‘ideal’ and ‘present’ means for total cholesterol.

It is accepted that atherosclerosis starts in childhood, is also associated with a diet high in saturated fat and low in polyunsaturates, and is therefore a paediatric problem (Widhalm, 1988; Sanders, 1987). Major changes occur in childhood for CHD risk with variations in BP, TC and HDL levels (Berenson, 1893; Lauer, 1988; Hofman, 1989; Mauer, 1991). Baseline HDL levels have been shown to be lowest in boys of poor physical fitness, declines in physical fitness associated with decreases in HDL levels (Hofman, 1989).

Children can be screened using recognised techniques with regard to major risk factors for later life CHD – lipids, blood pressure, obesity, level of physical activity. Also an important feature of disease suscept­ibility is the family history of CHD. In a survey of an adolescent population particular attention needs to be paid to familial aggregation of coronary risk factors, an aspect of CHD aetiology that has an impOrtant bearing on their future health.

2. Aims

There is still uncertainty surrounding the identification of hyperlipidaemia, hypertension, obesity in children yet by the age of ten many have already developed overt signs of predisposing factors of coronary heart disease (CHD). This underlines the necessity of more research into early screening to evaluate and define potential susceptib­ility to later coronary heart disease. The challenge becomes one of defining risk status more precisely (Lancet, 1991).

The proposed project would screen for major risk factors indicating possible susceptibility to CHD in 13 years plus school children. It is believed that community orientated prevention of CHD should start during childhood and that this requires established population distributions of lipid and blood pressure variables within young populations. In addition information gathered by this programme could be linked into diabetes research elswhere, with correlation with birthweights of the subjects. The study has both cross-sectional and longitudinal components – one in ten boys and one in ten girls will be selected for follow-up studies.

Firstly, the project will aim at establishing baseline data on demo­graphic, socioeconomic and geographical factors in relation to detected levels of primary biological risk factors for CHD (blood lipids, blood pressure etc), in a young premorbid population. The project would thus contribute to the development of “treatment strategies that are effect­ive and safe in young people.” (Lancet, 1991).

A second stage will provide an innovative evaluation of apoprotein AI (associated with ‘protective’ high density lipoprotein) and apoprotein B (associated with ‘atherogenic’ low density lipoprotein) to evaluate the value of these apolipoproteins as putative markers for adult risk of CHD. The dry chemistry reagent cartridges are still under development and will not be available for the first stage of the screening project.

3. Blood lipids in children

If serum lipids track over time then high risk profile adolescents would become high risk adults – in fact such tracking over time has been shown to be the case (Stein, 1981) with other longitudinal studies defining defining the tracking of lipid elevations into adult life (Lancet, 1991; Lauer, 1988). The Cincinnati Study (quoted in Stein, 1981) showed, on the on average, adolescents with high range cholesterol levels (e.g 4.65 mmol/1) are approximating adult levels (e.g. 6.2 mmol/1). An Ohio Study showed 20% of 3-18 year olds above total cholesterol 4.8 mmol/1 (Garcia, 1989).

The Heartbeat Wales Clinical Survey of 1985 showed children aged 12-19 years had mean cholesterol levels of 4.42 mmol/1 in boys and 4.67 in girls (Heartbeat Wales, 1985). In a Northern Ireland survey some 20-25% of young adults aged 18-21 years had blood cholesterol levels above the WHO recommended optimum of 5.2 mmol/1 (Brown, 1989). For people under 20 years every cholesterol measure­ment higher than 5.2 mmol/1 (200mg/d1) must be considered elevated (Widhalm, 1988).

Numerous epidemiological surveys of children indicate that “differences in cholesterol and triglyceride levels appear early in childhood among cultures, among race-sex groups within cultures, and among socioeconomic groups within cultures.” (Stein, 1981). Figure 1 compares adult and child­hood ‘ideal’ and present means for total cholesterol according to the WHO (1990).

It has been estimated that children who are heterozygous for the inherited condition of familial hypercholesterolaemia (FH) have a mean serum cholesterol level of 7.75 mmol/1 or 300mg/d1 (Kwiterowich, 1974). FH confers susceptibility to premature coronary heart disease and underlies about 4% of heart attacks occurring during middle-age (Coronary Prevention Group, 1988). The condition can be identified in childhood and has a frequency of about 1:500 individuals. Elevated lipids can also be found in less common inherited hyperlipidaemic conditions, including familial combined hyperlipidaemia (FCH).

Evidence shows that it is worthwhile not only to screen children (as well as a necessity in terms of preventive cardiology) but also to track them (if possible) over a period of years – especially those found with lipid levels above 5.17 mmol/1 if not a possible optimum level of 4.65 mmol/1.

4. Blood pressure in children

There is considerable variability in childhood blood pressure with blood pressure in adolescents being far more labile than adults, nonetheless ‘normal’ values have been established in relation to sex and age in children (Purcell, 1985). In the UK 1 in 100 children have mild persistent essential hypertension, with 1 in 500 with evidence of severe secondary hypertension (Chantler, 1983). Hypertension in children is regarded as factual when a persistent BP of 130/90 mm Hg is present – by such criteria 1 or 2% of children are hypertensive (Catzel, 1984).

Studies have also shown that tracking of children with elevated BP’s still show high levels in later years (Purcell, 1985). Chantler suggests (1985) that “all British children should have their blood pressure measured by the school nurse at five and eleven years.” ence.” (Stein, 1981).

Height and body mass are significant determinants of blood pressure and obesity (Purcell, 1985),It is believed that blood pressure patterns “may therefore be established from an early age, which would be consistent with reports that emphasise the importance of childhood in the origins of cardiovascular disease.” (Whincup, 1988). There is some tendency for children with raised blood pressure to become hypertensive as adults.” (Coronary Prevention Group, 1988).

5. Methods

There are difficulties in the assessment of risk factors for CHD in in children for physiological and anatomic reasons – risk variable parameters vary with age due to early life hormonal and biochemical processes that are connected with growth and development (Brown, 1989). For this reason it is therefore important to establish a large body of baseline data via a population screening survey. In addition, the lipid testing would be of a non-fasting free-living population – though to obtain greater accuracy all blood tests would be obtained prior to lunch time.

Surveys of school pupils provide a comprehensive profile of the distrib­ution of the major risk factors across an adolescent population as well as help illuminate class, ethnic and regional variations and indicate areas for action in disease prevention and health education. Secondly surveys would collect data on the geographic and social origin of individuals, their parents, and possibly grandparents. This would enable factors such as spatial and social mobility to be analysed in association with the prevalence of risk variables.

The project would comprise 2 parts: clinical evaluation and a questionaire, directed at 13+ years pupils in three of the six Upper Schools of Oxford City. The clinical assessment would be of a minimally invasive nature that would involve (1) anthropometric measurements; (2) BP recording, (3) two finger stick blood samples. The questionaire would seek to establish information on the subject’s (1) demographic, (2) socioeconomic and (3) geographical back­ground in order to account for social class, origin and family history of CHD. An initial draft of the questionaire is shown as Appendix 1. The following biological variables will be sought:

1. Blood total cholesterol (TC)
2. Triglycerides (TG)
3. High density lipoprotein (HDL)
4. Low density lipoprotein (LDL) by estimation
5. Blood glucose
6. LDL/HDL Ratio by calculation
7. TC/LDL Ratio by calculation
8. Mean systolic blood pressure
9. Mean diastolic blood pressure
10. Mean pulse rate
11. Blood group (ABO)
12. Weight, height, skin-fold thicknesses, waist, hips and right arm circumference
13. Body mass index calculation

Anthropometric records would be done with stadiometer, metric tapes, digital scales, and Harpenden type skinfold calipers. Blood pressure would also be recorded by a digital electronic sphygmomanometer (DES) using a COPAL UA 751, taking the mean of two readings with appropriate size cuffs.

The blood sample measurements will be done using the portable Abbott Diagnostics ‘Vision’ autoanalyser (offered for 18 months use) for lipids and glucose (using four cartridges in the Abbot ‘Cardiac Evaluation’ pack). Portable autoanlyzer use removes the need to rely on expensive and time consuming laboratory analysis, is minimally invasive and ethically of an acceptable nature especially where children are concerned. Blood samples would be obtained using an Autolet II capillary blood sampler using Unilet stylets with platforms (Autolet ‘white’ for young skin) appropriate for thumb skin puncture. See Appendix 1 for a preliminary cost analysis of the project.

6. Analysis

Analysis of baseline data would use the SPSS-X statistics package using appropriate analyses of variance (ANOVA), multivariate analyses of variance (MANOVA), significance tests, establishment of confidence intervals and the and calculation of odds ratios and relative risk (‘R’) as required.

7. Sample

The six Upper Schools in Oxford City will comprise a forecast population of 3,490 13-18 year-olds in 1992 (the year of the proposed screening survey) of which 2187 will be 13-18 in the three selected upper schools – Cherwell, Cheney, and Peers Schools – which would provide an even geographical spread across the City. The sample of 2187 comprises some 62% of the upper school population within the City. The sample size is determined by costs and the feasibility of screening all upper school children within three school terms. Forecast pupil populations are shown in Table 1 with school location within the City boundary illustrated in Figure 2.

Table 1.  Oxford City Upper School Forecasts 1990-93.

Figure 2.  Map of Oxford showing location of City’s Upper Schools (13-18 years).

Appendices 1 to 4.  Survey forms for the investigation.

References

American Health Foundation, 1983, Summary and recommendations of the conference on blood lipids in children; optimal levels for early prevention pf coronary heart disease. Prev. Med 12, 728-40

Berenson, G.S, 1983, Clinical and anatomic correlates with cardio­vascular disease in children from the Bogalusa Heart Study, in Schettler, F. et al. (eds), Atherosclerosis IV, Berlin, 1983.

Brown, J.S, 1989, Screening for coronary heart disease: the sooner the better? Modern Medicine, April 1989, p279.

Catzel P & G Roberts, 1984, A Short Textbook of Paediatrics, 2nd ed, p147, Hodder & Stoughton.

Chantler C, 1983, Paediatric hypertension. Midwife, Health Visitor and Community Nurse. Feb 19

Coronary Prevention Group, 1988, Children at risk: should prevention of coronary heart disease begin in childhood? A Policy Statement from the Scientific and Medical Advisory Committee.

Enos W.F. et al, 1953, Coronary disease among United States soldiers killed in action in Korea: preliminary report. JAMA, 152, 1090-4.

Garcia R.E & D.S Moodie, 1989, Routine cholesterol surveillance in childhood. Pediatrics, 84, 751-55.

Heartbeat Wales, 1985, Heartbeat Report No 20, Heart of Wales: Clinical Results of the Welsh Heart Health Survey, 1985, Directorate of the Welsh Heart Health Programme, Cardiff.

Hofman, A, 1989. The association between physical fitness and cardio­vascular disease in children in a five year follow-up study. Int.J.Epidem. 18, (4), 831-35, 1989.

Kwiterowich P.O et al, 1974, Familial hypercholesterolaemia (one form of familial type II hyperlipoproteinaemia): a study of its biochemical, genetic, and clinical presentation in childhood. J. Clin. Invest. 53, 1237-1249.

Lancet, 1991, Cholesterol screening in childhood, Editorial, 29.6.91.

Lauer R.M, et al, 1988, Factors affecting the relationship between childhood and adult cholesterol levels: the Muscatine Study. Pediatrics, 82, 309-18.

McNamara J.J, et al, 1971, Coronary artery disease in combat casualties in Vietnam. JAMA, 216, 1185-87.

Mauer, 1991. Should there be intervention to alter serum lipids in children? Ann.Rev.Nutr. 11, 375-91, 1991.

Purcell H, 1985, Blood pressure and hypertension in children. Card. in Practice, January, 8-9.

Sanders T.A.B, 1987, What should our children eat? J.Roy.Soc.Health, 107, 6, Dec, 222-23.

Stein E.A, et al, 1981, Coronary risk factors in the young. Ann.Rev.Med. 32, 601-13.

Whincup P.H, et al, 1988, Blood pressure in British children: associations with adult blood pressure and cardiovascular maortality, Lancet, Oct 15, 890-93.

WHO, 1990, Prevention in childhood and youth of adult cardiovascular diseases: Time for Action. WHO, Geneva, 792.

Widhalm K, 1988, Dietary treatment of hypercholesterolaemia in children: recent aspects., in Widhalm & Naito (eds).

Postscript

The proposal (1993) was accepted by the Department of Biology at Oxford Brookes University, as well as laboratory facilities, and supervision. A qualified practice nurse to carry out tests was also nominated. The cooperation of the Lipid Clinic of the John Radcliffe Hospital, Oxford was agreed. Abbot Laboratories agreed to supply the portable analyser and technical backup, training plus supplies of lipid analysis modules. The response from Oxford City Council Department of environmental Health was somewhat muted despite the existence of the Oxford Heart Health Project.

Eventually the project was unable to raise the necessary finance and studentships from medical research organisations and councils to inaugurate and carry out the research. Local authorities, both health and educational, were also muted in their responses, stating that childhood diabetes and obesity were not a problem in Oxford or likely to be in the future.

Proposed Blood Group Determination of Human Skeletal Remains in Oxford (1974-75)

Aim of Research.

The determination of ABH blood groups in human skeletal remains from the City of Oxford and its environs. An examination of skeletal remains to determine the presence of pathology, abnormality, anomaly, age and sex. Special note will be made of the presence and incidence of osteoarthitic changes.

Methods of Research.

Serological techniques would be those used by Boyd & Boyd, (1931; 1933; 1934; 1937; 1939), Candela (1936; 1937; 1939; 1939a; 1940), Berti & Parenti (1964), Kellerman, Lengyel & Nemeskeri (1965; 1967), and Borgognini. The techniques used by Kellerman (1971; 1972;) and Borgognini (1967;1969), have achieved positive results in approximately 88% of cases. ABH antigens have been found to be present in bone 2000 BC at death. In some cases the use of radiographic techniques to confirm pathology, abnormality, age and to assist analysis of developmental criteria (e.g., Harris Lines).

Material.

Some 400 to 500 complete and incomplete skeletons from the City of Oxford and its environs. Covering a period from sub-Roman to late medieval times. Most material is from the priories of Blackfriars, Greyfriars, All Saints Church (High Street), St Frideswides at Osney, St Budoc’s, the Roman site at the University Museum, Queensford Farm at Dorchester, Appleford, and Abingdon. The material is obtainable from the Oxfordshire Archaeological Committee. Portions of the skeletons for serological analysis will be mainly proximal portions of femora and/or vertebrae.

Results of Research.

Possible determination of the ABH system distribution, this having value historically, serologically and in terms also of population genetics and human biology. This palaeoserological and palaeopathological work will help provide information concerning disease and arthritis incidence in earlier populations. Indicate the presence of anomalies and abnormalities in earlier populations, this being of value genetically and medically. Palaeoserological results will have also some value in the field of forensic medicine.

Work to Date.
Analysis for Oxford Archaeology Unit of some 35 skeletons from All Saints, High Street, 1973 excavation. Evidence to date indicates high incidence of arthritic changes, plus an age of death in the 30’s to 40’s. Specimens are from infancy to late 40’s. No serological work possible as yet. Various non-metrical evidence apparent including metopism, lambdoid ossicles, sacralisation of lumber 5th.

Overall Analysis of Skeletal Material (Lengyel & Nemeskeri).

Allows for decomposition, and permits a general biochemical and anatomical analysis. Combined chemico-analytical, serological, histological method. Analysis of post-mortem decomposition and fossilisation processes (Lengyel, 1967).

Two steps. (1) fresh bones, and (2) fossil bones. Method (a) is determination of water content by drying to 105 degrees centigrade. Then incineration and removal of chemically bound water. Method (b) is the determination of organic substances:

Method (b) determines total nitrogen content; non-protein nitrogen; the water soluble organic fraction; the protein-polysaccaharide complex; collagen; and other resistant proteins after extraction of collagen. Standard tests are available. In addition determination of citrate for sex determination; carbonate content; and organic phosphorus.

Method (c): determines calcium, inorganic phosphorus, magnesium, and sulphur.

Determination of Blood Groups.
Determination of blood groups are achieved by modified fluorescent antibody technique by microscope; and also by the Boyd-Candela precipitation test which is macroscopic.
Histological analysis comprises staining with Haematoxylin-Eosin, Schwart’s Method, and Azan. The histochemical analysis includes metachromatic staining, and the peroxide reaction.

Boyd and Boyd Method.

Evidence of presence of group specific antigen may be presumed if antiserum of suitable strength is inhibited in its activity with red cells of appropriate group. Prolonged contact with tissue sample is required. There are four naturally occurring human anti-A sera and four naturally occurring anti-B sera. Use on each specimen with specimen quantity permitting. Dilution of resulting titres of absorbed and unabsorbed sera to convenient level for titration. Titrations are fresh 2% suspensions of A2 and B cells.

Candela’s Technique (also as modified by Smith/Glemser).

Uses different dilution ranges. From each dilution tube take 0.5cc serum to which is added 0.05cc of 1% suspension of cells. Agitation followed by final microscope readings after 30 minutes. This micro-method means there are more test cells relative to the serum. This method is better for ground up bone.
Candela’s Technique modified by Smith (Glemser) uses 0.2 gm of prepared tissue placed in a 75 x 10mm tube. Then 0.4 ml of antiserum added to each sample. Tubes placed in a refrigerator for 24 hours then moderate centrifuging for 2 to 3 minutes. Super-natant is removed to a clean tube and any remaining bone particles removed. Tritration according to Boorman & Dodd (1961). A buffered saline of 1% sodium azide is used as preservative. The result is the observation of consistent inhibition over a series of tests. See Smith (1959; 1960; and Glemser, 1963).

The Borgognini Method for the ABH System

There are three methodological improvements to the Boyd and Candela method (Berty, 1964). There is (1) colorimetric reading of the degree of haemoglobin which ensures greater sensitivity; (2) the use of aqueous extracts instead of bone powder as the absorbing medium in haemoagglutination-inhibition test. This reduces or eliminates non-specific absorption; (3) the systematic use of anti-H sera for group O determination.

Since 1964 Borgognini (1967; 1969) introduced 4 modifications to the Berti & Parenti (1964) technique. There followed (1) systematic decalcification of bone powder with disodic and trisodic EDTA solutions at pH 7.0; (2) the use of an electric stirrer to standardise readings; (3) the systematic purification of aqueous extracts from bone powder by gel filtration, though columns. This uses the macromolecular portion only and removes degradation products. Finally (4) occasional removal of lipids from the powder with solvents such as acetone, chloroform or ether.

The Kellerman Method for the ABH System.

Requires 4 to 5 gm of spongiosa ground in a mortar. Extraction of bone powder mixed with 10ml of 5% Na2/Na3 EDTA at pH 6.5-7.0, for 12 hours on a magnetic stirrer at room temperature. Centrifugation for 10 mintes at 5000 rpm and then decantation of the supernatant.

Centrifugation again for 20 minutes at 25,000 rpm. This gives a volume of extract of 6 to 8 ml. Decantation with partial purification gel filtration through Sephadex G.25 in coarse columns of 1.5 x 30 cm. Aqua dest with 0.02% NaN3. Bacterioatatium used as eluting medium. Bring back eluate to original volume, then concentrate by ultrafiltration.

Blood typing is with the Ouchterlyontest and immunophoresis. Using immunophoresis anti-sera is diluted to 1:4. With the Ouchterlyonytest the human anti sera (anti-A; anti-B; and anti-H) is from Ulex europeans. Preparation of anti-sera is using the Borgognini method (1967). All sera are titred at 1:1024 to 1:2048. Test anti-sera with human saliva.

Summary of other researches.

Borgognini (1968) tested ancient bones dated to 2000 BC. !20 tests of 33 skeletons typed 88% or 29 skeletons. Thus the results were 12 x A; 9 x B; 1 x AB; and 7 x O groups. Four noy diagnosed.

Kellerman (1971) tested 169 femora out of which 149 (88.2%) showed a reaction. This meant that the ABH blood group distribution for the period 15th to 17th centuries gave the result: 149 = 36.2 x A; 22.8 x B; 30.9 x H; and 3.5 x AB. From 891 modern specimen samples the results were: A x 50.3; B x 8.8; H x 37.4; AB x 3.5.

Kellerman (1972) tested 151 femora from the 12th to 14th centuries. !26 or 83.4% showed a positive reaction. Specimens numbering 126 = A x 53.9%; B x 16.7%; H x 23.8%; AB x 5.6%.

Appendix 1. Diagram of Methodology.

Appendix 2. Diagram of Factors of Decomposition.

References Cited and Sources Consulted. (some lost over passage of time).

Borgognini. (1969). Proc.XVIII. Int.Cong.Anth & Ethno Sci.
Boyd & Boyd. (1931). J. of. Immun. 26 (6).
Boyd & Boyd. (1933). Science. 78 (578-).
Boyd & Boyd. (1934). Proc. Sci. Exp. Biol. Med. 81 (671-).
Boyd & Boyd. (1937). Blood Grouping in Forensic Medicine. J. Immun.
Boyd & Boyd. (1939). Blood Group Reactions in Preserved Bone and Muscle. Am.J.Phys.Anth. 21 (429-).
Candela. (1936). Blood Group Reactions in Human Skeletons. Am.J.Phys.Anth. 23 (429-).
Candela. (1937). Blood Group Determination upon Skeletal Material. Am.J.Phys.Anth. 23 (71-).
Candela. (1939). Blood Group Determination upon 30 Aleut Mummies. Am.J.Phys.Anth. 24 (36-).
Candela. (1939a). Blood Group Tests on Stains, Mummified Tissues, Bone. Am.J.Phys.Anth. 25.
Candela. (1940). Reliability of Blood Group Tests on Human Bones. Am.J.Phys.Anth.
Garlick, J. D. (1969). Buried Bone – N content and Blood Group Activity. In: Science in Archaelogy ed Brothwell, D.
Glemser (nee Smith). 1963. Science in Archaeology. 1st edition, 1963.
Kellerman. (1971). Humangenetik. (14).
Kellerman. (1972). Humangentik. (14).
Lengyel & Nemeskeri (1963).Application of Biochemical Methods to Biological Reconstruction. Z.Morph.Anthrop. 54 (1).
Lengyel & Nemeskeri. (1965). Investigation of Chemical Composition of Aged Bones. Int.Conf.Gerontogy.
Lengyel. (1967). Biochemical Aspects of Early Skeletons. In: Skeletal Biology. Brothwell, D. ed.
Smith, M. (1959). Blood Grouping of the Remains of Swedenborg. Nature. 184 (867-).
Smith, M. (1960). Blood Groups of the Ancient Dead. Science. 131.

The programme was unable to obtain facilities or a grant to carry out the research. Reasons given in a department of Oxford University were that it was unlikely that blood groups or other genetic material could be obtained from bone or teeth. This despite active interest and cooperation from the Pathology Department, Nuffield Orthopaedic Centre, and Faculty of Medicine, Oxford, and offer of preliminary help from H. M. Forensic Science Department, Harwell, Berkshire. As well as the availability of skeletal material from Oxfordshire Archaeological Services.

Report on Human Remains from Abingdon, 1976.

Skeletal report on human remains from Ashville, Abingdon

The material comprised fragments from six Bronze Age cremations (SAB/MG76) numbered 1017; 1032; 1033; 1043; and 1054.  Together with the above fragments miscellaneous human bones (SIB/MG 74) were also examined, these being 69(2); 72; 79; 3921 and 388. These fragments were associated with Iron Age features.

All of the above cremations had been subjected to post-process pounding. A technique that does not always allow for accurate identification or analysis. Most of the above material was mimed with animal bones (both burnt and unburned), stone and flint fragments, a mollusc shell, and also unburned human bone. The size of the fragments varied as did the level of combustion. Cremation heat had varied – the charring and whitening indicating a relatively low temperature compared to that which fissured, distorted and twisted other fragments. Blue staining indicated pretence of uncombusted organic matter,  The above applies to cremations listed above except for 1033.

The following is a further tentative analysis concerning that individual due to some peculiarities of the burning. The results of the heat in this specimen were restricted to blackening (charring) of the bones. However, a portion of skull indicated a black coloured glaze which suggests blood was still present, Other portions of bone showed signs of distortion due to fire. It is a possibility in this case that the burning have been accidental, although intentional mutilation cannot be ruled out. [Supportive evidence is in Brothwell: Digging Up Bones].

Usually cremated bones vary in colour from white, grey, grey-brown through to brown, grey-blue, to. black. Blue colouration indicates remaining organic material, whilst blue-green or green staining indicates proximity to metal. The large amounts of lightish bones-in the above cremations suggests some measure of protection (urns, pots etc), Cremation 1054 which is possibly an infant may also be a token interment of a fraction of the remains, (see Gejfalis:  Science in Archaeology, page 471, 1969).

Age and sex determination of the cremated fragments was based on the data from that used for determinations in uncremated remains. Statistical data from cremated fragments (Gegen, ibid) also indicates that on average male remains are more robust than female (bone walls are about 1/4 thinner in females).
The animal bones found with the human fragments were from small animals (rabbits, chickens, lambs?) and from a much larger animal (as with 1017) (cow? calf?) which were unburned. Animal remains may be associated with a burial feast. If lamb bones are found it may indicate season of the cremation (lambs are born March-April), Biometrically the ages of the individuals and their sex can be deduced after long and complicated statistical analysis, however in this instance approximate estimations have been made on the basis of average tables from other researches.

Summary of Cremation 1017. Young adult, possible female (possible gracile male), Associated animal bones, Varied temperature range in cremation process.
1632: Late adolescent, possible male. Incomplete combustion of organic matter indicates variable temperature. dental burning or incomplete cremation due to unknown circumstances.  1043: Young adult. Gracile features indicate female sex. Associated with burnt animal bones and one half of a bivalve (freshwater?) mollusc.

Fragments evidence variable cremation temperature. 1054: Infant. Minute fragments and organic matter (charcoal?). Suggests token deposition or combustion loss of remainder of burnt individual. Miscellaneous bones SAH/MG 74.  An assortment of individual bones from different individuals (at least 3). Number 69 comprises 2 individuals – an lutist and an older. child (about 4 yrs). Specimen 72 comprised a tibial portion which was light and gracile suggest¬ing female sex evidenced also by weakly pronounced ridges and articular surfaces. The appearance of the shaft indicated also young adulthood, In Specimen 79 there was only an incomplete occipital bone the robustness of which indicated male sex. Suture analysis (exercise caution) indicated an age range of mid-20’s to late 30’s. Specimen 388 consisted of a lumbar vertebrae showing developing osteophytosis and possible osteoporosis. If it is osteoporosis we could conclude post menopausal female. Tentatively conclude that this individual was a mature female with articular degenerations of region of the spine due to advancing age. Specimen 392 was a piece of the proximal shaft of femur. Robustness in the absence of pathology indicates male sex and adulthood.

14.7.1976

Eventually published in Report Number 1. Oxfordshire Archaeological Unit and Council for British Archaelology, Research Report no. 28 (1978).

Commentary on Childhood Origin of Coronary Heart Disease.

Post-mortem studies of children killed in road accidents show signs of early degenerative changes in their arteries (Sanders, 1987). Post-mortem examination of Korean War casualties showed 77% of USA servicemen had some degree of atherosclerosis, with some 15% having considerable coronary narrowing (Enos, 1953). USA casualties in Vietnam showed 45% with some degree of atherosclerosis (McNamara, 1971).

The Coronary Prevention Group has stated that “the physiological conditions that predispose to adult CHD can occur during childhood: children can have raised blood pressure, raised cholesterol levels or be overweight.” In addition – middle-aged atherosclerosis is related to the extent of fatty streaking in childhood, whilst other population studies have shown that levels of blood cholesterol in youth correlate with adult ,levels of cholesterol and incidence of CHD (American Health Foundation, 1983).

It is accepted that atherosclerosis starts in childhood, see Figure 12.1, is also associated with a diet high in saturated fat and low in polyunsaturates, and is therefore a paediatric problem (Widhalm, 1988; Sanders, 1987). Major changes occur in childhood for CHD risk with major changes in BP, TC and HDL levels (Berenson, 1983; Lauer, 1988; Hofman, 1989; Mauer, 1991). There is still uncertainty surrounding the identification of hyperlipidaemia, hypertension, obesity in children yet by the age of ten many have already developed overt signs of predisposing factors of ten. The challenge becomes one of defining risk status more precisely Lancet, 1991b).

If serum lipids track over time then high risk profile adolescents would become high risk adults – in fact such tracking over time has been been shown to be the case (Stein, 1981) with other longitudinal studies defining the tracking of elevated lipids into adult life (Lancet, 1991b; Lauer, 1988). The Cincinnati Study (cited in Stein, 1981) showed, on the average, adolescents with high range cholesterol levels (e.g 4.65 mmol/l) approximate adult levels (e.g. 6.2 mmol/1). An Ohio Study showed 20% of 3-18 year olds above total cholesterol 4.8 mmol/1 (Garcia, 1989).

The Heartbeat Wales Clinical Survey (1985) showed children 12-19 years had mean cholesterol levels of 4.42 mmol/1 (boys) and 4.67 (girls). (Heartbeat Wales, 1985).  In a Northern Ireland survey some 20-25% of young adults aged 18-21 had blood cholesterol levels above the WHO recommended optimum of 5.2 mmol/1 (Brown, 1989). For people under 20 years every cholesterol value higher than 5.2 mmol/1 (200mg/dl) must be considered elevated (Widhalm, 1988). Baseline HDL levels have been shown to be lowest in boys of poor physical fitness, declines in physical fitness associated with decreases in HDL levels (Hofman, 1989).

Numerous epidemiological surveys of children show “…differences  in cholesterol and triglyceride levels appear early in childhood among cultures, among race-sex groups within cultures, and among socioeconomic groups within cultures.” (Stein, 1981). Figure 12.2 compared adult and childhood ‘ideal’, ‘present’ and ‘feasible’ mean TC according to the WHO (1990).

It has been estimated that children who are heterozygous for the inherited condition of familial hypercholesterolaemia (FH) have a mean serum cholesterol level of 7.75 mmol/1 (Kwiterowich, 1974). FH confers susceptibility to premature coronary disease and underlies about 4% of heart attacks (AMI) during middle-age (Coronary Prevention Group, 1988). The condition can be identified in childhood – with a frequency of about 1:500 individuals. Elevated lipids are found in less common inherited hyperlipidaemic conditions e.g., familial combined hyperlipidaemia (FCH).

Evidence shows that it is worthwhile to screen children (as well as  a necessity in terms of preventive cardiology) but also to track them (if possible) over a period of years – especially those found with lipid levels above 5.17 mmol/1 if not a possible optimum level of 4.65 mmol/1. There is considerable variability in childhood blood pressure with BP in adolescents being far more labile than adults, nonetheless ‘normal’ values have been established in relation to sex and age in children Purcell, 1985).

In the UK 1/100 children have mild persistent essential hypertension, 1/ 500 have evidence of severe secondary hypertension (Chantler, 1983). Hypertension in children is regarded as factual when a persistent BP of 130/90 mm Hg is present – by such criteria 1 or 2% of children are seen as hypertensive (Catzel, 1984). Studies have also shown that tracking of children with elevated BP still show high levels in later years (Purcell, 1985). It is suggested that “all British children should have their blood pressure measured by the school nurse at five and eleven years.” (Chantler, 1985).

Blood pressure distribution curves for child populations show a gradual increase in both systolic and diastolic values from infancy through adolescence.” (Stein, 1981). Height and body mass are significant BP and and obesity determinants (Purcell, 1985), and that that blood pressure patterns “may therefore be established from an early age, which would be consistent with reports that emphasise the importance of childhood in the origins of cardiovascular disease.” (Whincup, 1988).

There is a tendency for children with raised blood pressure to become hypertensive as adults. (Coronary Prevention Group, 1988).  There is a strong familial element in CHD susceptibility the extent of which is mediated by other major risk factors (Tunstall-Pedoe, 1982a). CHD is a multifaceted disease where heredity and familial aggregation play an important role (Bloor, 1972), especially “…in the development of premature coronary heart disease.” (Deutscher, 1970).

Family studies show “…serum cholesterol levels are correlated between parents, offspring and siblings while the levels of spouses are not.” (Coronary Prevention Group, 1988). Children whose parents suffer heart attacks before fifty have “…significantly increased cholesterol levels relative to control children born to parents without early myocardial infarction.” (Stein. 1981). Table 12.1 is an example showing family history and CHD from the Kilkenny Health Project. Noteworthy is the predominance of females for strong and positive correlations of CHD within families for deciles 35-64 years – relatives who were/are fathers uncles, brothers, sons. There occur significant correlations between parents and children for total cholesterol, triglyceride and high density lipoprotein (Morrison, 1980). For TC, PBP and BMI it has been shown that “Fathers and daughters exhibit aggregation on a greater number of these factors than fathers and sons.” (Feldman, 1973).

Familial aggregation must not be seen only in terms of inherited traits. Familial aggregation must be understood in terms of communicated and shared dietary habits, smoking and other shared lifestyle factors (Deutscher, 1966). Familial aggregation includes common environments as well as shared genetic susceptibility. Cholesterol levels are a family characteristic (Strunge, 1976) with low, but positive, correlations between children’s TC values and those of their parents. Moreover, “Daughters of men with high levels of cholesterol, uric acid, skinfold and ponderal index also had high levels of these variables.” (Feldman, 1973). In addition, familial aggregation is far more common in young women with CHD (Wenger, 1985).

Familial aggregations exist for blood pressure with known “positive aggregation of blood pressure exist(ing) between parent and child and between siblings.” (Wilson, 1974). The aggregation of BP’s “…of parent and child appeared more marked if the relationship involved mother and child.” (Wilson, 1974). It is believed BP patterns may be “established from an early age, which would be consistent with reports that emphasise the importance of childhood in the origins of cardiovascular disease.” (Whincup, 1988). Furthermore, BP aggregation is “…always positive, and in most instances significant, for relationships involving siblings only.” (Wilson, 1974).

References to follow.

Originally Appendix 182 to my MPhil thesis entitled “Population Variation for Risk Factors for Ischaemic Heart Disease.” CNAA. Oxford Polytechnic/Oxford Brookes University, 1987-1992.

Palaeopathological Investigation of Human Skeletal Remains

A proposed investigation of the palaeopathology of human skeletal remains from Oxford and its environs with special reference to arthritis.

Purpose:
There will be an examination of available human skeletal material from Oxford and the surrounding area to determine the occurrence and incidence of pathology and abnormality, both congenital and acquired. Preliminary examinations of the remains to determine sex and chronological age will be carried out using the standard procedures and references for such assessments. Further from this there will be the determination of differences and similarities in the constitutional nature of the skeletal material that has been excavated from different areas of the City and its environs. Note will be made of the state of preservation, type and length of burial. This will be done to eradicate false diagnoses due to any artifacts or pseudopathological changes. From this data it will be possible to make a comparison of differences in social conditions and modes of life of the individuals whose remains will be the object of the research.

With regard to the study of the pathology special emphasis will be put on the determination of morphological and histological changes due to diseases that are Rheumatoid and Osteoarthritic in origin. Further details of the main conditions to be studied will be outlined under a following section.

Methods of Research:
Techniques employed in the above study will be photographic, radiographic and micro-radiographic. These techniques will be employed for the determination of macroscopic and microscopic bone changes. For example, analyses will be made from ground down sections of bone that have been embedded in, e.g methylmatacrylate. Such an analysis, using radiographic methods, will help to establish diagnoses of pathology, abnormality, age at death, as well as to clarify the criteria of skeletal development. In regards to pathological evidence there will be an examination for porosity perforations); sclerosis (intravital polishing); osteophytes; ankylosis; plus other evidence of bone and joint pathology.

Material for the Research:
Approximately 500 human skeletons from the City of Oxford and the surrounding area will form the basis of the study. These remains have been obtained from the Oxford Archaeological Unit. Further skeletal material will be available from certain current and future excavations. In addition interest in examining skeletal material held by the British Museum was expressed.

Some of the material comes from the protected environments of the Medieval City priories and monastic institutions. Further skeletal material comes from the lay cemeteries, churchyards and crypts of excavated ruins. Priory burials were all male (until a recent examination by the applicant revealed the presence of male and female juveniles and adolescents amongst skeletons excavated from the chapter house of Blackfriars). City burials of a lay nature, plus the skeletal remains from without the city, demonstrate a far broader spectrum of the previous populations, including infant, child, adult and senile interments.  The historical periods covered by the material date from pre-Roman times up to and through early and late medieval periods until the 17th and 18th centuries.

Work to Date on the Remains:
Preliminary examinations of some of the remains have revealed the existence of pathological changes and other abnormalities. Certainly various forms and stages of arthroses have been identified, e.g. Spondylosis cervicalis, Osteochondrosis intervertebralis, osteophytoses, ligamentous calcifications. Other pathological changes involving vertebrae indicate a possible infectious aetiological factor; perhaps Brucella could be considered as responsible? Any such diagnoses require the more sophisticated methodology outlined above to confirm tentative conclusions. Further analyses of the remains has been in order to assess age and sex, stature and dentition characteristics. Age groups for current work are delineated as Infans; Juvenis; Adultus (20 to 39); Maturus (40 to 59); and Senilis (60+). Sex determination has been by the collation of the morphological characteristics of pelvis, sternum, skull and mandible. Age determination has been by collation of the morphological evidence from the dentition, attrition, epiphyseal development, symphysis pubis, and occasionally by cautious consideration of cranial suture closure.

Outline Classification of the Main Diseases to be Considered:
These are those diseases of bones and joints classified under the general heading of Rheumatology. Full details of those that can be identified from skeletal remains are appended as Appendix 1.

Other Diseases to be Noted:
A number of other affections occur in bone. These are for the purpose of the study classified separately as diseases of a non-arthritic origin, although some may accompany Rheumatoid or arthritic diseases. Full details of those afflictions that can be identified in skeletal remains are appended as Appendix 2.

Summary:
The main aim of the research is to be a palaeopathological study of human skeletal remains. The main emphasis will be on the determination of the incidence and occurrence of bone and joint diseases that are due to rheumatoid and osteoarthritis. Complementary to this theme will be the elucidation of any other evidence of other pathological conditions in the said remains.

It is felt that such a study will contribute something to the understanding of the aetiology of the arthroses and other bone disorders. Such a study will place these diseases in a historical as well as a clinical perspective, especially in their relationship to ancient conditions and environments. Such s study may help to give a clearer indication as to the mechanisms, aetiology and persistence of these diseases in both modern and previous populations, and that such research may elucidate whether there have been any changes in the incidence and form of the outlined arthritic diseases.

Appendix 1. 

Rheumatoid and Arthritic Diseases to be Studied in Respect of Human Skeletal Remains in Oxford.

RHEUMATOID ARTHRITIS: Including developmental stages; Still’s disease.

SERO-NEGATIVE:  including Psoriatic arthritis; Reiter’s sndrome; Ankylosing spondylosis; Enteropathic arthritis.

DEGENERATIVE JOINT DISEASE: including Osteoarthroses; Cervical, dorsal, lumbar spondylosis; Osteochondroses; Sychondroses.

CRYSTAL SYNOVITIS: including gout and chondrocalcinosis.

CONNECTIVE TISSUE DISORDERS: including Scleroderma.

OTHER FORMS OF ARTHRITIS: including Acromegalic arthritis; Hypertrophic pulmonary osteoarhtropathy (which may indicate intra-thoracic disease); and Neuropathic arthritis (which may be associated with syphilis, diabetes, or syringomyelia); Sarcoidosis; Ochronosis; Myelomatosis; Haemachromatosis.

Appendix 2.

OTHER DISEASES OF BONE DISCENIBLE IN SKELETAL REMAINS

INFLAMMATION OF BONE:including Osteitis; Periostitis; Osteomyelitis; tuberculous disease of bone; Syphilitic disease of bone; Leprosy.

TUMOURS OF BONE: including Osteosarcoma; Button Osteomas.

DISEASES OF JAWS AND TEETH: icluding caries, periodontal disease; hypoplasia; chronic abscesses.

DEFORMITIES: including poliomyelitis; hip deformities; congenital dysplasia of the hip.

BONE CHANGES DUE TO ENDOCRINE DISTURBANCES: including Hyperpituitarism; and Hypopituitarism.

EFFECTS OF DIET ON BONE: including Ricketts; Osteomalacia; other deficiencies.

ACQUIRED AFFECTIONS OF UNKNOWN ORIGIN: including Paget’s disease; Osteoporosis.

CONGENITAL DEVELOPMENTAL ERRORS: including Achondroplasia; Acrocephaly; Microcephaly; other congenital anomalies.

SYNOSTOSES OF UNKNOWN ORIGIN: including Scaphocephaly; Trigonocephaly; and Plagiocephaly.

BONE CHANGES ASSOCIATED WITH BLOOD DISORDERS: including Haemophilia.

Originally accepted and supported by the Nuffield Orthopaedic Centre, Department of Medicine, University of Oxford, in 1975-1976. However it was not possible to raise the research grants to start and continue the research programme.