Re-expansion pulmonary edema (RPE) is a non-cardiogenic pulmonary edema, and is secondary to pulmonary collapse caused due to various reasons. However, RPE is rarely encountered during non-thoracic surgeries and is associated with much higher risk than that occurring in thoracic surgeries.Herein we have reported a case report of a 55-years-old male patient. Preoperative examination indicated occupying lesions in the bronchus and cerebellar hemisphere. Under general anesthesia, the patient received resection of cerebellar lesion and developed acute atelectasis, and RPE occurred when cannulation was withdrawn after re-expansion. Supportive and symptomatic treatment was given to the patient for recovery well.RPE.The trachea was cannulated and connected to a ventilator for assisted ventilation. The patient was also given symptomatic treatment including nebulization, diuresis, and anti-inflammation.The patient recovered well and was discharged on day 8 after surgery.Patients with occupying lesions of the airway should undergo bronchoscopy to determine the location, size, and distance of the lesion from the incisors. The anesthesiologists should determine appropriate anesthetic regimens according to the examination results to avoid acute atelectasis and postoperative pulmonary edema. In this study, we reported a case that had bronchial occupying lesions before surgery and developed RPE due to bronchospasm-induced transient atelectasis. The informed consent was obtained from the patient for publication of this manuscript.Re-expansion pulmonary edema (RPE) refers to pulmonary edema when the lung tissue re-expands after collapse. The onset of RPE is acute, and the patients might experience a sharp declination in oxygen saturation, hypotension and shock might be seen in some seriously affected patients, threatening their life.2We reported a case report of a 55-years-old male who received resection of right cerebellar occupying lesions 3 years ago. Postoperative pathology suggested large cell neuroendocrine carcinoma of the lung. In the past year, the patient had instable gait, dizziness, headache, and cough, and visited our hospital due to continuously aggravating symptoms. Positron emission tomography-computed tomography (PET-CT) examination suggested left cerebellar lesion with local hemorrhage, and chest computed tomography (CT) suggested soft tissue nodules in the left and right main bronchi Fig. . Based o2 and arterial pressure and provided a mask for oxygen inhalation at 6L/min. The baseline characteristics of the patient showed BP of 145/85 mmHg, SpO2 94%, HR 110 beats/min, and ECG showed no abnormalities. Anesthesia induction was performed using intravenous administration of sufentanil 20 μg, etomidate 20 mg, and rocuronium 50 mg. After 60 seconds of assisted ventilation with low tidal volume, a #7.5 tube was cannulated under glidescope guidance, and the depth was fixed at 23 cm. Auscultation of both lungs showed no significant abnormalities, so the ventilator was connected, the mode was set as mechanical ventilation, VT at 400 mL, and RR at 13 times/min. Anesthesia was maintained by 1.5%∼2.5% sevoflurane in combination with 50% O2 and 50% N2O, and intravenous infusion of remifentanil was also given to maintain BP within 120 to 140 mmHg, HR 80 to 100 beats/min, SpO2 95% to 100% and PETCO2 25 to 30 mmHg. Intraoperative hemodynamics remained stable, and the arterial blood gas analysis showed no significant abnormalities. However, during the operation, the patient showed 3 times of unexplained SpO2 declination, and the lowest level reached to 90%. After giving lung expansion, the SpO2 was increased to 95%. During surgery, the patient was asked to lie in a prone position, and the operation lasted for 3 hours and 47 minutes. 1.7U of red blood cells was infused, and the volume of compound lactated Ringer's injection was 1260 mL, colloid 1000 mL, and urine 450 mL. When the patient was recovered from anesthesia and showed spontaneous breathing, 1 mg of neostigmine was used for antagonizing muscle relaxation, and 0.5 g of doxapram for the excitation of respiratory center. However, when performing sputum suction, the sucking-tube was obstructed, and the SpO2 was dropped rapidly to 80% after sputum suction. Immediately, lung expansion with pure oxygen was performed, which led to no remission, but the SpO2 further declined to 55%. We then auscultated both the lungs and found no breathing sounds in the hilum, upper and lower lobes of the left lung. Blood gas analysis suggested pH: 7.281, PaCO2: 37.4mmHg, PO2: 38.8 mmHg, and Lac:4.2mmol/L. Thus, an intravenous infusion of 120 mL sodium bicarbonate was given, and lung expansion was continued with 100% O2 as well as sevoflurane. About 8 minutes later, the SpO2 was increased gradually to 100%. After that, the patient was sent to ICU, and he showed intolerance to tracheal cannulation approximately 20 minutes later. The doctor even after withdrawing the cannulation, the patient again showed breathing difficulty and sudden drop of SpO2, with the lowest level of 65%, and oxygen mask failed to relieve the condition. Auscultation of both lungs at the moment showed moist rales of the left lung, and the patient had much white foam secretions from his mouth. After full oral cavity aspiration, the trachea was cannulated and connected to a ventilator for assisted ventilation. The patient was also given symptomatic treatment including nebulization, diuresis and anti-inflammation, and reached weaning indications after 3 days of operation. Auscultation suggested weak respiratory sounds in the hilum and upper field of the left lung, and some moist rales were still audible from the lower left lung. The ventilator was weaned and cannulation was withdrawn, and the patient underwent CT examination. The results showed no abnormalities except for a slight increase in the amount of fluid in the left thoracic cavity . To be specific, when the lung is expanded, mechanical damages would increase the permeability of pulmonary capillaries and uplift the hydrostatic pressure. This, in turn, causes outflow of fluid and protein from the pulmonary vessels to the interstitial lung, resulting in pulmonary edema.Currently, there is no special method for RPE diagnosis and is determined mainly by glass-like changes of diseased vessels on pulmonary CT images. However, for acute RPE, immediate respiratory support should be provided. CT scanning cannot be performed immediately, as the conditions are stabilized and the special imaging features would disappear, leaving only a slight amount of pleural effusion.In the reported case, dyspnea and white foam sputum occurred 1 hour after atelectasis. This in combination with later imaging features , we speculated that the patient had RPE. Yet it was different when compared with the previously reported cases, as this patient did not receive any chest surgery or operation, and had a history of atelectasis before surgery. Therefore, his RPE occurred in ICU due to transient atelectasis during the recovery period from anesthesia, and the reason why the patient showed atelectasis is the focus of our discussion. Reviewing the whole process, we found that the obstruction of the left bronchus was the direct cause of atelectasis during the recovery period. There are 2 main reasons for airway obstruction, 1 due to the blocks of the same diameter as the airway, and the other include airway contractures due to various reasons. A closer look at the CT images before operation showed an occupying lesion of large diameter in the left main bronchus, which occupied 3/4 of the diameter of the whole airway the patient had a coughing history for years due to bronchial occupational exposures, causing inflammation of the airway;2)sputum suction under light anesthesia was a common reason for bronchospasm.In this case, sputum suction might cause vagal excitation, leading to intense contraction of the smooth muscles. Fortunately, our anesthesiologist performed timely and effective treatment for the patient, and so the airway spasm was quickly relieved, and the time of atelectasis was reduced. Under stable hemodynamics, a negative fluid balance should be maintained to reduce pulmonary edema. Since RPE was diagnosed and treated immediately, the patient was recovered well in the following days and showed no other complications.At present, the main treatment for RPE is to maintain adequate oxygen supply. Non-invasive nasal catheter and oxygen mask can be used to improve hypoxemia, and invasive airway cannulation or ventilator therapy can be performed as soon as possible. In addition to oxygen supply, glucocorticoids should be given for anti-inflammatory treatment.4For patients with airway occupying lesions and those planning for general anesthesia, the size and location of the lesions should be determined before operation to develop appropriate anesthetic regimens. This could avoid the fall off of the occupying lesions, and also reduce the airway stimulation during the perioperative period to prevent spasm. If atelectasis occurs for any reason, we should be vigilant for the development of RPE after pulmonary re-expansion.Data curation: Ying Wang.Project administration: Ruozhu Cheng.Resources: Hongzhi Chen.Software: Xuanyu Chen.Writing – review & editing: Jiang Yu, Xueli Yang.


Proteobacteria, dominated by Alpha- and Deltaproteobacteria, was the most abundant phylum (34.51%) in the karst forest soils. Other dominating phyla were Actinobacteria (30.73%), and Acidobacteria (12.24%). Soil microbial taxa showed spatial dependence with an autocorrelation range of 44.4–883.0 m, most of them within the scope of the study plots (500 m). An increasing trend was observed for Alphaproteobacteria, Deltaproteobacteria, and Chloroflexi from north to south in the study area, but an opposite trend for Actinobacteria, Acidobacteira, and Firmicutes was observed. Thaumarchaeota, Bacteroidetes, Gemmatimonadetes, and Verrucomicrobia had patchy patterns, Nitrospirae had a unimodal pattern, and Latescibacteria had an intermittent pattern with low and high value strips. Location, soil total phosphorus, elevation, and plant density were significantly correlated with main soil bacterial taxa in the karst forest. Moreover, the total variation in soil microbial communities better explained by spatial factors than environmental variables. Furthermore, a large part of variation (76.8%) was unexplained in the study. Therefore, our results suggested that dispersal limitation was the primary driver of spatial pattern of soil microbial taxa in broadleaved forest in karst areas, and other environmental variables  should be taken into consideration.Spatial patterns and drivers of soil microbial communities have not yet been well documented. Here, we used geostatistical modeling and Illumina sequencing of 16S rRNA genes to explore how the main microbial taxa at the phyla level are spatially distributed in a 25-ha karst broadleaf forest in southwest China.  The spatial distribution of plants from small to large scales has been documented for a long period . Shifts Acidobacteria , which is the largest forest reserve in the karst region and is a component of Chinese Forest Biodiversity Monitoring Network (CForBio) . The mic2 with a range of 19.80 km from east to west and a distance 10.75 km from south to north. The subtropical monsoon climate has an average annual temperature of 19.38°C and average annual precipitation of 1,529.2 mm (mainly from April to August). In addition, the annual accumulated temperature above 10 is 6,260°C. The frost-free period is 310 days, and the mean annual relative humidity is 79% , which is in the northwestern region of Guangxi Province, China . The plot was divided into a grid of 625 cells 20 × 20 m in size. All plant characteristics and topographical factors  were measured as previously described , with the bottom left (southwestern) corner as the point of origin , the Y axis running north and south, and the X axis running east and west  forest plot was established in MNNR in 2014, and subsequently the first census was conducted according to the standard field protocol of the Center for Tropical Forest Science , and the samples were collected in the four corners and the center of each cell  were collected within a circle with a radius of 2 m  was determined by NaOH fusion-flame spectrophotometry. Available nitrogen (AN) was determined using the diffusion-absorption method, available phosphorus (AP) was determined by NaHCO3 extraction-ammonium molybdate spectrophotometry, and available potassium (AK) was determined by (NH4)2CO3 extraction-flame spectrophotometry (Soil pH was determined using a pH meter after shaking the soil water (1:5 soil/water) suspension for 30 min. Soil organic carbon (SOC) and total nitrogen (TN) were determined using an elemental analyzer , total phosphorus (TP) was determined colorimetrically  after wet digestion with HClOotometry .®SPIN Kit for Soil, MP), according to the manufacturer’s instructions. The concentration and quality of the extracted DNA were assessed with a spectrophotometer  and agarose gel electrophoresis. The extracted soil DNA was stored at −80°C for PCR amplification and 16S rRNA gene sequencing.Soil microbial DNA was extracted from each soil sample three times from 0.5 g of fresh soil  with the soil DNA kit  at Novogene Biotechnology Co., Ltd. .The V4–V5 region of 16S rRNA gene sequencing was targeted and amplified via PCR with the primers set 515F (5′-GTGCCAGCMGCCGCGGTAA-3′) and 907R (CCGTCAATTCCTTTG AGTTT-3′) . The priThe raw reads of microbial 16S rRNA genes were demultiplexed, quality-filtered, and processed by using QIIME based on three criteria . SequencChloroflexi, Nitrospirae, Latescibacteria, and Verrucomivrobia) followed a normal distribution after using the Box-Cox transformation  is semivariance for interval distance class h; iz is measured sample value at point i; i+hz is measured sample value at point i+h; and N(h) means total number of sample couples for the lag interval h. Either higher value of the higher determination coefficient (R2) or lower value of the residual sums of squares (RSS) of the best fitting model, which indicates that the spatial structure of soil microbial taxa at the phyla level can be better reflected , soil properties , topographical variables , and plant characteristics . The relationships between spatial position, soil properties, topographical factors, plant characteristics, and microbial phyla were determined by Pearson’s correlation analysis in SPSS 18.0 software package. In order to decrease the false discovery rate, Benjamini-Hochberg procedure were conducted for multiple testing corrections. The relationship between soil bacterial phyla and the above mentioned environmental factors were identified using redundancy analysis (RDA) and conducted using Canoco 5.0 software. Before the RDA analysis, a detrended correspondence analysis (DCA) for the relative abundance of the main microbial taxa was performed to confirm that the linear ordination method was suitable for analysis of the microbial taxa data (gradient length <3). The result of RDA analysis revealed the effect of the environmental factors on microbial communities based on the arrow length and the angle between lines . Soil pH and SOC varied from 6.35 to 8.25 and 28.96 to 129.39 g kg−1, respectively. TN, TP, TK, AN, AP, and AK ranged from 3.00 to 14.41 g kg−1, 0.35 to 3.39 g kg−1, 1.05 to 13.96 g kg−1, 166.71 to 860.20 mg kg−1, 0.95 to 18.54 mg kg−1, and 1.23 to 12.91 mg kg−1, respectively, and had a medium variation with CV (Coefficient of variation) between 25 and 75%, except for pH (Table 1).According to the first census in 2014, there were 144,552 individuals belonging to 51 families, 127 genera, and 228 species in the forest plot. The most dominant species were communis . In the Proteobacteria (34.51%), Actinobacteria (30.73%), Acidobacteria (12.24%), Chloroflexi (6.00%), Thaumarchaeota (4.17%), Nitrospirae (3.61%), Bacteroidetes (2.45%), Gemmatimonadetes (2.00%), Latescibacteria (1.06%), Verrucomicrobia (1.04%), and Firmicutes (1.04%) , which has two dominant Proteobacteria classes, Alphaproteobacteria and Deltaproteobacteria. Thus, Alpha- and Deltaproteobacteria were included in our analysis. At the class level, Alphaproteobacteria (18.43%) and Thermoleophilia (11.57%) were the most dominant classes  of soil microbial phyla were: Figure 2). First, the spatial dependence of Thaumarchaeota was very small, the Moran’s I index was close to 0, and the regularity was not strong. The other ten phyla had a certain degree of spatial dependency, ranging from −0.157 to 0.495, and with a decreasing order of Bacteroidetes, Nitrospirae, Proteobacteria, Actinobacteria, Latescibacteria, Firmicutes, Chloroflexi, Gemmatimona, Acidobacteria, and Verrucomicrobia. Secondly, Proteobacteria, Nitrospirae, and Firmicutes had a similar spatial structure in that the Moran’s I index of these phyla gradually declined as the lag distance increased and reached 0 around 226.27 m. Then, the Moran’s I index of the other phyla decreased to negative and then increased after a minimum as the lag distance was extended, which illustrated a distinct spatial structure.There were three trends in the spatial autocorrelation of the relative abundance of the main microbial phyla in the karst forest . Geostatistical modeling showed a very low nugget effect (C0) and autocorrelation range of 44.4–883.0 m for the main microbial phyla relative abundance in the karst forest soil . The range of most of the main microbial taxa (except Deltaproteobacteria and Firmicutes) was less than the sampling range (500 m). Moreover, the range of Thaumarchaeota and Verrucomicrobia was very small, 44.4 and 84.3 m, respectively , but Actinobacteria, Acidobacteira, and Firmicutes showed an opposite trend . Moreover, Thaumarchaeota, Bacteroidetes, Gemmatimonadetes, and Verrucomicrobia had a distinct patchy pattern . Nitrospirae displayed a unimodal distribution pattern with the peak value of relative abundance in the middle part of the plot . By and large, Latescibacteria exhibited an intermittent pattern with high and low value strips .The kriging maps showed an increasing trend in the spatial distribution of Y values of the plot locations, phosphorus, elevation, slope, plant density, plant diversity , and the relative abundance of many soil microbial taxa (Table 2). Dynamics in soil microbial community composition, induced by relative abundance, were most closely related to the plot location, phosphorus, and plant factors. However, microbial community composition was unrelated to SOC, AK, soil depth, rock outcrop coverage, and slope aspect. We also found that plant traits and topographical factors were highly correlated with X value, TK and TP were highly correlated, tree abundance and Simpson index were highly correlated with Shannon index, soil depth and rock outcrop coverage were highly correlated, and slope and elevation were also highly correlated . The results showed that environmental variables, especially Y value of location, TP, elevation, and plant density, significantly affected the soil dominant microbial community. Furthermore, the relative abundance of Firmicutes, Actinobacteria, Bacteroidetes, and Chloroflexi was positively correlated with Y value of location, while Alpha- and Deltaproteobacteria showed the opposite trend. Latescibacteria, Gemmatimonadetes, Acidobacteria, Verrucomicrobia, and Bacteroidetes were significantly affected by soil TP, elevation, and plant density. Variance partitioning indicated that environmental factors explained 8.4% of variation in spatial distribution of soil microbial taxa relative abundance, and spatial factors explained 13.7% of the variation. The interaction between environmental factors and spatial factors was 1.1% of the variation .The relationship between environmental variables  and the dominant microbial taxa relative abundance were examined using RDA , Actinobacteria (30.73%), and Acidobacteria (12.24%)  compared with other microbial phyla (ranging from 44.4 to 412.8 m)  was also observed by 2  represented the location of sample plot i by grid method from the origin. Y value showed to account most for soil microbial community composition in the karst forest among the selected environmental factors . It is well confirmed that soil properties, including soil microbial taxa, are spatially differentiated by both internal factors , which accounted for causing a strong spatial variability of soil properties, and by external factors (field management), which are thought to be responsible for the weak spatial dependence of soil properties , which was responsible much for the distribution of microbial community composition. Soil phosphorus, most of which was obtained from the parent material, was gradually depleted and fixed in plants and animal tissues and its concentrations became unsatisfactory for microorganisms . On one hand, this is because fine particles eroding from higher elevation and then deposing at the lower areas of the field where relatively fine soil offers more affordable living environment for microbes . Higher plant density means more fine roots and a competition for soil nutrient in the soil. Root exudation extremely affects the availability of soil organic C and influences soil nutrient status , indicating that plant diversity can drive the changes in microbial diversity , and we found a low correlation between pH and the main microbial phyla relative abundance (Data not shown). Thus, our results indicated that soil pH did not play an important role in shaping microbial community composition in the karst forest soil. In addition, Soil pH has been documented as the major factor determining the soil microbial community composition in many soils and ecosystems, such as soils across North and South America , BritishAlphaproteobacteria, Deltaproteobacteria, and Chloroflexi had an increasing trend from the north to the south in the forest plot, whereas the opposite was found for Actinobacteria, Acidobacteira, and Firmicutes . Overall, these six phyla could be differentiated into copiotrophic or oligotrophic categories. Our results indicated that the spatial heterogeneity of soil nutrients affect the r- and K-selected categories of microbial taxa , but the trend of the latter was weaker, which may be related to sampling period peaking in plant litter and root exudates that prefer Actinobacteria rather than the more oligotrophic Acidobacteria . Moreover, variance partitioning showed that spatial factors better explained the total variation of soil microbial communities than environmental factors, which indicated that dispersal limitation was the primary driver of soil microbial spatial pattern in broadleaved forests in karst areas , which was dominated by Alpha- and Deltaproteobacteria. Actinobacteria (30.73%) and Acidobacteria (12.24%) were other dominating phyla. We demonstrated that spatial patterns of the microbial taxa relative abundance at the phyla level could be detected and modeled at the study scale, which suggested that the microbial communities were spatially distributed in the karst forest soil of southwest China. Moreover, kriging maps displayed that no single spatial pattern was shared by all the main bacterial communities, which indicated that the patterns of microbial phyla in the karst forest soils were heterogeneous and complex. Furthermore, location, soil TP, elevation, and plant density were significantly correlated with main soil bacterial taxa in the karst forest. However, the total variation in soil microbial communities better explained by spatial factors than environmental variables. Moreover, a large portion of the variation was unexplained in our study. Our results suggested that dispersal limitation was the primary drivers of soil microbial distribution in broadleaved forest in karst areas, and environmental factors  may be taken into consideration.The dominant microbial phylum in the karst forest soils was WP, FZ, and QX were responsible for experiment design and writing guidance. MS and WP were responsible for experiment performance and paper writing. QP, HD, LC, and FZh were responsible for experimental data processing and analysis.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


HOXA3, HOXA7, HOXA10, and HOXA11), meat quality , appetite (NUCB2) and disease resistance traits  were identified in ROH islands. Moreover, several quantitative trait loci for ham weight and ham fat thickness were detected. Genes in ROH islands suggested, at least partially, a selection for economic traits and environmental adaptation, and should be subject of future investigation. These findings contribute to the understanding of the effects of environmental and artificial selection in shaping the distribution of functional variants in the pig genome.Jinhua pig, a well-known Chinese indigenous breed, has evolved as a pig breed with excellent meat quality, greater disease resistance, and higher prolificacy. The reduction in the number of Jinhua pigs over the past years has raised concerns about inbreeding. Runs of homozygosity (ROH) along the genome have been applied to quantify individual autozygosity to improve the understanding of inbreeding depression and identify genes associated with traits of interest. Here, we investigated the occurrence and distribution of ROH using next-generation sequencing data to characterize autozygosity in 202 Jinhua pigs, as well as to identify the genomic regions with high ROH frequencies within individuals. The average inbreeding coefficient, based on ROH longer than 1 Mb, was 0.168 ± 0.052. In total, 18,690 ROH were identified in all individuals, among which shorter segments (1–5 Mb) predominated. Individual ROH autosome coverage ranged from 5.32 to 29.14% in the Jinhua population. On average, approximately 16.8% of the whole genome was covered by ROH segments, with the lowest coverage on SSC11 and the highest coverage on SSC17. A total of 824 SNPs (about 0.5%) and 11 ROH island regions were identified (occurring in over 45% of the samples). Genes associated with reproduction ( It can result from several different phenomena, such as genetic drift, consanguineous matings, population bottleneck, as well as natural and artificial selection . Jinhua ic drift . In addiic drift . For theG Morgan, where G is the number of generations since the common ancestor (Runs of homozygosity (ROH) are contiguous homozygous segments of the genome where the two haplotypes inherited from the parents are identical . The devancestor , the numancestor . The autancestor  and alsoancestor . In addiancestor . Recentlancestor , chickenancestor , and sheancestor , but lese and different measures of inbreeding from pedigree and genomic information, were also investigated. For that, we used genotyping by genome reducing and sequencing (GGRS)  , which wg (GGRS) .Ear tissue samples were collected from 202 Jinhua pigs  from conservation pig farms in Zhejiang province. Those pigs were born between 2014 and 2017, with an average depth of about four generations. A commercial kit  was used to extract genomic DNA, and verified the integrity and purity of DNA by agarose gel electrophoresis and the A260/280 ratio. The Genomic DNA samples were genotyped using the GGRS protocol . Quality1). These SNPs were annotated according to the Ensembl pig gene annotation set (Ensembl release 922) as previously reported by To determine novel variants in our sequence data, we compared the identified SNPs with the dbSNP data (Build 152o) and expected heterozygosity (He) were estimated using PLINK v1.07  is the effective population size t generations ago, calculated as t = (2f (tc))-1; ct is the recombination rate for a specific physical distance between SNPs, which was estimated using f is the Haldane mapping function built between recombination rate and genetic distance measured by Morgan; α is a correction for the occurrence of mutations.where Linkage disequilibrium between SNP pairs was estimated using PLINK v1.07 . Haplotyhomozyg were used to define ROH  thefine ROH , a minimPED) for all pigs were estimated using R package “pedigree.”Different types of inbreeding coefficients were estimated based on pedigree and genomic information. Pedigree-based inbreeding coefficients (FROH), as the ratio of the total length of genome covered by ROH to the total length of the genome covered by SNPs or sequences, as proposed by Genomic inbreeding for each animal was estimated from ROH , 5–10 Mb (FROH5-10Mb), 1–5 Mb (FROH1-5Mb), and ROH > 1 Mb , corresponding to 5 generations, 5 to 10 generations, 10 to 50 generations, and 50 generations, respectively.in which LSNP1, was based on the variance of the additive genotypes , and n is the total number of SNPs. Note that these coefficients were corrected by the allele frequencies of the current population and they can take negative values  - 0.5|], where Φ(x) represents the Gaussian cumulative distribution function and piHS is the two sided p-value associated with the neutral hypothesis of no selection (p < 0.005) were considered as putative signatures of selection  test was performed within Jinhua pigs. The iHS is a measure of the amount of extended haplotype homozygosity at a given SNP, designed to use phased genotypes to identify putative regions of recent or ongoing positive selection in genomes . The hap package  as previelection . Correspelection . In thisA total of 166,661 informative SNPs satisfying the quality filters were obtained, 26,458 of which were identified as unreported in the pig SNP database of NCBI. The SNP density was about 1 SNP per 13.6 kb and they were equally distributed on each chromosome, with the exception of some isolated regions . Accordio) and expected (He) heterozygosities in this Jinhua pig population were 0.312 ± 0.070 and 0.429 ± 0.057, respectively. The value of He was slightly higher than that reported by e was estimated from five to 1000 generations ago in our study. The results show that Ne has decreased through time, at a faster rate at 1,000 to 970 generations ago (The average observed (Hions ago . This fiROH based on larger segments (0.041–0.053) was closer to FPED (0.01) than the average FSNP. This was to some extent expected, given that the pedigree depth (about four generations) is in agreement with larger ROH segments. In addition, these two coefficients vary in the same range (0–1), while SNP-by-SNP coefficients estimated here can take lower or larger values. These low average FROH values of inbreeding suggest that recent inbreeding was low. However, according to SNP-by-SNP based coefficients, which reflect deviations of the observed inbreeding from the expected values in the current population, recent inbreeding seems to be considerably higher (0.262) than that based on pedigree and ROH.The average inbreeding coefficients estimated using different approaches are shown in PED with all the genomic coefficients was low , increasing between coefficients computed from the same source of information, as expected , thus suggesting that genotype-based estimates provide greater accuracy on relatedness as supported by previous studies  had higher correlations with FSNP1, FSNP2, and FSNP3. A similar trend was also reported by SNP2 had higher correlations with FROH1-5Mb, FROH5-10Mb, FROH>10Mb and all FROH_all. These results corroborate previous results observed in cattle (SNP2 based on excess of homozygosity correlated relatively highly with FROH detected from 50k and sequence data. This trend may be due to the fact that both FROH and FSNP2 directly reflect homozygosity on the genome (SNP2 (to some extent) capture all of the homozygosity, whereas, the FROH uses only ROH. Furthermore, the moderate to high correlations between FROH and the three other estimates of genomic inbreeding  suggested that the proportion of the genome in ROH can be used as an accurate estimate of individual inbreeding levels  in a ROH were considered as candidate SNPs . A totalChromosome position, start and end position of ROH, ROH length, number of SNPs, and number of genes within the genomic regions of extended homozygosity are reported in ADCK1, involved in phosphate metabolism, which was in the selection signature region between Berkshire and Korean native pig breeds   . The MYOds group .HOXA3, HOXA7, HOXA10, and HOXA11 on SSC18, which affects embryo implantation and prolificacy traits  with F4 fimbriae (F4ac) receptor  database islands . In partIn summary, the results show that the genomic regions that display autozygosity in the Jinhua pig breed are related to important production traits under selection, and possibly also help improve their adaptability to survive in hot and very humid environments.Results from the iHS test revealed that this coefficient had an average value of 0.77, with a maximum value of 4.69 on SSC7, thus indicating that the iHS values were not uniform across the genome. p-value < 0.005 that harbored signatures of selection, 92 of which were found in ROH islands  Sequence Read Archive (SRA). 202 samples are available under the Bioproject No. All experimental procedures were approved by the Institutional Animal Care and Use Committee of Shanghai Jiao Tong University, and all methods involved pigs were in accordance with the agreement of Institutional Animal Care and Use Committee of Shanghai Jiao Tong University (Contract No. 2011–0033).YP, QW, and ZX designed the experiments. ZX, HS, QZ, XZ, QL, and YY performed the experiments. ZX, ZZ, and PM developed some of the analysis software. ZX wrote the manuscript with the help of BO. All authors read and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Peripheral artery disease (PAD) is a common atherosclerotic disease characterized by narrowed or blocked arteries in the lower extremities. Circulating serum biomarkers can provide significant insight regarding the disease progression. Here, we explore the metabolomics signatures associated with different stages of PAD and investigate potential mechanisms of the disease. We compared the serum metabolites of a cohort of 26 PAD patients presenting with claudication and 26 PAD patients presenting with critical limb ischemia (CLI) to those of 26 non-PAD controls. A difference between the metabolite profiles of PAD patients from non-PAD controls was observed for several amino acids, acylcarnitines, ceramides, and cholesteryl esters. Furthermore, our data demonstrate that patients with CLI possess an altered metabolomic signature different from that of both claudicants and non-PAD controls. These findings provide new insight into the pathophysiology of PAD and may help develop future diagnostic procedures and therapies for PAD patients. Peripheral artery disease (PAD) is an atherosclerotic condition of the arteries supplying the lower extremities. PAD affects over 200 million people around the world, with an estimated prevalence of more than 20% for individuals over 80 years old ,2. The mMetabolomics, the study of small-molecule metabolites in biological systems ,19, has 1H NMR metabolomic profiles of plasma lipid molecules are correlated with mortality in PAD patients [The clinical application of metabolomics in the study of PAD has been thus far explored with two studies evaluating near-term mortality and arterial stiffness in PAD patients. The first study showed that the patients . Specifipatients . These tTwenty-six non-PAD controls, 26 patients with IC, and 26 patients with CLI were recruited by vascular surgeons at the University of Nebraska Medical Center , the Veterans Affairs Nebraska-Western Iowa Medical Center, and Baylor Scott and White Hospital  under approved IRB protocols. IC or CLI diagnoses were made after examination of medical history, a physical examination, measurement of the ankle-brachial index (ABI), and computerized or standard arteriography. All non-PAD controls had normal blood flow to their legs and were undergoing operations for manifestations other than PAD . These pg at 4 °C. Serum was aliquoted into separate polypropylene tubes and immediately stored at −80 °C. The Biocrates AbsoluteIDQ p400 HR kit  was used to analyze 100 µL of serum from each patient. Compared to manual liquid chromatography-tandem mass spectrometry (LC-MS/MS) ) analysis and other technologies, the Biocrates kit allows for higher efficiency of separation, better limits of detection, decreased consumption of solvents, and absolute quantification of metabolites [Blood samples were obtained in the morning after an overnight fast. In total, 30 mL of blood was obtained from each patient and was immediately centrifuged for 10 minutes, 2000 × abolites .The Biocrates AbsoluteIDQ p400 HR kit was used to measure more than 400 metabolites, including 21 amino acids, 21 biogenic amines, the sum of hexoses , 55 acylcarnitines, 18 diglycerides, 42 triglycerides, 24 lysophosphatidylcholines, 172 phosphatidylcholines, 31 sphingomyelins, 9 ceramides, and 14 cholesteryl esters. The complete list of metabolites assayed are provided in the We calculated the ratio of phenylalanine to tyrosine as a marker of inflammation  and the www.metaboanalyst.ca)  was used for statistical analysis of the metabolites’ data, processed with normalization, scaling, and filtering [Baseline characteristics between non-PAD control, IC, and CLI subjects were compared using Chi-square and Fisher exact tests for categorical variables and analysis of variance (ANOVA) for continuous variables. One-way analysis of covariance (ANCOVA) was used for the rest of the analyses controlling for age, ABI, and diabetes mellitus. MetaboAnalyst 4.0 . IC patients were younger than CLI patients (p = 0.044) and CLI patients had a higher ratio of diabetes mellitus (p = 0.005). No other differences were found among the different groups of subjects.The baseline demographic and clinical characteristics are presented in Nineteen amino acids were measured for all subjects, and the phenylalanine/tyrosine ratio was also calculated. The amino acids arginine, glutamine, proline, tryptophan, and tyrosine were significantly lower in CLI patients when compared to both IC patients and non-PAD controls . In addir = 0.463, p < 0.001), ornithine , tryptophan , and the phenylalanine/tyrosine ratio .Of the amino acids, ABI was significantly correlated with histidine . In contrast, hydroxypropionylcarnitine, propionylcarnitine, and tiglylcarnitine were significantly higher in both the IC and CLI patients compared to non-PAD controls  (40:1), (41:1), and (42:1) were significantly lower in CLI patients compared to IC patients and non-PAD controls . Cer 43. Additior = 0.505, p < 0.001), Cer (41:1) , Cer (42:1) , and Cer (43:1) . Of the CEs, ABI was significantly associated with CE (16:0) , CE(17:0) , CE (17:1) , CE (18:2) , and CE (20:5)   (< 0.001) .The discriminant function analysis model was able to correctly classify the non-PAD control and PAD patients with a 93.6% accuracy. Using a cross-validation procedure to evaluate the discriminant model performance and stability also yielded an 87.2% accuracy in patient classification. Sensitivity and specificity are two basic quantities for measuring the accuracy of a diagnostic test. The sensitivity of a diagnostic test quantifies its ability to correctly identify non-PAD control subjects without the disease and is a measure of how well the test detects non-PAD control subjects. The sensitivity of the analysis was 73.1%. The specificity refers to the ability of a test to correctly identify subjects with PAD. The specificity of the analysis was 94.2%. The discriminant function analysis model correctly classified the IC and CLI patients with a 90.4% accuracy. Using a cross-validation procedure to evaluate the discriminant model performance and stability also yielded an 84.6% accuracy in patient classification. For this model, the sensitivity (correctly identify IC patients) was 80.8%, and the specificity (correctly identify CLI patients) was 88.5%. r = 0.638). It is possible that these metabolites alone or in combination can be used to produce a high-risk profile for PAD patients, allowing a personalized approach  to providing care for PAD patients. The utility of such a profile should be tested in the near future as it may be able to direct the general care of PAD patients.We conducted a broad metabolomic profiling of small molecules and lipids and compared metabolites between patients with IC, patients with CLI, and non-PAD controls. To our knowledge, this is the first example of metabolomics applied to evaluate patients in the two symptomatic categories of PAD versus controls. Compared to non-PAD controls, we found significant changes in the circulating levels of multiple metabolites in patients with CLI and patients with IC . Our disL-arginine, lack of availability of this substrate is believed to be a factor that can lead to decreased plasma NO [r = −0.428). An elevated phenylalanine/tyrosine ratio has similarly been shown in different conditions associated with oxidative stress and inflammation, including acute brain ischemia [). Notably, oxidative stress and inflammation are hallmarks of PAD [Several of the metabolite changes observed in this study in PAD patients are consistent with other reports from different pathologies. For example, serum levels of arginine were significantly reduced in CLI, which is consistent with several disorders linked to nitric oxide (NO) deficiency ,37,38. Llasma NO . Impairelasma NO . Furtherischemia ,40 . The rate-limiting step in the β-oxidation of long-chain fatty acids is the conjugation of carnitine to fatty acyl coenzyme A (coA) by the enzyme carnitine palmitoyltransferase (CPT1) [In patients with more severe PAD, however, a reduction in total and acylcarnitine content has been shown . This ise (CPT1) . Since ae (CPT1) . Consiste (CPT1) . HoweverSphingolipids are major components of cellular membranes, critical for the fluidity and architecture of the membrane. Sphingomyelins are a type of sphingolipid usually consisting of phosphocholine and ceramide. The metabolites of sphingolipids, such as ceramides, are important for regulating cell proliferation and survival, as well as the inflammatory responses . In thisCurrently available options  for the management of PAD are limited. There are two medications, with only modest efficacy, approved for claudication, and operations are associated with considerable morbidity and poor durability ,70. PAD One important limitation of this study is the sample size was relatively small. Thus, external validation from a larger sample could help add to the translational impact of the study results. Furthermore, while there is an emerging use of metabolomics in clinical settings, complexities and challenges, for example, related to testing strategies and quality control, limit its immediate clinical impact. Thus far, the field of metabolomics has primarily been limited to biomedical research and biomarker discovery; however, greater considerations must be taken into account for use as a clinical test. Therefore, this may also affect the translational impact of this study.Another important point to note is the use of only serum may limit the generalizability of these findings to other fluids and tissues. Specifically, during centrifugation to separate serum from coagulated blood, platelets release proteins that include cytokines and metabolites into the serum . Since aIn conclusion, we identified a number of metabolites that are altered in PAD. To our knowledge, this is the first time that a complete metabolomic profiling comparing patients with different severities of PAD and non-PAD controls is presented. These data provide unique metabolomic fingerprints that may be helpful in screening for the presence of PAD, and may also be useful in risk-stratifying PAD patients and predicting their clinical outcomes. Further, these alterations provide insight into the disrupted pathways that underlie the pathophysiology of PAD and may contribute to a better understanding of the disease and to the development of novel therapeutic interventions for PAD patients.


Homo sapiens relative to other hominins is a major focus for human evolutionary studies. It has been argued that the procurement of small, difficult-to-catch, agile prey is a hallmark of complex behavior unique to our species; however, most research in this regard has been limited to the last 20,000 years in Europe and the Levant. Here, we present detailed faunal assemblage and taphonomic data from Fa-Hien Lena Cave in Sri Lanka that demonstrates specialized, sophisticated hunting of semi-arboreal and arboreal monkey and squirrel populations from ca. 45,000 years ago, in a tropical rainforest environment. Facilitated by complex osseous and microlithic technologies, we argue these data highlight that the early capture of small, elusive mammals was part of the plastic behavior of Homo sapiens that allowed it to rapidly colonize a series of extreme environments that were apparently untouched by its hominin relatives.Defining the distinctive capacities of  As modern humans migrated out of Africa, they encountered novel habitats. Here, Wedage et al. study the archaeological site of Fa-Hien Lena in Sri Lanka and show that the earliest human residents of the island practiced specialized hunting of small mammals, demonstrating ecological plasticity. Homo sapiens had a unique capacity to adapt to a diversity of extreme environments, both within and beyond Africa, when compared with other members of the genus Homo1. Nevertheless, studies of migrations of our species into Europe, the Middle East, and Asia have often focused on its increased efficiency in hunting, butchering, and consuming medium-to-large game in open “savanna” settings3. Alternatively, coastal settings have been highlighted as providing homogeneous, protein-rich resources that stimulated human evolution as well as migration beyond Africa from the Late Pleistocene5. Focus on these environments has meant that small mammals have been neglected in discussions of the human colonization of new environments, despite the fact that a specialization in their procurement is often considered a feature of technological and behavioral “complexity” or “modernity” unique to our species7. Concentration on Europe and West Asia in this regard has linked increased usage and capture of agile, but abundant, small mammals to human population growth or climatically driven crises associated with the end of the last glacial period6. Nevertheless, the onset and behavioral context of small mammal hunting in other parts of the world, and beyond temperate environments, has remained poorly studied.There is growing evidence that 9. This was mainly due to the fact that mammalian megafauna (> 44 kg10), thought to have been attractive to Late Pleistocene humans, and even driven to extinction as a result of our species’ expansion12, are lacking in these settings8. Nevertheless, in Sri Lanka, Southeast Asia, and Melanesia, as well as other parts of the world, the earliest evidence for human occupation is often associated with rainforest environments16. In Sri Lanka, stable isotope evidence has demonstrated that humans relied on rainforest resources for over 30,000 years17, perhaps aided by the complex microlith and bone toolkits found at Late Pleistocene and early Holocene sites in the region18. However, owing to a lack of detailed faunal analyses, it has remained unknown which foodstuffs sustained human populations during this time, as well as the hunting strategies employed to obtain them.From the Late Pleistocene onwards, our species inhabited a number of diverse environments as it dispersed beyond Africa. One of these environments, tropical rainforests, has been considered a barrier to human dispersal20. Fa-Hien Lena documents the earliest fossil appearance of H. sapiens in Sri Lanka, and indeed South Asia, alongside small, quartz microlith technology, and a variety of pointed bone technologies20. Rainforest mammals, reptiles, molluscs, and plant remains have been identified at the site21. However, human exploitation of specific resources has yet to be directly demonstrated owing to a lack of systematic taphonomic study. Similarly, the early, enigmatic microlith and bone technologies discovered here and elsewhere in South Asia have undergone limited analysis, and their use and adaptive function have remained obscure22. The results of our new multidisciplinary analyses document specialized, sophisticated hunting of semi-arboreal and arboreal prey taxa from ca. 45,000 years ago, in the tropical rainforest environments of Sri Lanka.We apply new chronometric, taphonomic, archaeozoological, and artifactual analyses to the earliest dated archeological site in Sri Lanka, Fa-Hien Lena Fig. , previou23. The phases correspond to concentrations of charcoal, faunal remains, and artifacts, including osseous tools, shell beads, and quartz flakes  and Middle  Holocene, respectively. One radiocarbon date falls outside these phases  and may represent a short-lived episode of human presence in the cave.We divide the dates available for the site into four distinct phases based on our new, and previous, excavationsc. 170 cm of detrital sediment deposited above heavily weathered and karstified gneiss blocks. Phase D consists of pebbly loams and clayey and sandy silt deposits with laminated ash representing intermittent/episodic human occupation and colluvial inwash. The deposits yielded a variety of evidence for human activity, including heavily burned/calcined faunal remains, shell beads, bone tools, and ocher fragments, in addition to micromorphological analyses of sediments evidencing in situ burning  . These animals, including carnivores such as the civet cat, account for more than 90% of the NISP, suggesting deliberate hunting from the Late Pleistocene until the Mid-Holocene . The full dataset can be found in Supplementary Note Macaca sinica (toque macaque), the colobine monkeys Trachypithecus vetulus (purple-faced langur), and Semnopithecus priam (tufted gray langur). These species occur sympatrically and all were identified in the site. Macaques slightly outnumber the leaf monkeys in the faunal assemblage . A high proportion of the small mammal (17.1%) remains identified at the site exhibit evidence for burning, including 16.1% of the monkey remains.Bone fragments with anthropic modification, ranging from burning to butchery marks, were recovered in all phases of site occupation. Butchery marks were recorded on a total of 92 bone fragments 0.64%), the majority of which were from small mammals (92.2%)  of the site (1.3% of the NISP). These consist of 10 fragments of finished implements, including proximally hafted unipoints, mesially hafted bipoints, and small geometric bipoints. The rest are fragments that represent either waste pieces or tool blanks. These specimens are characterized by the presence of heavy surface and/or edge polish and striations or grinding marks. In situ tool production accounts for the high level of fragmentation of cercopithecid bones in all levels of site occupation, but most notably in the Late Pleistocene layers  Fig. . Tools a34, with perhaps one exception35. Even with access to rifle technologies and wire cord and snare traps, modern foragers never show such a bias34. Late Pleistocene hunting of arboreal primates has also been demonstrated at the Niah Caves, Borneo from 50,000 to 35,0000 years BP. However, here, in contrast to Fa-Hien Lena, humans seemingly primarily relied on large ungulates as their main source of protein28. This, alongside associated evidence from what is, to our knowledge, one of the earliest bone tool assemblages in South and Southeast Asia , and also one of the earliest beyond Africa, implies highly tuned hunting abilities in tropical rainforest settings upon arrival in this part of the world. Moreover, despite targeting prime age adults, these human populations were able to exploit primate and giant squirrel taxa, often considered to be rainforest game types that are among the most vulnerable to overhunting36, from ~45,000 to 4,000 years ago. This suggests close knowledge of life cycles, territories, and sustainable hunting strategies37.The consistently high percentage of arboreal small mammal taxa in all phases of occupation in Fa-Hien Lena is unheard of even among modern ethnographic groups hunting in tropical rainforest environmentsH. sapiens beyond Africa have tended to focus on human reliance on large, mammalian megafauna that are often linked to open grassland or mixed woodland and grassland environments11. Alternatively, scholars have focused on reliable coastal resources as providing adaptive corridors for a rapid dispersal around the Indian Ocean, through Southeast Asia, and into Australia5, and also into the Americas38. Our current data, demonstrate instead that some of the earliest known H. sapiens in Sri Lanka, and indeed in the South Asian tropics, focused on the specialized hunting of small semi-arboreal and arboreal mammals in tropical rainforests. Traditionally, the use of such difficult-to-catch resources has been associated with a “broad spectrum” revolution in the face of growing populations and climate change. However, continued emphasis on prime age animals across over 40,000 years, rather than a broadening of capture strategy, implies no such stress in the tropical rainforests of Sri Lanka. Furthermore, while stable isotopic data from human and faunal tooth enamel in the Wet Zone of Sri Lanka highlights subtle environmental changes from the Late Pleistocene to the Holocene, the persistence of Wet Zone and Intermediate Zone rainforest, as well as human reliance on this forest39, suggests these environments did not reach carrying capacity.Discussions of Late Pleistocene dispersals of H. sapiens. These complex subsistence strategies appear to be part of the adaptive ecological plasticity of our species that enabled it to inhabit diverse Late Pleistocene habitats across the world1. The primary niche of non-H. sapiens hominins within and beyond Africa appears to be diverse forest and grassland mosaics in the vicinity of rivers and lakes41. By contrast, following its evolution in Africa c. 300 ka42, our species came to occupy higher-elevation niches than its hominin predecessors, as well as deserts, palaeoarctic settings, and tropical rainforest habitats stretching across Asia, Melanesia, and North, Central, and South America1. Moreover, it was even able to alter and manage environments, such as tropical forests, to meet its own subsistence and cultural needs through ever-intensifying niche-construction43. Detailed paleoecological and archeological analysis, such as that presented here, offers to yield more insights into the variety of cultural and subsistence strategies that facilitated the eventual colonization of all of the world’s continents, and resilience to increasingly extreme Pleistocene climatic fluctuations, that left H. sapiens the last hominin standing on the face of the planet.As a consequence, the utilization of these energetically expensive resources developed in the absence of resource pressure, documents the behavioral and technological flexibility of 45. The cave, on the slope of a gneiss cliff, has a c. 30 m by 20 m east-facing entrance, an interior that extends c. 10 m into the cliff, and two main chambers (termed shelters A and B). First recorded by S.U. Deraniyagala in 1968, Fa-Hien Lena was systematically excavated over several seasons from 1986 to 1988 by W.H. Wijeyapala, and from 2009 to 2012 by a team led by O. Wedage, S.U. Deraniyagala, and N. Perera. Shelter A, the larger of the cave’s chambers, was excavated to a depth of over 6 m. However, the shelter’s archaeological deposits are disturbed by recent Buddhist constructions. Shelter B, on the other hand, produced a sequence of archaeological deposits spanning from what appears to be the earliest occupation of Sri Lanka by our species  through to the Middle Holocene.Fa-Hien Lena  is located in Sri Lanka’s Wet Zone region, near the town of Bulathsinhala, some 75 km southeast of Colombo in a lowland evergreen and semi-evergreen rainforest environment47, which we calibrated using OxCal 4.348, we present a total of 30 radiocarbon dates . c. 30-μm thick, covered, large format thin sections (7.5 × 11 cm) were manufactured from the hardened impregnated blocks (sample code FH). Thin sections were observed with a polarizing microscope at magnifications of ×12.5 to ×400, using plain polarized (PPL), cross-polarised (XPL), and oblique incident light (OIL). The relative abundance of sediment components was estimated using standard semi-quantitative estimation charts50.A set of undisturbed sediment samples were collected from the excavated profile in clear polyurethane boxes. Sample boxes were labeled, photographed, and plotted on the profile drawing before removal from the profile. Four of these samples, all from Phase D sediments, were selected for micromorphological analysis  in Paris and photographs from the mammalian collections of the Field Museum of Natural History and American Museum of Natural History. Following von den Driesch52, individual dental specimens and specific anatomical features of diagnostic skeletal elements were measured to differentiate between closely related taxa. The naming of identified taxa follows the nomenclature for mammalian species of Wilson and Reeder53. The taxa identified in the sites were assigned to size class based on live weight (modified from refs. 55): (a) micromammals: 100 g to1 kg, (b) small mammals: 1 kg to 25 kg, (c) large mammals class 1: 25 kg to 200 kg, (d) large mammals class 2: 200 kg to 1000 kg, and (e) large mammals class 3: > 1000 kg.We analyzed faunal remains recovered from the 2009 and 2012 excavations of Fa-Hien Lena. All bone fragments from sedimentary contexts with secure radiocarbon dates (including those from deposits sandwiched by dated layers) were included in the analysis. All specimens, including diaphyses and rib shafts, were sorted, counted, and measured  using a digital caliper Mitutoyo 500–463). Identified specimens were recorded in detail using codes for anatomic zones00–463. I57, abrasion58, burning, staining, and butchery marks32. Bone surface modifications were recorded/observed using an Olympus BX53 light microscope and a Keyence VHX-6000 digital microscope. Burnt bone fragments were identified based on color61. They were distinguished into different classes based on the degree of burning56: (1) partially burnt, (2) charred (blackened), and (3) calcined . Burnt bones were quantified by determining the percentage of the total bone fragments that is comprised of burnt specimens63.All fragments were examined for natural, animal, and anthropic modifications, including weathering51 zonation system. This system is based on the recording of morphologically distinct zones in a skeletal element. The MNE was taken as the total number of non-repeatable zones  for every skeletal element of a taxon. The highest MNE value, considering side and age , was used to estimate the MNI. The MNE counts were converted to minimum animal unit (MAU) values by taking into account the number of times the element occurs in the skeleton. The normed MAU values (% MAU) were used to compare skeletal part representation in the different phases of cave occupation65.The minimum number of element (MNE) and minimum number of individual (MNI) counts were calculated following a modification of Dobney and Rielly’s67: (1) fragments with less than half of the circumference/length of the complete specimen, (2) fragments with more than half of the circumference/length of the complete specimen, and (3) fragments with the complete circumference/length of the complete specimen.The length and circumference of long bone fragments were also recorded in relation to complete specimens to measure the extent of bone fragmentation in the assemblage. Long bone fragments were assigned the following fragment circumference and length scoreschaîne opératoire concept69, a methodological framework that defines the reconstruction of the various processes of flake production from the procurement of raw materials, through the phases of manufacture and utilization until the final discard. The chaîne opératoire concept provides systematic sequences of the flaking activities in which is possible to determine the temporal phase and the position of the artifact produced70. The lithic material is composed of 5070 items ; two flakes and a fragment in context 136 (Phase B); a flake fragment in context 141; and one flake and one blade from context 248 (Phase C).78 and mapped onto photographs taken with a Canon digital SLR camera.For the analysis of osseous artifacts, the materials were examined using a Zeiss Stemi 508 stereomicroscope fitted with an AxioCam 105 camera. Taphonomic and anthropogenic alterations were identified based on published worksFurther information on research design is available in the Supplementary InformationPeer Review FileReporting Summary


P < .05) than children with normal development. Overall, 30.4% of children had minimum dietary diversity. A total of 47.7% of children received nutrient supplementation. This epidemiological profile of infants remains a challenge for Ecuador’s health programs.We assessed the development, nutritional status, and complementary feeding of 12- to 23-month-old children from Cuenca, Ecuador in 2013. Ecuador, an upper-middle-income country, developed a child policy in accordance with World Health Organization (WHO) guidelines. We collected cross-sectional survey data. Child development was assessed using the Integrated Management of Childhood Illness Guide–2011. The nutritional status was defined with WHO Child Growth Standards−2006. We investigated nutrient density, WHO Infant and Young Child Feeding Indicators, and nutrient supplementation intake of the complementary feeding. In all, 11.7% of children had “possible developmental delay,” stunting was identified in 29.4% of the children, and 25.3% faced overnutrition (overweight risk/overweight/obesity). The complementary feeding composition can be summarized as having adequate fat, high energy (MJ/day) and protein, and low iron and zinc. Children with “possible developmental delay” received less iron ( To ensure a high density of macronutrients and micronutrients, CF must include foods with a variety of flavors and textures, including bitter vegetables, meat, and allergenic foods. There is limited scientific evidence regarding CF recommendations and practices between and within countries.10 In the past few decades, there has been a shift toward the increased consumption of foodstuffs that are high in fat and sugars and low in fiber and micronutrients, resulting in poor dietary diversity and low nutrient density.11 A study of the quality of CF in 46 countries from 2002-2008 using the WHO Infant and Young Child Feeding Indicators (WHO IYCF)12 reported inadequate nutritional practices especially in diet diversity.13Adequate nutrition during the first 2 years of life from breast milk and complementary feeding (CF) promotes optimal growth and development. The World Health Organization (WHO) and the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN)1 that influence a child’s comprehensive health include the following: genetics, epigenetics,14 comorbidities,7 psychological relationship of the parents with the child,15 eating behavior of the child and the family,16 security of and access to the food supply, unequal access to health and other social services,17 and levels of anxiety and stress due to natural disasters or to outbreaks of violence, war, or terrorist attacks.18 In response to these challenges, the WHO has recommended strategies for promoting the health of women and children.19Policies to promote the comprehensive health of children should be based on an up-to-date epidemiological profile of development, nutritional status, and CF in children younger than 2 years and the causal relationship of these variables. Relevant biological, psychological, and sociocultural factors20 and the World Bank (2013)21 reclassified it from the lower-middle-income countries (LMICs) group to the upper-middle-income countries (UMICs).22 The National Health and Nutrition Survey (ENSANUT-ECU) report23 showed that between 1988 and 2013, there was a decrease in the prevalence of stunting (from 33.5% to 25.3%) and in underweight status (from 12.8% to 6.4%) and an increase in OW/OB status (from 4.2% to 8.6%). Wasting remained constant at 2.4%. In addition, the report revealed the high proportion of carbohydrates and fats in the infant diet, accompanied by a low intake of protein, iron, zinc, and fiber. There are no official data series on the frequency of developmental delay in children younger than 2 years.In recent decades, Ecuador has aligned itself with WHO strategies. The country’s nutritional profile changed in the period 1988-2013 when Ecuador rose to the 88th position based on the Human Development Index (HDI),23 The only available data come from a study conducted in 2008, which indicated a prevalence of 11% for child developmental delay.24 The present observational study focused on the development, nutritional status, and CF evaluation of 12- to 23-month-old children in Cuenca. In addition, relational analyses were carried out between these indicators. CF was investigated through the intake, nutrient density, WHO IYCF, and nutrient supplementation intake. Findings were compared with data from Latin America and the Caribbean (LAC) and from low-, lower-middle-, and upper-middle-income countries ,25 while food intake and nutrient density were compared with WHO 2002 data10 or Faber et al 2016 data.11 In this way, the similarities and differences between the profiles of Cuencano children and children from elsewhere in the world can be observed.There is a lack of information on developmental delay, nutritional status, and CF practices among young children in the city of Cuenca.26A cross-sectional study of all children aged 12 to 23 months who attended the “Healthy Child Program” at 18 Public Health Centers (MSP-HC) in urban Cuenca was conducted between January and June 2013. Cuenca is located in the Sierra Region of Ecuador, and according to the 2010 census, of its population, 1.44% are indigent and 10.8% are poor; 4.9% of the population older than 15 years is illiterate, 40.9% has access to the internet, 9.6% of people with disabilities attend special education establishments, while 70% of households receive all the basic public services.27 3% inference error, 95% confidence, and 20% losses (n = 214 children). The exclusion criteria were acute or chronic illnesses or disabilities. Although a randomization procedure was established, application of the exclusion criteria resulted in a sequential composition of the sample. A total of 214 cases were collected, respecting stratification by centers and sex. All children received iron and vitamin A supplementation in MSP-HC according to the “Norms and Protocols for Micronutrient Supplementation.”28The population sample was calculated with a frequency of 7.3% chronic undernutrition in Cuenca,The clinical evaluation and data collection were carried out by a group of health professionals: pediatricians , psychologists and early-childhood teachers (for assessing child development), and nutritionists .29Surveys collected demographic data including age, sex, family residence (urban and peri-urban), family type , family caregiver , emigration (whether father or mother or both have lived outside the country for more than a year), whether the mother had completed secondary education and, if so, when.30Child development was assessed using the Integrated Management of Childhood Illness (IMCI) 2011 procedure table-chart B. “No” meant normal while “possible developmental delay” indicated the absence of one or more of the skills appropriate to the child’s previous developmental age.31 using previously calibrated SECA instruments. Nutritional status was categorized by the WHO Child Growth Standards 2006 using weight for age Z-score (WAZ), length for age Z-score (LAZ), and body mass index (BMI) for age Z-score. The following definitions were used: underweight WAZ < −2SD; stunting LAZ < −2SD; wasting BMI for age Z-score < −2SD; overweight risk between +1SD and +2SD; overweight between +2SD and +3SD; obesity >+3SD; normal when all indicators were within −2SD and +2SD; overnutrition: overweight risk, overweight or obese.Anthropometric measures of weight and length were taken following WHO protocolsa) food intake: uploaded to Nutrimid software (version 2012), which reports calories, macronutrients in grams  and micronutrients in milligrams ; (b) density: amount of each nutrient per 100 kcal or 416 kJ11; and (c) WHO IYCF were assessed following the methodology proposed by WHO. The questions were translated and validated in Spanish, and some questions were adapted to include the food products available in Cuenca. Four child age–specific indicators were investigated: (a) continued breastfeeding (CBF) (proportion of children 12-23 months of age who received breast milk during the previous day); (b) bottle-feeding (proportion of children fed with a bottle); (c) minimum dietary diversity (MDD) (proportion of children who received foods from 4 or more food groups); and (d) minimum meal frequency (MMF) .12 Additionally, nutrient supplementation  and the intake of commercial infant foods  were recorded. No maternal milk or nutrient supplementation was quantified because of the difficulty in accurately evaluating the quantity and the quality of the nutrients.CF was determined through a 24-hour dietary recall interview using a standardized dietary kit that allowed the caregiver to specify the type and amount of food consumed by the child. The following parameters were determined:  and Mann-Whitney U (nonparametric) were applied to search for significant differences (P < .05) in sex, stunting, overnutrition, or development. For qualitative demographic variables, prevalence percentages with CI = 95% were obtained. The chi-square (χ2) test in the bivariate analysis was derived by means of the contingency tables with WHO IYCF, nutrient supplementation, stunting, overnutrition, and development. The Cramer V statistic was used if χ2 was P < .05 in cells that had an expected frequency less than 5, measuring the relationship between variables as strong (approximately 1 and P < .05) or weak (approximately 0 and P > .05). Multiple linear regression models and multivariate logistic regression models were used to evaluate the strength of the association between a dependent variable and multiple independent variables, but no significant association was found. These types of models were useful to find confusing variables such as children’s age.Data were analyzed using SPSS software, version 21. Normality was assessed by asymmetry, kurtosis and QQ plot graphs. Mean and standard deviation (SD) were determined for “normal” variables and median and quartiles for “nonnormal” variables. The Student The Ethics Committee of the Faculty of Medical Sciences of the University of Cuenca, Ecuador approved this study with number 1811-M. Written consent was obtained from the children’s parent. The study was carried out in accordance with the ethical principles established by the Declaration of Helsinki. In addition, reports on the children’s health status were provided to the parents as well as to the physicians and health centers to ensure care after evaluation.P < .05). 10 and Faber et al data (2016)11 (first column). Children with “possible developmental delay” received less iron (P < .05) than children with normal development  between the following indicators and feeding practices: (a) children with overnutrition consumed fewer eggs and (b) children with possible developmental delay had less MDD and ate fewer fruits and vegetables.24 This result is difficult to compare with other investigations because of differences either in the studied populations or in the guidelines and methodologies.33 The published prevalence of child developmental delay values range from 1% to 3%,34 from 7.1% to 18.0%, or up to 66.0%.36 The highest rates are reported for children living in extreme poverty and in at-risk populations such as children with low birth weight, prematurity, or perinatal asphyxia. The prevalence of developmental delay, 30% in Ecuador37 and 18%2 in LAC, is typical for poor children and stunted growth.Demographic characteristics of the children in this study are broadly similar to the latest data reported for Ecuador and LAC , althoug2 In Ecuador as a whole, poverty due to unsatisfied basic needs (UBN)  was estimated at 38.7% in 201338 and 31.8% in 2017.39 Multidimensional poverty  in the year 2013 at the national level was 38.7%38 while in 2017 it was 34.6%.39 For this reason, when interpreting the prevalence of 11.7% of “possible developmental delay” in the children of Cuenca, it is essential that poverty-related factors be considered.Child development refers to the acquisition of the motor, cognitive, and social skills that enable people to carry out age-appropriate activities of daily living; to acquire academic skills; to participate in the community; and to deal with the problems they encounter. Although these skills have a genetic and biological basis, research shows that the development potential of children also depends on several factors that interact with each other. These factors include health status, nutrition, security and safety, responsive caregiving, and early learning. Two other important aspects may be noted: the immediate caring environment (family and community) and the broader social, economic, political, climatic, and cultural context. All these dimensions can have an impact on the early development of the brain and, therefore on children’s development. “Health” here includes disease prevention and treatment, and health promotion. “Nutrition” refers to dietary diversity, complementary food, macro- and micronutrients, and breastfeeding. “Security and safety” entail the reduction of threats , noninstitutional family care and early intervention for vulnerable children, and birth registration. “Responsive caregiving” means responsive parenting, feeding, home-visiting, parenting programs, caregiving routines, supporting emotional development, caregiver nurturance, and continuity. “Early learning” includes transition to primary school; access to quality child care and preschool; home opportunities to explore and learn from books, toys, and play materials; and home visiting. “An enabling environment” for caregiver, family, and community is based on parental education, parental physical and mental health, age at marriage, nutrition during pregnancy, antenatal care, safe delivery, birth spacing and family planning, safe and clean neighborhoods, and absence of stigma. Finally, “social, economic, political, climatic, and cultural contexts” refers to family-supportive governance, stable governance, employment, security, housing, gender parity, the absence of extreme climatic conditions, and political commitment. When there is poverty, not all of these factors are necessarily present. However, poverty and adverse experiences in childhood have a long-term physiological and epigenetic effect on brain development and cognition.40 Second, although Ecuador, in common with all LAC countries, reduced the prevalence of poverty according to income, this decrease was slower than in the other LAC countries. Moreover, the percentage of people moving from the middle class to the vulnerable class (16%), was one of the highest among the 12 LAC countries with the best performing economies.41 Ecuador did not reach the level of development of other LAC countries because (as of 2013) it failed on a number of relevant dimensions. Ecuador ranks second in South America according to infant mortality rate (19.1 per 1000 live births) and children under-5 (22.5 per 1000 live births). Only 40.1% of women older than 25 years had at least some secondary education, 2.5% of the labor force had tertiary education (university), while 51.2% of employees were in vulnerable employment. In 2012, the country ranked third among countries with the highest rates of deaths due to tuberculosis (2.7 per 100 000 people) and suicide rate for women (5.2 per 100 000 women). It ranked second in terms of prevalence of violence against women (46.3%).42 Finally, although Ecuador aligned itself with the Millennium Development Goals and WHO strategies, as of 2013 it had failed sufficiently to expand coverage of social protection systems for poor or vulnerable people.41The high percentages of both undernutrition (stunting) and overnutrition  affirm t43 In Latin America, more than 20% of the population was OW/OB in 4 countries, and the average rate of obesity was 4.6% in 17 countries.44 The increasing prevalence of overnutrition in recent years is believed to be due to the child’s genetics (birth weight), the parents’ weight,45 and a western lifestyle that leads to a caloric imbalance due to higher food intake and limited physical activity.46 The Baltimore study concludes that an increased weight for length (WFL) during the first 2 years of life increases the risk of obesity at the age of 3 years and that Latino children have a higher incidence of obesity than non-Latinos.47 Research in the United States indicates that the prevalence of OW/OB in children aged 0 to 2 years slightly declined from 2003-2004 (9.1%) to 2011-2012 (8.1%).48 Ecuador has been moving toward globalization, urbanization, with changes in occupational structures, causing the population to acquire food patterns that adapt to new lifestyles.23 Families, even the poor, consume processed or easy to prepare foods with high energy content due to the high presence of carbohydrates, sugar, salt, and fats.8 In Ecuador, the prevalence of obesity in adults (62.8%), the incorrect feeding of pregnant women could mark an epigenetic pattern so that children are also OW/OB.50 The risk of OW/OB increases if the inadequate diet is exacerbated by the fact that children have restrictions on moving in reduced physical spaces in the rooms or apartments where families live, or because children are held by their caregivers so they do not cry or do not hurt.46This study also reveals that a significant percentage (21%) of children is at risk for future OW/OB. A study of obese children younger than 2 years found that 25% of them were already overweight at 3 months of age.35 while others show that developmental delay is due to the sum of biological, psychological and sociocultural factors.51 While cross-sectional studies do not establish cause-effect relationships, they do point to associations that merit further research. So, although the data from this study do not reveal a causal relationship between nutritional status and child development, we believe the study does suggest where future research could usefully focus.There are studies that demonstrate the relationship between undernutrition and developmental delay52 but in this study, the results were compared with nutrient density values published by the WHO in 200210 and by Faber et al.11 It was found that the CF of Cuencano children were low density  because few of them had MDD because children mainly ate grains, roots, tubers, dairy products, but their diets were poor in fruit, vegetables, legumes, nuts and fresh foods. These findings are worrying because toddlers need healthy CF with high nutrient density and dietary diversity because they have high energy needs and eat small amounts. Children with “possible developmental delays” ingest less iron than children with normal development, perhaps because their CF is less diverse (53Various recommendations for Dietary Reference Intakes (DRIs) for children have been published, diverse  and 5. T54Children with overnutrition consume fewer eggs than the others . The qua23, and found in other research.56 This suggests that this pattern is due to cultural practices, to historic socioeconomic influence on the production and distribution of food in different population groups,57 and finally due to the messages that health personnel give to the mothers. Thus, despite the availability of a variety of foods, many families prefer to give their children carbohydrates , while they consume little meat because they view meat as for rich people. According to the research of Waters et al,56 although eggs are readily available in Ecuador, and their nutritional value recognized, Ecuadorians eat few eggs. This too seems to have roots in local culture. First, the egg is reserved as a gift that is offered only to honored visitors, to healers, religious authorities, and godparents. Second, the egg is credited with healing properties. It is used to cure children of diseases caused by spells. Third, people consider that eggs raise cholesterol, and cause allergic reactions or digestion problems. Fourth, there is an economic consideration. The cost of an egg for a child is generally affordable, but when it comes to satisfying the needs of the whole family, eggs are more expensive than other foods.The CF pattern of the children found in this research is consistent with the feeding practices of Ecuadorian children reported by ENSANUTThe positive findings were that most of the children were CBF, achieved MMF, and did not consume commercial infant foods, and almost half of the children received nutrient supplementation from their caregiver, even if they received micronutrients from MSP-HC -5.58 while the Euro-Growth study found that among European children aged 12 to 24 months, there was only a weak relationship between increased weight/length and breast milk/CF consumption.59 However, studies in Senegal60 Bangladesh, Ethiopia, India, and Zambia13 did find an association between linear growth and WHO IYCF.No association was found between nutritional status and CBF, MMD, or MMF. This is similar to research findings in Cambodia with children aged 6-23 months,The limitations of this study were that the mothers of the children attending MSP-HC received periodic nutrition workshops. It is, therefore, possible that they concealed information about inappropriate practices in CF. The mother’s weight and height, important parameters for establishing correlations that would enable better identification of problems, were not recorded.The results of this research indicate that Ecuadorian policies and programs, even though they have succeeded in decreasing wasting and underweight in children, have not been able to control stunting, overnutrition, or the quality of CF. Furthermore, periodic records of child development are lacking, which makes it difficult to assess the impact of public policy.


Familial hypertrophic cardiomyopathy is an autosomal dominant genetic disease considered the most common cause of sudden cardiac death in individuals under 35 years old, especially the athletes. This study aimed to investigate the association between the presence of late potentials and a family history of sudden death, syncope, and complex ventricular arrhythmias on patients with hypertrophic cardiomyopathy. A case series study was carried out from March 2001 to December 2002, including 22 patients with hypertrophic cardiomyopathy according to transthoracic echocardiogram criteria. Patients on a cardiac pacemaker, right bundle branch block, cardiac transplant, and under no possibilities to realize the exams were excluded. The results showed that asymmetric septal hypertrophy was the most common type (73%), 63% had a positive familial history of hypertrophic cardiomyopathy, 55% sudden cardiac death, and 23% syncope. Also, complex ventricular arrhythmias were detected in 14% and late potentials in 23% of patients. According to this study, the presence of late potentials was not associated with familial sudden death, syncope, and complex ventricular arrhythmias. Hypertrophic cardiomyopathy (HCM) is an uncommon cardiac condition that has a 1:500 population prevalence and is the most common cause of sudden death in the young, especially in the athletes . The cliHCM presents an important familial characteristic. Even considering that ethnic and racial differences can affect the familial history and genetic profile of the affected subjects, around 1,500 mutations in at least 20 genes encoding the myofilaments of the sarcomere or Z-disc have been studied and associated to this condition -6.The histopathological features include myocytes disarray with disorganized sarcomeric alignment, abnormalities in the coronary arteriolar walls, diastolic dysfunction, elongation, or malformation of mitral valve leaflets and presence of myocardial fibrosis ,7-9. HCMThe primary method to evaluate and diagnose HCM is echocardiography, which provides the characterization of diastolic and systolic function, intraventricular obstruction, and valvular abnormalities . HCM diaAs a complementary exam, the cardiac magnetic resonance (CMR) provides a better analysis of the morphology, function, and tissue characterization, being mainly used to evaluate the presence of fibrosis as well as morphological abnormalities on the mitral valve (MV) apparatus, especially elongation of the MV leaflets ,9. The pA retrospective case series was performed from March 2001 to December 2002 at the Federal University of Pernambuco Clinics Hospital (HC/UFPE). The diagnosis was based on the identification of hypertrophic ventricle  in the absence of another cardiac or systemic disease capable of explaining the cardiac hypertrophy -8.The inclusion criteria were HCM diagnosis, according to a two-dimensional transthoracic echocardiogram. Those subjects with a cardiac pacemaker, right bundle branch block, and cardiac transplant were excluded. Initially, 32 patients were selected following the two-dimensional transthoracic echocardiogram criteria for hypertrophic cardiomyopathy (HCM).Data were collected from medical records, including a family history of HCM and sudden death, history of syncope, 24-h Holter, and high-resolution electrocardiography results. From the initial sample, 10 patients were excluded: three presented right bundle branch block; two had cardiac pacemaker implant; two did not follow-up the consults; one was submitted to cardiac transplant; one did not collect the necessary exams due to technical issues. A total of 22 patients were included in the final analysis.Definition of sudden deathSudden death was defined as witnessed acute collapse, which has taken place within one hour from the onset of symptoms and signs of disease in previously healthy subjects or unexpected non-witnessed death during sleep.Dynamic electrocardiography (24-h Holter)A continuum digital recorder  was used to record and analyze the Holter tests in 24 h. The electrodes were positioned in the electrocardiographic derivations CM1, CM5, and modified D2. The results were analyzed in the DMI Burdick analyzer®  software by an independent observer searching for complex cardiac arrhythmias.High-resolution electrocardiographyA multivariate digital cardiograph  was used to record the high-resolution electrocardiogram for continuous 16 minutes. The electrodes were positioned in the orthogonal bipolar derivations X, Y, and Z. A 40-Hz filter was applied. The results were analyzed in the DMI Burdick analyzer® . A positive result was defined as the presence of at least two of the following parameters: a) filtered QRS durations > 144ms; b) QRS terminal voltage <20 µV in the last 40 ms; and c) late potential total duration > 38 ms. In complete left branch bundle blockage, the reference values adopted for the QRS terminal voltage and the late potential duration were 17 µV and 55 ms, respectively.Statistical analysesX² test. A significance level of 0.05 was adopted to reject the null hypothesis.Data were analyzed descriptively using the Statistical Package for the Social Sciences version 20.0 . Continuous variables were presented with measures of central tendency and dispersion (mean and standard deviation), and categorical variables were described as absolute (n) and relative (%) frequencies. Fisher's test was used to identify any correlations between late potential, family sudden death, history syncope, and complex ventricular arrhythmias as the distributions did not meet the criteria for the Ethical standardsThe study was approved by the Institutional Ethics Committee and conformed to the Resolution 466/12 of the Brazilian National Health Council, which deals with the guidelines and standards for research involving humans. The investigation was also conducted in accordance with the Declaration of Helsinki. Informed consent was not necessary as the data were collected from medical records, and there was no direct contact between researchers and subjects.In this study, we analyzed 22 patients with HMC. Their ages ranged from 7 to 54 years (mean: 25.6 ± 14.7 years), and 55% (n = 12) were women. Clinical characteristics of the sample, including symptoms and imaging exam results, are available in Table Most patients were asymptomatic . Dyspnea and precordial pain were the most frequent symptoms. A familial history of HCM was reported in 64% (n = 17) of subjects. About 59% (n = 13) of the individuals were in use of medications: β-blockers ; calcium channel blocker ; and amiodarone . Only one patient was in use of more than one medication. The other nine either used no medication or used medications that do not interfere with the presence of late potentials.Regarding the ventricular hypertrophy predominance on echocardiography, 73% n = 16) of the individuals presented septal asymmetrical hypertrophy, 9% (n = 2) presented concentric hypertrophy, 14% (n = 3) presented medium-ventricular hypertrophy, and 5% (n = 1) presented septal asymmetrical hypertrophy associated to right ventricular hypertrophy. Regarding the hemodynamic status, the non-obstructive hypertrophy was the most prevalent type . Figure 6 of the p = 1.00). Syncope and late potentials were associated with two patients, with no significant statistical correlation between them (p = 0.54).Familial sudden death was found in 55% (n = 12) of patients, and 23% (n = 5) of them reported a history of syncope. A total of 23% (n = 5) of the sample had the presence of late potentials in the electrocardiogram. Only in three subjects, both familial sudden death and late potential were present. However, no significant correlation between these variables was found (p = 1.00).Complex ventricular arrhythmias were found in three patients (14%). The concordance between late potentials and complex ventricular arrhythmia was found in only one patient, with no statistical association . A recent study conducted by Tobita ividuals -14.Regarding the pattern of hypertrophy, asymmetric septal hypertrophy was the most common in our sample, corresponding to 73%, which is compatible with previous studies . HoweverIn our sample, late potentials in electrocardiograms were identified in 23% of subjects. Its role in the physiopathology of HCM is still controversial. Nevertheless, some evidence suggests it might be a useful marker for sudden death as it is correlated to an increased risk of fatal arrhythmias . CurrentThe implantable cardioverter-defibrillator (ICD) is the most effective therapy in preventing sudden cardiac death. However, in HCM patients, the indications for the implant remain unclear. Primary and secondary sudden death prevention in HCM patients is supported by the European Society of Cardiology Guidelines, especially in patients with a familial history of HCM, unexplained syncope, severe left ventricular hypertrophy, non-sustained tachycardia and history of aborted sudden death -19. MaroAdvances in biomolecular allow the genetic diagnostic of HCM; however, this laboratory approach is not globally available in clinical practice. New studies are needed to determine specific mutations for high-risk individuals. This way, early pharmacological and clinical intervention might reduce the disease progression and the mortality in this population. Nevertheless, in our reality, risk stratification for HCM is expected to be as practical, and low cost as possible, so pharmacological management or ICD implants might be attempted as preventive measures.The most obvious challenge to conducting rigorous research with rare diseases such as HCM is the small number of eligible participants for a given study, which possibly might be a limitation from our analysis.According to this study, the presence of late potentials was not associated with familial sudden death, syncope, and complex ventricular arrhythmias. Familial history of sudden death was present in most of the subjects, which is compatible with the literature description, but complex ventricular arrhythmias and syncope were only observed in a minority of them. On echocardiography, the asymmetric septal hypertrophy was the most common variable, and the non-obstructive form was the hemodynamic pattern most seen.