Homo antecessor-bearing subunit. We also present an analysis of several lithic refits found in TD6, as well as certain technical features that may help characterise the hominin occupations. The archaeo-palaeontological record from TD6 consists of 9,452 faunal remains, 443 coprolites, 1,046 lithic pieces, 170 hominin remains and 91 Celtis seeds. The characteristics of this record seem to indicate two main stages of occupation. In the oldest subunit, TD6.3, the lithic assemblage points to the light and limited hominin occupation of the cave, which does, however, grow over the course of the level. In contrast, the lithic assemblages from TD6.2 and TD6.1 are rich and varied, which may reflect Gran Dolina cave’s establishment as a landmark in the region. Despite the occupational differences between the lowermost subunit and the rest of the deposit, technologically the TD6 lithic assemblage is extremely homogeneous throughout. In addition, the composition and spatial distribution of the 12 groups of lithic refits found in unit TD6, as well as the in situ nature of the assemblage demonstrate the high degree of preservation at the site. This may help clarify the nature of the Early Pleistocene hominin occupations of TD6, and raise reasonable doubt about the latest interpretations that support the ex situ character of the assemblage as a whole.This paper aims to update the information available on the lithic assemblage from the entire sequence of TD6 now that the most recent excavations have been completed, and to explore possible changes in both occupational patterns and technological strategies evidenced in the unit. This is the first study to analyse the entire TD6 sequence, including subunits TD6.3 and TD6.1, which have never been studied, along with the better-known TD6.2  TD6 is a three metre-thick unit divided into three subunits, from oldest to youngest: TD6.3, TD6.2 and TD6.1. TD6.3 comprises at least six debris flow events from a northwest entry point with distal ón River . Towardsn facies . This sen facies , and con and TD7 . TD7 is  and TD7 .Unit TD6 has been the subject of several studies, primarily focusing on hominins , 12–29, However, most of these studies involved partial assemblages, primarily because the excavations in the southern section of Gran Dolina have only recently been completed (2011 field season). In addition, most of these publications focused on TD6.2, the hominin-bearing subunit, and disregarded subunits TD6.3 and TD6.1, which also contain data of archaeo-paleontological interest.facies and inputs, and interpreted the site with the archaeo-paleontological remains as being in a secondary position [TD6.2 was first suggested to be a base-camp , 65, butposition , 9.2 , 91 are is seeds , 1,046 aThe archaeo-paleontological remains are distributed over three subunits , and several layers. Some of these layers were extremely difficult to distinguish over the entire area during the excavations due to various lateral sedimentary discontinuities . In addiFurthermore, it is important to bear in mind that the excavated area is not continuous, making this correlation even more difficult. Unfortunately, a recent work on the TD6 stratigraphy  only anaEventually, we managed to correlate the different layers as follows  Fig 3)::Fig 3): We considered the general archaeo-palaeontological composition of the layers, as well as the hominins that can be ascribed to each layer and their age range if available, based on previous studies , 32, 67 The knapping methods represented in TD6  suggesting their use as hammerstones for striking or knapping.Finally, we also analysed the presence and type of refits, as well as the distance between the refit pieces. The aim was to find additional evidence that could be used to demarcate the layers within each excavated area, and correlate the layers excavated in different stages.The Sierra de Atapuerca and its surroundings presented hominins with a wide range of raw materials during the Pleistocene, all found no further than 3 km from the sites .Five primary rock types have been identified archaeologically: chert , quartzite , sandstone , quartz, and limestone.The chert is divided into two petrological groups based on its origin: either Cretaceous or Neogene. The Neogene chert is from the Late Miocene and it is found as large blocks. Irregularities in the texture and quality of this chert, from block to block or even within the same block, limit its workability . Nevertheless, its abundance in the plains surrounding the Sierra de Atapuerca, its ready availability, and the profusion of blocks of suitable sizes, make it the predominant raw material in the archaeological record.The Cretaceous chert is from the Turonian-Lower Santonian, and there are two sources a short distance from the Trinchera del Ferrocarril sites. The first outcrop consists of a fossiliferous chert with a microcrystalline wackestone structure, and it is found towards the SSE end of the hill, and is. Nodules are 20 cm in diameter on average. The second outcrop is located in the central area of the Sierra de Atapuerca, and offers smaller nodules rarely exceeding 10 cm in diameter. Chert from this outcrop contains fewer fossils and has a compact siliceous mudstone texture. Both varieties outcrop in easily accessible exogenous karstic formations. Their suitability for knapping differs slightly, as the smaller nodules are better than the larger pieces for this purpose.The archaeological chert, particularly the Neogene chert but also one Cretaceous variety, typically has an altered shape with a disintegrated internal structure , as are metamorphic rocks such as metasandstone, schist, shale and, less abundantly, some strata of quartzite and infilled quartz veins. These rivers also carry high-quality metaquartzite, quartz and orthoquartzite.For the technological study, some of the lithologies identified in these source areas have been grouped as either quartzite or sandstone, based on their mechanical properties  and certain macroscopic textural features. All of these rocks exhibit a gradation of quartz composition, cement type, and degree of metamorphism. Thus, the tenacious rocks (compact quartzarenite), and the very tenacious lithologies  have been generically labelled quartzite. Less tenacious (non-compact quartzarenite) and soft rocks  have also been grouped together and generically labelled as sandstone.facies.Finally, the limestone originated in the karstic Cretaceous substratum of the Sierra de Atapuerca. It is likely that some of the knapped cobbles were procured from the uppermost parts of the Pico River, which erodes that The knapping and production properties of all these raw materials can be consulted in .This is the thickest subunit of TD6, and has yielded evidence of the earliest hominin occupation in TD6. Subunit TD6.3 was mainly formed by sediment gravity flows . Here, TThis stage contains 1,153 faunal remains , and 28 lithic pieces . There aThe 28 lithic pieces consist of : 3 fragmc. 65%). The lack of flakes suggests that this percussive material was used to break bones or undertake another as yet unclassified activity, rather than to knap cores or make tools.Only three complete pebbles show no traces of percussion. This means that a high proportion of pebbles (82%) were used for striking or knapping, and they bear the corresponding battering and crushing marks. Complete and fractured pebbles account for 61% of the assemblage (n = 17), which means that most of the Lower-TD6.3 material is percussive. This may explain the dominance of fluvial raw materials in this group, particularly quartzite . The limestone pebbles are a little larger and have more varied morphologies .Lower-TD6.3 contains one refit made up of a broken hammerstone and a fragment of quartzite pebble with percussion marks (micro-conglomerate)  , although lacking Cretaceous chert.In our view, this lithic assemblage represents a marginal hominin occupation, mainly comprising pebbles transported into the cave. Based on their fracture and percussion marks, these pebbles were used but not knapped. The occupation of the cave by other animals, evidenced among other things by the presence of 126 hyena coprolites, is probably responsible for the faunal accumulation, with hominins being merely marginal and sporadic visitors .This second stage, the remainder of this subunit, includes 1,305 faunal remains  and 56 lithic pieces  Figs 6 . There aPercussive material, including pebbles with no battering marks, still dominates the assemblage (43%), although it is less frequent in Upper-TD6.3 than in Lower-TD6.3, due to the existence of produced flakes and other tools. The complete pebbles are similar in size than those from Lower-TD6.3 , although the largest are sandstone, and the smallest are quartzarenite. The morphologies vary, although oval pebbles are particularly common. Most fractured pebbles and fragments of pebbles also bear percussion marks. One has also been slightly flaked as a core. Production processes are reflected by the presence of three cores and one core fragment, along with 18 knapping products.The three complete cores are of fluvial materials and have undergone unipolar longitudinal knapping, unifacial in two cases and bifacial in one. Two of these were knapped using the bipolar-on-anvil technique. The core fragment is made of Neogene chert and seems to have been flaked using the unifacial unipolar longitudinal strategy.The only retouched flake is a carinated denticulate from a Neogene chert fragment.Complete flakes average 38x30x11 mm in size, with no item being smaller than 20mm in any dimension. Some of these may actually be fragments of hammers. The percentage of fractured flakes and flake fragments is the highest (41% of the group of flakes) seen in the entire lithic assemblage from TD6. They mainly comprise diverse quality fluvial materials, which may point to the limited workability of these materials, as well as poor hominin knapping skills. Technically, the flakes may retain some cortex on their dorsal surfaces, have a mean of two dorsal scars and flat butts, which are natural  or unifaceted, and have great variety of flaking angles (between 85° and 140°), and ventral faces with varied delineations and diffuse bulbs. The morphology of the complete flakes is also varied.Upper-TD6.3 contains two groups of refits: one core and one flake fragment of quartz from a bipolar-on-anvil knapping episode, and one core and one fractured flake of quartzarenite from a knapping process   the greater number of lithic remains found in consecutive layers; 2) the presence of cores and flakes that reflect production; and 3) the diversification of the lithic categories, including the first retouched piece from Gran Dolina.facies, mud layers and floodplain and debris flow facies [The majority of the archaeopalaeontological assemblage of TD6 is concentrated in this subunit. TD6.2 is a complex deposit of channel w facies , 36. AltThis is the oldest layer of subunit TD6.2, and is composed of gravitational inputs . It contThis subunit contains more of all the generic raw material varieties  , indicatSubunit TD6.2.4 contains notably less percussive material than in other subunits , represeThe 11 cores are made of all of the different raw materials , reinforThe group of flakes  containsNineteen complete flakes are smaller than 20 mm, and 10 are larger than 60 mm, but none exceeds 85 mm. The average size is 36x32x14 mm. Technically, there is an even distribution of between zero and two dorsal scars. They are quite variable with regard to the dorsal cortex, which is particularly well preserved in the quartzite items. Butts are flat, unifaceted or natural , and non-cortical for limestone, sandstone, and Neogene and Cretaceous chert, while they are cortical for the majority of the fluvial items. Bulbs are equally marked and diffuse; the ventral delineations are vary widely, although they are predominantly straight. The flaking angles vary between 85° and 135° for all raw materials. Three Neogene flakes stand out because of their thinness and length, and the fact that their flaking axes have the same direction as their dorsal scars. They belong to the same raw material blank, and are therefore perhaps the work of a single knapper.épines, six denticulates, two points , and one sidescraper. In many cases, the blanks are thick flakes with a natural back.There are 13 retouched tools , one of This layer contains three refits (see the Refits section) : one quafacies and floodplain and debris flow facies [c. 11 years old), Hominin 4 (juvenile) and Hominin 6 (juvenile) belong to this layer. None of the hominin refits found to date are more than 15 cm away one from each other.This is the richest deposit of unit TD6, formed by channel w facies . It contThe raw materials and varieties are as diverse as in the previous layer, with a dominant use of Neogene chert (c. 35%).Percussive material  decreaseAs in the previous layer, the 17 cores  represenThe average size of these cores is larger than in previous layers, up to 92x74x60 mm, although this is mainly due to the presence of seven large cores, four of them Neogene chert. Among the latter, the smallest core measures 117x109x85 mm, and the largest is 178x154x131 mm. This is one of the major characteristics of this archaeo-paleontological layer: the presence of huge Neogene chert blanks transported from the surrounding hills to the cave for use as cores, and which are abandoned at an initial or intermediate stage of knapping, after a few successful strikes. There are only two other large cores of Neogene chert in TD6, and these were found in the overlying layer (TD6.2.0–1), as described below. These large cores are distributed throughout the excavated areas of this layer  .Only eight Neogene chert flakes are larger than 60 mm, but there are five Neogene chert cores, four of them measuring more than 115x100x80 mm, all with large and medium-sized scars. This means that an indeterminate number of medium and large flakes extracted from these cores are missing, because they are either still buried in the unexcavated areas of TD6, or they were transported away from the site.The group of flakes  consistsTwenty-four flakes are smaller than 20 mm and 13 are larger than 60 mm, but only one exceeds 100 mm (99x148x36 mm). This large flake was neither retouched nor shaped. The average size of the complete flakes is 34x32x12 mm, similar to the previous layer. Technically, these flakes have two to four dorsal scars; most are non-cortical on their dorsal surfaces, regardless of the raw material. Butts are mainly flat, unifaceted or natural , and ventral delineations are varied. Flaking angles range between 65° and 135° in all the raw materials. Trapezium morphologies dominate although there is a wide variety of shapes.Meanwhile, the production of retouched flakes  increase2 approx.), compared to the central (8 items/c.9m2) and eastern areas (Test Pit) (21 items/c.7m2). The western and central areas also contain most of the faunal remains, with twice as many as were found in the Test Pit. However, the western area yielded fewer hominin remains.The density of retouched flakes in the western area of the occupation is actually high  and, technically, do not differ from one other. Retouching is limited to less than 25% of the perimeter, and is simple or semi-abrupt, and straight, convex or concave in delineation. There are eight items with two generations of retouch: The dorsal surface of the piece was modified first and then, retouching was superimposed to delineate the edge. These items were made of Cretaceous chert, Neogene chert, and quartzite. The 35 retouched flakes include two abrupt-retouched pieces, seven side and distal scrapers, one carinated point and 25 denticulates, including five notches, four There are four groups of refits in TD6.2.2/3 (see the Refits section) , as wellfacies [c. 14 years old), Hominin 2 (c. 4 years old), Hominin 5 (c. 6 years old), Hominin 7 (c. 17 years old), and Hominin 10 (juvenile) pertain to this layer. The remains of Hominin 1 (n = 15) were found less than 50 cm away from one another, horizontally, while the two pieces of Hominin 5 were found about 2 m from one another.This set of two layers represents the youngest TD6.2 subunit, and it is formed by channel, debris flow and floodplain facies . TD6.2.0The raw materials and varieties present are as diverse as in the preceding layers, with the use of Neogene chert once again being predominant (c. 36%).The percussive material in TD6.2.0–1  decreaseCores of all raw materials are present , althougAs in TD6.2.2/3, TD6.2.0–1 also contains two large Neogene chert cores, scarcely flaked, from large fragments transported into the cave from the area surrounding Sierra de Atapuerca. One of these two very large cores is the largest archaeological specimen from TD6 (270x150x100 mm) see . It was The group of flakes  compriseThere are 19 flakes smaller than 20 mm and 5 larger than 60 mm. Only one flake exceeds 100 mm (165x170x70 mm). After being detached, this large flake was knapped as a core. The average size of the complete flakes is slightly smaller than in preceding layers (30x28x10 mm), but their technical features are similar. They may have one to three dorsal scars, and are mainly non-cortical or with small cortical areas. Their butts are flat, either natural or unifaceted. The ventral delineation is varied and the bulbs are diffuse. The flaking angle ranges between 85° and 135°. The morphologies vary greatly, but trapezium shapes dominates. Particularly noteworthy items include fluvial materials with long, sharp edges.The number of retouched tools documented increases in this group of layers (10%) . One pebTD6.2.0–1 contains two groups of refits (see the Refits section) . The firfacies [c. 4 years old) belongs to this layer, as does the tooth of an immature individual. An adult individual has also been identified. This layer is characterised by the presence of 228 coprolites, leading to its interpretation as hyena latrine [This is the final deposit in TD6, formed by channel and floodplain facies . It has  latrine .More than 35% of the lithic assemblage comprises indeterminable pieces of Neogene chert. In addition to sedimentary reasons, this poor state of preservation could be related to the chemical alterations produced in a hyena latrine .Unlike the other layers, TD6.1 contains no pebbles or cores. Retouched flakes and simple flakes have been documented in all the raw materials, but predominantly in Neogene and Cretaceous chert. The percentage of fracturing in the flakes is high at 29%, but for the first time this figure is similar for all the raw materials.There are 10 flakes smaller than 20 mm and three larger than 60 mm, but none reaches 70 mm . The aveépines, seven denticulate side-scrapers and one denticulate point.The 14 retouched flakes (11%)  are on aTD6.1 is the only layer in which no clear refits have been identified.2 and is at the side of the cave , and refits resulting from the core knapping process. None of the refits involves more than three pieces.The most spatially distant pieces belong to a sandstone refit from layer TD6.2.2/3 in the eastern area that correlates with layer 40–41 from the central excavation. This act makes this particular refit very important in terms of archaeostratigraphic correlation. It comprises three pieces see : one corin situ knapping accidents [In addition to this important refit, other refits also provide significant insight into actions carried out inside the cave. This is the case of fractures (conjoins) whose pieces are separated 5 cm, 25 cm, 50 cm, and as much as 100 cm from one another, which are proven distances for ccidents , 75. TheNo refit have been documented between pieces from different, non-correlating layers. The only exception is refit code CZT-1-TD6 see , formed 2 area at the edge of the occupation, spatial distribution analyses will only provide reliable data when the entire surface of TD6 has been excavated.No particular concentrations of and/or gaps in raw materials or categories of pieces have been identified. However, and given that this work is based on a 20mFinally, it is interesting to note that the connections between the refit pieces show no specific pattern of orientation. Furthermore, some of the refits in TD6.2 made up of pieces found in close proximity to one another correspond to knapping sequences, and are located in the southern area of the excavation see . Taken tThis work aimed to update the information available on the lithic assemblage found in Gran Dolina unit TD6, now that the latest excavations in the southern section of the site have been completed, and to identify changes in the occupational patterns and technological strategies of the hominins that occupied the cave. In fact, this is the first study to analyse the three subunits of TD6 , as only data on TD6.2, and recently TD6.3  has beenThe lithic assemblage of TD6 can be divided into two groups: that belonging to the underlying subunit TD6.3 and the remainder of TD6 (TD6.2 and TD6.1). This distinction is based on the technological composition of the subunits: TD6.3 has a poor lithic assemblage, mainly made up of pebbles, most of which present percussion marks and chipping, and which we have grouped as “percussive material”. This evidence is particularly clear in the oldest layers (Lower-TD6.3), as technological diversity increases in younger subunit (Upper-TD6.3). In addition, these evidences are coincident with the zooarchaeological interpretation of this sub-unit, where hominins were merely marginal and sporadic visitors . In contThree main knapping methods were employed: unipolar longitudinal, multifacial orthogonal and centripetal, in addition to the bipolar-on-anvil method, which is almost entirely restricted to quartz cores. Whatever the raw material, cores were abandoned at all stages of flaking in all the layers, although half of those abandoned in their initial stages belong to TD6.2.2/3, half of the cores abandoned at an intermediate stage of production were documented in layers TD6.2.4 and TD6.2.0–1, and half of the exhausted cores were abandoned in TD6.2.0–1. These results would appear to have an occupational significance, although they are difficult to interpret before the excavation of TD6 is entirely completed.épines, denticulate scrapers, and points, with some notable Tayac Points. The flake-blanks for retouching show the same technical features as simple flakes, but are a little larger in most layers.The flakes detached from these cores are not standardised, as their technical features vary greatly. The retouched tools are mainly the denticulate type, including notches, Several noteworthy observations have arisen with regard to the raw materials in the unit. Interestingly, the less significant the hominin occupation (TD6.3) , and conCore knapping presents one of the strongest pieces of evidence for differential raw material usage: Fluvial cobbles and pebbles were mostly knapped using the unipolar longitudinal method, although this technique was also applied to chert. On the other hand, centripetal and multifacial orthogonal knapping were principally used with Neogene and Cretaceous chert. In addition, the bipolar-on-anvil technique was mostly used to work quartz pebbles. Taken together, it seems that two flaking methods were the background and dominant techniques for the TD6 hominin community: 1) the unipolar longitudinal knapping method, as applied to all materials; and 2) multifacial orthogonal knapping, for Neogene and some Cretaceous chert. The hominins selected large, angular, massive cobbles of fluvial materials for the former; and big blanks of Neogene chert, as well as some small irregular nodules of Cretaceous chert, for the latter.It is possible that these long-term knapping strategies began as technical responses in case that hominins were not skilled enough to control the original volumes through knapping. This way, the hominins appear to have adapted to the original volumes, instead of changed them. In the long term, this technical practice may have given rise to a habitual behaviour even when flat blanks were available. Flat blanks are ultimately bifacial blanks, and are suitable for knapping methods such as the centripetal technique. Flat blanks near the Sierra de Atapuerca can be found as flat pebbles, as well as large flakes of Neogene chert that could have been produced when trying to extract fragments from the huge blocks scattered around the Sierra. However, the hominins from Gran Dolina either did not produce these or did not choose to transport them into the cave. In addition, they usually selected quadrangular and irregular pebbles for flaking. It is possible that bifacial blanks were of little use with the technical strategies they employed, and therefore they did not use them. In short, the bifacial management of blanks is absent.However, they eventually began to develop the centripetal knapping trend, and they undertook this mainly on small, irregular Cretaceous chert nodules. These nodules are not especially flat, but they are small, so the likelihood of creating an adequately angled percussion platform with the first detached flakes is greater than when using larger Neogene chert fragments. Cretaceous chert is higher quality than Neogene chert, and the percussion platform and the small size of the nodules means the flakes encompass the entire thickness of the core. Therefore, the easiest way to knap these nodules is by making an initial strike, then striking a place adjacent to the site of the first strike, and then striking a place adjacent to that second site, and so on. This eventually leads to centripetal knapping. The high quality of the Cretaceous chert may also be the reason it was differentially selected for small retouched tools.Interestingly, all these characteristics are maintained throughout the stratigraphy. TD6.2 and TD6.1 evidence a very homogeneous lithic industry in terms of both technical and raw material usage, with the exception of few features that seem to be related to occupational traits. This may explain the increased production of retouched flakes over time, and the presence of large Neogene chert cores in some layers of subunit TD6.2. The presence of these large cores with little knapping denotes the fact that these occupations were planned, and that the hominin impact was greater, since they thought they would require such large quantities of chert. It also coincides with episodes of more substantial and more frequent cannibalism.Furthermore, the fact that these large cores are distributed throughout the excavated areas of TD6.2.2/3 and TD6.2.0–1 supports the argument for the limited diachronous occurrence of these occupation events.in situ, and that any sediment movement, if present, was not significant. Interestingly, these results clearly contrast with recently published work, which claims a secondary position for TD6 [Our results show no evidence of technological evolution, merely an increase in lithic production up through the stratigraphy, and certain features that may point to occupational differences. Technically, the TD6 lithic assemblage is very homogeneous; this may be because the hominin occupations occurred more or less consecutively over quite a short period. However, the long-lasting technical character of European Mode 1 technology makes finding evidence of change unlikely. Nevertheless, some elements must be taken into account: 1) the existence of technological evidence pointing to planned occupations; 2) the use-wear identified on a TD6 tool sample related to butchering processes, where evidence for cutting actions on soft animal tissues are well represented , 76; 3) Concerning the technological position that TD6 occupies with respect to other Early Pleistocene sites, its lithic industry seems to represent Mode 1 technology with archaic and derived features. Archaic features include both the use of a single flake-production method  and a diversification of flaking strategies such as orthogonal, bipolar-on-anvil, and centripetal, where none predominates. Examples of this can be seen in the deposits from Atapuerca-TE9 (1.2 Ma) , 80, AtaIn contrast, derived features include the diversification of raw materials , the proIn our view, TD6 represents evolution and diversification within the European Mode 1, whose earliest representative is the lithic assemblage of Dmanisi (Georgia) , 95. Altif it acquired over time some features [An interesting question is whether the technology represented in TD6 might have evolved into the Acheulean industry, as it is known in Europe, such as the contemporary site of Barranc de la Boella (Tarragona) –99, and features , 63. TheThe TD6 archaeo-palaeontological record seems to represent two main stages of occupation. During the oldest (TD6.3), both the type of pieces and their scarcity evidence light and infrequent hominin occupation of the cave. This may represent a certain degree of continuity with the earliest hominin evidence at the site, from the lowermost units of Gran Dolina (TD3-4 and TD5). In fact, a great deal of evidence of carnivores and hyenas has been found in TD6.3, while the hominin impact is relatively scarce and marginal . Howeverin situ character of the various hominin occupations; this also raises doubts about recent interpretations of the TD6 unit as being in a secondary position [The lithic assemblages from both TD6.2 and TD6.1 display a greater range of production processes, with a greater diversity of the different raw materials being used. These comprise a very rich and varied lithic assemblage associated with the processing of faunal carcasses and hominin bodies , 57, 77.


Methanobrevibacter smithii and an enrichment in potentially pathogenic Proteobacteria, Fusobacteria and Streptococcus gallolyticus. A complex of 12 species identified only in healthy children using culturomics and metagenomics were identified as probiotics candidates, providing a possible, defined, reproducible, safe, and convenient alternative to fecal transplantation to restore a healthy gut microbiota in malnourished children. Microbiotherapy based on selected strains has the potential to improve the current treatment of severe acute malnutrition and prevent relapse and death by reestablishing a healthy gut microbiota.Severe acute malnutrition is the world-leading cause of children under-five's death. Recent metagenomics studies have established a link between gut microbiota and severe acute malnutrition, describing an immaturity with a striking depletion in oxygen-sensitive prokaryotes. Amoxicillin and therapeutic diet cure most of the children with severe acute malnutrition but an irreversible disruption of the gut microbiota is suspected in the refractory and most severe cases. In these cases, therapeutic diet may be unable to reverse the microbiota alteration leading to persistent impaired development or death. In addition, as enteric sepsis is a major cause of death in this context, identification of missing gut microbes to be tested as probiotics (live bacteria that confer a benefit to the host) to restore rapidly the healthy gut microbiota and prevent the gut pathogenic invasion is of foremost importance. In this study, stool samples of malnourished patients with kwashiorkor and healthy children were collected from Niger and Senegal and analyzed by culturomics and metagenomics. We found a globally decreased diversity, a decrease in the hitherto unknown diversity (new species isolation), a depletion in oxygen-sensitive prokaryotes including  Each colony was deposited in duplicate on a 96 MSP microplate and covered with 2 μL matrix solution. The solution was made of saturated α-cyano-4-hydroxycinnamic acid, 50% acetonitrile and 2.5% trifluoroacetic acid. Each obtained spectrum was matched against the 7562 spectra of Bruker's and the Laboratory of La Timone's home database (as of January 2016). A score >1.9 allowed identification at the species level  was extracted using EZ1 DNA Tissue Kit from Qiagen in an automated EZ1 advanced instrument according to the manufacturer's instructions. The DNA was amplified with primers FD1 and RP2 targeting all bacteria at an annealing temperature of 52°C. The amplified product was purified on a 96-well-purification plate and then re-amplified using the BigDye Terminator v1.1 cycle sequencing kit (Qiagen) at an annealing temperature of 52°C with primers FD1, RP2, 536F, 536R, 800F, 800R, 1050 F, and 1050R . Two-tailed exact Fisher test or uncorrected Chi-squared test were used to compare proportions. Barnard two-tailed test was used when the sample size was very small , 2,975]. For control samples, 59,578 colonies were tested using MALDI-TOF MS with an average of 11,916 ± 404 colonies per sample. A total of 335 species were isolated in kwashiorkor samples whereas 281 species were isolated in control samples. All 15 samples were analyzed by 16S rRNA gene-targeted metagenomics. A total of 2,933,416 and 1,842,831 reads were generated from the 10 kwashiorkor and 5 control samples, respectively.Ten patients with kwashiorkor and five controls were selected. Six patients and three controls were recruited in Senegal and four patients and two controls were recruited in Niger, so that the proportion of patients with kwashiorkor originated from Niger and Senegal was identical (67%). No significant difference was observed for the age and sex of the patients with kwashiorkor and controls Table . All 15 p < 3 × 10−7, Table n = 10) including nine new species and nine new genera (Table Neofamiliaceae fam. nov.), 14 are known but had not been previously found in humans and six are already known in humans but had not been previously found in the gut. The hitherto unknown diversity assessed by culturomics was dramatically decreased in the kwashiorkor group  was significantly lower in the kwashiorkor group indicating a lower β-diversity . The difference was significant .According to the “culturomics” results, both aerotolerant and anaerobic β-diversities were significantly lower in kwashiorkor Table  but the t-test, p = 0.1, Table p = 0.02, Table The metagenomics analysis showed a non-significant increased aerotolerant α-diversity , followed by 56 Proteobacteria, 47 Actinobacteria, 21 Bacteroidetes, and 3 Fusobacteria. A total of 108 genera were isolated including Clostridium (46 species), Bacillus (28), Streptococcus (18), Staphylococcus (17), Enterococcus (13), Paenibacillus (11), Lactobacillus (13), and Corynebacterium (9). In control samples, only four phyla were isolated: Firmicutes (192 species), Actinobacteria (42), Proteobacteria (25), and Bacteroidetes (21). Strikingly, there was no Fusobacteria species. A total of 91 genera were identified among these four phyla. The most represented were Clostridium (45 species), Bacillus (30), Paenibacillus (18), Streptococcus (12), Staphylococcus (9), and Lactobacillus (8) (Table Proteobacteria was found in kwashiorkor  whereas Prevotella and Bacillus were less frequent in kwashiorkor  and S. gallolyticus [7/10 (70%) in kwashiorkor vs. 0/5 (0%) in controls, two-tailed Barnard test p = 0.014, Figure At the genus level,  [40/589 .8% vs. 2Firmicutes phylum (32) followed by a few species from the Actinobacteria (5), the Bacteroidetes (4), and the Proteobacteria (4) phyla. Among the missing repertoire, strikingly, 23 species (51%) were strictly anaerobic.Species identified by metagenomics and culturomics in kwashiorkor and control patients were compared and 45 species were identified only in control samples Table . These sFirmicutes, two Bacteroidetes, and one Actinobacteria were found to have possible probiotic features or were representative of a healthy flora: Alistipes indistinctus, Anaerostipes caccae, Bacillus licheniformis, Bacillus subtilis, Bacteroides salyersiae, Bifidobacterium adolescentis, Intestinimonas butyriciproducens, Lactobacillus perolens, Lactobacillus parabuchneri, Lactobacillus vaccinostercus, Terrisporobacter glycolicus, and Weissella confusa , only S. gallolyticus has such a pathogenic potential. The species-level resolution of the characterization of the gut microbiota alteration associated with SAM is also critical as a species and strain specificity of probiotics effect on weight regulation has previously been demonstrated  and a loss of the reduced environment which both are culture requirements for most strict anaerobes. The depletion of anaerobic species in the gut microbiota of patients with kwashiorkor is here observed for the first time using a culture-based approach, except for a study by Mata et al. in 1972, realized at a low scale, which reported a decrease in anaerobic species in the proximal gut and the feces of malnourished children (Mata et al., Roseburia intestinalis, Ruminococcus broomii, and Adlercreutzia equolifaciens can also be beneficial in the restoration of a healthy flora, short chain fatty acid production, and antioxidants metabolism. These species are extremely oxygen-sensitive bacteria requiring specific culturomics strategies using fresh samples and antioxidants in the transport medium to enhance growth and protect them from oxygen (Dione et al., Faecalibacterium prausnitzii.Of the 30 species enriched in controls Figure  and idenThe number of patients who gave samples is small, however similar results have been found from larger studies and from elsewhere (Subramanian et al., We are not able to ascertain that the mothers have not given antibiotics to the children prior to attending the hospital as antibiotics are freely available for purchase in the market of such countries. Similarly, patients frequently consult a traditional practitioner prior to attending Western medical facilities. It is unknown what the effect of the traditional potions may have on the gut microbiota.The organisms which we focused on were those which we grew by culturomics and identified by metagenomics. Other organisms which we grew may also be useful probiotics species. The culture conditions that we used were not exhaustive but did include the conditions which grew most species and were practicable. Extending the culturomics to additional culture conditions may improve the overlap in the two conditions and allow us in the future to identify more useful species. The characteristics we use to judge the potential usefulness of a bacterium as a probiotic are not established. For example, the question of the sensitivity to bile acids is not clear. A bacterium that metabolizes cholic acid to lithocholic acid would be detrimental as lithocholate is hepatotoxic and bile acids are required for absorption of fat soluble vitamins and lipids. Alternatively, sensitivity to bile salts may prevent useful bacteria from establishing themselves in the lower intestine.Clostridium difficile outbreak (Lagier et al., In this study, we identified bacteria that met the characteristics of potential probiotics. In order to test the efficacy of these possible probiotics, we aimed at developing an experimental model with axenic mice on which this cocktail of probiotics would be tested. All studies concerning the gut microbiota of SAM patients are passive, exploratory studies. The value of culturomics is that we are able to ensure that identified bacteria are viable and can be grown in culture so that a clearly defined bacterial mixture can be administered to the patients whereas fecal transplant is likely to vary depending on the particular bacteria mixture of the donor. Each donor will be different. Efficacy of fecal microbiota transplantation to prevent death was recently demonstrated in the elderly in the context of the ongoing Conceptualization: JCL and DR. Methodology: SK and DR. Validation: MM and DR. Formal analysis: MTA, MM, and DR. Investigation: MTA, SIT, DM, and CR. Resources: SB, DA, CS, and AD. Data curation: DB, AC, and JD. Writing-Original draft: MTA, MM, and DR. Writing-Review and Editing: MTA, MM, JCL, MG, and DR. Visualization: MTA and MM. Supervision: MM, SK, JCL, BAD, and DR. Project Administration: PP and DR. Funding Acquisition: DR.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. The reviewer ES-T and handling Editor declared their shared affiliation, and the handling Editor states that the process nevertheless met the standards of a fair and objective review.


Congenital muscular dystrophies (CMDs) are a wide group of muscular disorders that manifest with very early onset of muscular weakness, sometime associated to severe brain involvement.The histologic pattern of muscle anomalies is typical of dystrophic lesions but quite variable depending on the different stages and on the severity of the disorder.Recent classification of CMDs have been reported most of which based on the combination of clinical, biochemical, molecular and genetic findings, but genotype/phenotype correlation are in constant progression due to more diffuse utilization of the molecular analysis.In this article, the Authors report on CMDs belonging to the group of dystroglycanopathies and in particular on the most severe forms represented by the Fukuyama CMD, Muscle-Eye-Brain disease and Walker Walburg syndrome.Clinical diagnosis of infantile hypotonia is particularly difficult considering the different etiologic factors causing the lesions, the difficulty in localizing the involved CNS area  and the limited role of the diagnostic procedures at this early age.The diagnostic evaluation is not easy mainly in differentiating the various types of CMDs, and represents a challenge for the neonatologists and pediatricians. Suggestions are reported on the way to reach a correct diagnosis with the appropriate use of the diagnostic means. Muscular dystrophies (MDs) encompass a group of disorders presenting with skeletal muscle weakness, peculiar histological muscle alterations and consisting in abnormal muscular architecture with loss of muscular tissue Fig.  and vari5. Norwood et al. [5. Recently, Graziano et al [5, specifically, in a total of 336 patients enrolled in the study, 135 (40.2 %) showed alpha-dystroglican glycosylation deficiency with a point prevalence 0.226 × 105; laminin alpha 2 deficiency was reported in 24.1 % with point prevalence of 0.136 × 105; collagen VI deficiency was registered in 20.24 % with a point prevalence of 0.114 × 105. Mutations in SEPN1 and LMNA were less frequently reported: 6.25 and 5.96 %, with point prevalence of 0.035 × 105 and 0034 × 105, respectively.Congenital Muscular Dystrophies (CMDs) are an uncommon group of MD disorders characterized by early onset of muscular weakness within 1 year of age and manifesting with more or less severe neonatal hypotonia as well as histologically presenting with features of dystrophic lesions . Muscle d et al.  in a stuSeveral classifications have been proposed to distinguish the different forms of CMDs. Parano et al. , 7 distiA classification of CMDs based on the combination of clinical, biochemical, molecular, and genetic findings was proposed by Voit and Tomè in 2004  who distLARGE); c) Fukuyama CMD, FCMD gene, protein Fukutin; d) Muscle-Eye-Brain (MEB) genes POMGnTI, FKRP, ISPD, TMEM5, Fukutin); e) Walker-Warburg syndrome (WWS), genes POMTI, POMT2; FKRP, ISPD, CTDC2, TMEM5, POMGnTI, B3GALNT2, GMPPB, B3GNT1, SGK196, Fukutin); e) CMD/LGMD with Mental Retardation ; f) CMD/LGMD without mental retardation including MDC1C .More recently, Bonneman et al.  reportedSEPN1 and FHL1 genes), multiminicore disease (SEPN1), and LGMD (LMNA gene).Kang et al. , followiClassifications, clinical features, and genotype/phenotype correlation in CMDs are constantly in progress due to the worldwide use of molecular analysis and an usually prolonged survival of the affected patients due to a more suitable clinical assistance.In this article, we want to point out our attention to CMDs belonging to the group of dystroglycanopathies   and in pDefective glycosylation of alpha-dystroglycans is one of the events that may cause CMDs. These disorders encompass several conditions that range from early and severe clinical involvements, as demonstrated by the WWS, MEB, and FCMD, to later and less pronounced muscle impairment and with/without comorbidity with other body-organs –12. ClinPOMT1, POMT2, POMGnT, FCMD, Fukutin, and LARGE genes are reported to code for specific or putative glycosyl-transferases involved in the pathway of alpha-dystroglycanopathies.Several genes have been implicated in the pathogenesis of the alpha-dystroglycanopathies. Among these, POMT1 in two, POMGnT1 in one, LARGE in one); MEB/FCMD-like in 24 with mutations identified in 13 ; CMD with cerebellar involvement in 15 with mutations identified in 8 ; CMD with mental retardation and normal MRI in 21 with mutations identified in 10 ; CMD with no mental retardation and normal MRI was reported in 4 patients with mutations identified in 3 .A multicenter Italian study carried out by Mercuri et al.  in 81 CMPOMGnT1 gene .CMDs are frequently associated to intellective delay (ID) and structural brain involvement and Messina et al  report aFCMD or FKTN) [FCMD was first reported by Fukuyama  in 1960.or FKTN) . Its proor FKTN) . Fukutinor FKTN) , 18 wereor FKTN) , 18 inclor FKTN)  reportedDuring the following years, the clinical features of the FCMD, as initially reported by Fukuyama et al., substantially have not changed. It appears evident that the affected patients show a variable degree of clinical manifestations, including variability into the members of the same family. The muscle involvement appears most frequent before and during the neonatal age with weakness and hypotonia and the history of poor fetal movements. The newborns appear floppy, and the cry is feeble. Usually, the look is vivid. Pulmonary infections may be frequent in the first months of life. Hypertrophy of the calves and quadriceps, cognitive delay, seizures, and difficulty in walking may later be present. Ophthalmologic examination may show retinal folding, fusion, focal dysplasia, and detachment . The braMuscle-eye-brain is known as “MEB disease” and is characterized by CMD, structural eye abnormalities, and cerebral malformations, first reported by Santavuori et al. in 1978 . The autPOMGnT1 cause a complete loss of function of the glycosyltransferase, but, as reported by Hehr et al. [The clinical and molecular aspects of MEB disease are typical and specific, but the grade of severity of each organ affected is quite variable. The disorder is inherited in autosomal recessive pattern and is associated with mutations in the gene at 1p34-p32 that codifies POMGnT1, a glycosyl transferase. All the mutations in r et al. , the typr et al. .Taniguchi et al.  reportedPDHGT1 gene. The child showed failure to thrive with height and weight under the 3rd percentile and a head circumference around the 3rd percentile. Her neurological examination showed speech delay, strabismus, proximal and distal weakness with hypotonia of the upper limbs, and signs of hypertonia in the lower limbs with slight contracture of the fingers and wrist. The eyes presented with severe myopia and retinal dysplasia. The MRI showed cortical gyration of the frontal lobes, micropolygyria of the temporal lobe, and bilateral microcystic degeneration of the cerebellar cortex. The course presented by this girl was milder than usually reported and is a confirmation of the variable clinical aspect of the disorder. As reported by Bonnemann [POMGnTI, FKRP, Fukutin, ISPD, TMEM5 with clinical features in summary consisting of mainly severe congenital weakness, inability to walk, spasticity and motor deterioration, mental retardation, and severe eye involvement. The brain MRI reflects what has been reported in FCMD with lissencephaly type II/pachygyria, brain stem and cerebellar anomalies and cysts.Falsaperla et al. reported a 13 year-old girl with a long-term survival, demonstrating the wide variability of MEB disease . The molonnemann , MEB disThe syndrome is named after Walker , who desA family was reported from Catania, Italy, in whom three members suffered from congenital hydrocephalus and ocular abnormalities . In two POMT1, POMT2, and less frequently POMGnT1, FKRP, Fukutin, and LARGE [WWS is reported to be genetically heterogeneous. The genes involved are nd LARGE –37. The nd LARGE  with detnd LARGE .Fig. 2ArFKRP, Fukutin, ISPD, GMPPB), which manifests with early onset weakness and early onset LGMD without brain involvement and cardiomyopathy.This subtype of CMD was first reported by Brockington et al. , who ideThis form manifests with variable deficiency of the glycosylated aDG epitope and secondary laminin alpha 2 deficiency. The muscle involvement manifests with proximal limb girdle weakness, muscle hypertrophy, particularly in the calf, and early respiratory failure .This disorder has been initially reported by Longman et al.  in a 17-The muscle biopsy in the case of Longman et al.  showed aA few years ago, two Sicilian siblings, a boy and a girl, born from consanguineous parents with congenital muscular dystrophy and peculiar phenotype were reported by Voit et al. . In thesAs previously mentioned, the causes of the neonatal hypotonia are several and to recognize the events that have provoked the disorders represents a great challenge for the pediatricians. Several conditions may manifest with infantile hypotonia, including anomalies of the central or peripheral nervous system with involvement of the spinal cord, anterior horn cell, peripheral nerves, neuromuscular junction, and muscles. The term “floppy Infant” is referred to as the most severe clinical form of hypotonia, and it is related to a child of an age ranging from first days to 1 year of life, presenting with severely reduced or absent muscle mobility.The diagnostic evaluation includes detailed family, pregnancy and, perinatal history. General physical examination to exclude malformative anomalies and body structural defects. The muscle tone is evaluated according to the standard maneuvers for hypotonic infant such as “pull to sit”, the “horizontal” and “vertical suspension” Figs. , 5 and 6The distinction between central and peripheral nervous system attainment may be only indicative since both these structures may be clinically affected, and both structural anomalies may co-exist in the same affected infants in a variable expression. In general, severe weakness with reduced or absent antigravitary movements, poor spontaneous movements, absent tendon reflexes, marked head lag and alert look are consistent with hypotonia of peripheral origin. Evaluation of the cry, suck, facial expression, antigravity movements , resistance to strength testing, and respiratory capacity are also to be established . InfantsOphthalmologic evaluation, electrocardiogram, electroencephalogram, and brain MRI should also be carried out according to the clinical examination.Among the group of floppy infants of peripheral origin, differential diagnosis is also difficult, including non-neuromuscular genetic conditions such as Prader-Willi syndrome . HypotonVery early Spinal Muscular Atrophy Fig.  is inherCongenital Myotonic Dystrophy (Steinert disease) Fig.  is the mFor the congenital myasthenic syndrome, two forms are classically recognized: 1) Myasthenia Gravis is the transient, acquired neonatal myasthenia present at birth or within the first 3 days of life. The hypotonia is generalized and severe. The patients show feeding difficulties with failure in sucking and swallowing, facial weakness, and feeble cry. Ptosis and ophthalmoplegia are frequently present, and these signs may be useful for obtaining a correct diagnosis.2) The Congenital myasthenia manifests with failure of the bulbar, ocular, limbs, and respiratory muscles. ECG may show heart block. EMG may be useful for diagnosis. The response to treatment with acetylcholinesterase inhibitors is diagnostic.MTM1, DNM2, MYF6, CCDC78, BIN1 genes); core myopathy including minicore ; nemaline myopathy ; congenital fiber-type disproportion ACTA1, SEPN1, TPM3, TPM2, MYL2 genes). In these disorders, the histochemistry or electron microscopic investigations are diagnostic [The patients with congenital myopathies (CMs) Fig.  present agnostic .Fig. 9A The muscle biopsy, together with specific molecular/genetic examinations, remains the gold standard for the diagnosis of specific CMDs and similar conditions. Muscle analysis is worthy for obtaining a correct diagnosis. The analysis should include the general histologic structure, histochemical and immunohistochemical reactions, and possibly specific enzyme quantification. In some cases, the investigation should be extended to electron microscopy analysis.At the present time, the treatment is led to ameliorate the course of the disease and to prevent or treat pulmonary and cardiac impairment. Antisense oligonucleotide has been shown to have a good response in the mouse model for myotonic dystrophy, and it is in course of trial in humans There is no pharmacological treatment for the CMDs. However, physiotherapic treatment is advisable to prevent joints deformity, muscles retractions, and scoliosis. Supportive treatment with non invasive respiratory support in case of respiratory distress, correction of gastro-esophageal reflux, support in cardiac failure, treatment of respiratory infections, and nutritional treatment with new modality must be constantly carried out. This treatment strategy has allowed these patients to a wider and better survival.CMDs are a group of disorders that involve more than only muscles; other body structures including the brain, eyes, and heart may be affected. Diagnosis is not easy, and the time when a muscular biopsy should be performed is not easy to be established. However, muscular biopsy becomes worthy to indicate the correct molecular/genetic analysis. The course of any of these forms is usually severe. Nutritional and respiratory support have prolonged the life of these children, but early fatal outcome is typical. Performing clinical and molecular diagnosis is extremely important for genetic counseling, prognosis, and anticipatory treatment and also for prospective treatment.


The same range of blood pressure values may reflect different vascular functions, especially in the elderly. Therefore, a single blood pressure value may not comprehensively reveal cardiovascular function. This study focused on identifying pulse wave features in the elderly that can be used to show functional differences when blood pressure values are in the same range. First, pulse data were preprocessed and pulse cycles were segmented. Second, time domain, higher-order statistics, and energy features of wavelet packet decomposition coefficients were extracted. Finally, useful pulse wave features were evaluated using a feature selection and classifier design. A total of 6,075 pulse wave cycles were grouped into 3 types according to different blood pressure levels and each group was divided into 2 categories according to a history of hypertension. The classification accuracy of feature selection in the 3 groups was 97.91%, 95.24%, and 92.28%, respectively. Selected features could be appropriately used to analyze cardiovascular function in the elderly and can serve as the basis for research on a cardiovascular risk assessment model based on Traditional Chinese Medicine pulse diagnosis. E), and higher-order statistics (HOS) features of wavelet packet decomposition coefficients (WPDC), were used in pulse classification of health versus subhealth and atherosclerosis versus nonarteriosclerosis  is defined as the expectation operation and X(·) is the random process.Let function .(1)ϕxw=Efined as (2)m2i=EXX(n), defined as [nth-order cumulants of X(n), represented as cn. The cumulants are defined as [i, j, k equals zero. The zero-lag cumulants have special names: c2(0) is the variance and is denoted by σ2; c3 and c4 are denoted by γ3x and γ4x known as skewness and kurtosis, respectively.The second characteristic function of fined as (3)Xw=lnfined as (4)c2i=m2In this study, the HOS methods are used to extract new and fewer number of features from the wavelet packet decomposition coefficients There were 30 subbands for the 4 levels as noted. Three features were extracted for each subband using HOS. We calculate HOS methods, second-, third-, and fourth-order cumulants including using cumulants functions in MATLAB 2013a:x represents the wavelet packet decomposition coefficients of every pulse cycle. Thus, 30 E features  and 90 HOS features  were obtained for analysis.In addition, Shannon entropy was used to calculate the energy of WPDC with the following entropy function in MATLAB 2013a:CfsSubsetEval and BestFirst were used for feature selection; these are built-in attribute evaluator and search methods in WEKA 3.8. CfsSubsetEval evaluates the worth of a subset of features by considering the individual predictive ability of each feature along with the degree of redundancy. Subsets of features that are highly correlated with the class while having low intercorrelation are preferred. The BestFirst method searches the space of attribute subsets by greedy hillclimbing augmented with a backtracking facility. Setting the number of consecutive nonimproving nodes allowed control of the level of backtracking. BestFirst may start with an empty set of attributes and search forward, with a full set of attributes and search backward, or at any point and search in both directions. The process is shown as k-Nearest Neighbor (k-NN) [k-NN is independent of statistical distribution of training examples and classifies objects by computing their distance to the training examples in the feature space. The object is assigned to the class most common among its k-Nearest Neighbors. In this study, when k = 1, the object is simply assigned to the class of its nearest neighbor.r (k-NN) , which iTP: true positive, number of positives;TN: true negative, number of negatives;FP: false positive, number of negatives;FN: false negative, number of positives;x-axis and y-axis are the False Positive Rate (FPR) and True Positive Rate (TPR), respectively.ROCA: receiver operating characteristic curve area, in which the To compare the results of classification, the statistical definitions used were as follows:In this study, positive means hypertension history, and negative means nonhypertension history. Finally, accuracy (ACC), sensitivity (SE), specificity (SP), and ROCA ware used as evaluation indicators. The relevant formulas are shown as follows:After data preprocessing and noise removal, 6,075 pulse wave cycles were analyzed for the NG, HerG, and HestG groups, and the hypertension history and nonhypertension history classes. The 6 data sets are detailed in E features were selected with 10-fold cross-validation. The occurrence frequency of these features was designated as OF. For example, a 5-fold selected feature was chosen 5 times in 10-fold selection (OF = 5/10 × 100 = 50%). All chosen features with different OFs were divided into different combinations by eliminating lower values. Finally, 1-NN was used to verify different feature combinations. The experimental software platform for 1-NN and feature selection was Weka 3.8. All features were extracted in MATLAB 2013a.In every experiment, 20 TD features, 90 HOS features, and 30 Using 10-fold selection, 26 features were selected in experiment 1 for NG, 9 features in experiment 2 for HerG, and 15 features in experiment 3 for HestG. The selected features and OF values are shown in All chosen features with different OF values were divided into different combinations by eliminating the lower OF in every experiment. For example, 26 features were selected in NG, including 10 with 10% OF, 5 with 20% OF, 3 with 30% OF, 1 with 40% OF, 3 with 90% OF, and 4 with 100% OF. Accordingly, NG experimental results were divided into 5 groups. The first group eliminated 10 features with 10% OF and retained the remaining features. Therefore, the last group only contained the 4 features with 100% OF. The grouping in HerG and HestG was the same as in NG. Moreover, based on all feature subgroups and all selected feature subgroups, NG, HerG, and HestG experiments were divided into 7, 6, and 9 subgroups, respectively.1-NN was used in every subgroup of experiments to evaluate the effectiveness of the features groups. The classification results for NG, HerG, and HestG are shown in Tables w51/t, t, HOS29, HOS81, and E15  show a distinct difference. The classification accuracy showed a decreasing trend as blood pressure values increased . Because of the normal blood pressure values in the NG group, there are essentially 2 classes of a wiry pulse: the healthy elderly wiry pulse and the hypertensive wiry pulse. However, in the HerG and HestG groups, the pulse wave in those without a hypertension history reflected the features of a hypertensive wiry pulse. Thus, the classification accuracy in the HerG group was lower than that in the NG group, and the accuracy in the HestG group was lower than that in the HerG group. The features selected in the classification all achieved accuracy of greater than 92.28% in the 3 groups. Although the features of a hypertensive wiry pulse were present in 2 classes (hypertension and nonhypertension history) in the HerG and HestG groups, the selected features can also reflect cardiovascular function under conditions of sustained hypertension.In elderly individuals, pulse wave cycle features in the same blood pressure range show significant differences according to hypertension history. Recognition rates of over 90% have been achieved in classification experiments using the selected features. This shows that not all equivalent blood pressure levels represent the same cardiovascular function. Meanwhile, the TD, HOS, and energy features of WPDC can be used to evaluate cardiovascular function according to blood pressure values.This study shows that management of health risk requires more than blood pressure medication in elderly individuals with hypertension. Changes in pulse wave and blood pressure values should be used in an evaluation index. Future research will focus on finding more effective features for assessment of blood vessels and analysis of the relationship between pulse features and central arterial pressure.


To compare the activity, efficacy and toxicity of docetaxel versus docetaxel plus cisplatin in patients with non-small-cell lung cancer.A literature search was performed in the EMBASE, Medline, Cochrane Library, Web of Science, China National Knowledge Internet, Wan-fang databases. The trials that were found were then evaluated for eligibility. The Cochrane Collaboration's Review Manager software was used to perform the meta-analyses.Nine clinical trials including 1257 patients were included. The docetaxel plus cisplatin regimens had higher overall response rates compared with the docetaxel regimen . No statistically significant difference was observed between the two regimens with respect to the one-year survival rate . Patients treated with the DP regimen were more likely to experience anemia, thrombocytopenia, nausea/vomiting, nephrotoxicity, hyponatremia, mucositis and treatment-related deaths compared with patients treated with docetaxel alone. No significant difference was observed between the two regimens with respect to the occurrence of neurotoxicity, diarrhea, fatigue, pneumonitis, neutropenia and leucopenia.The docetaxel plus cisplatin combination regimen resulted in a high response rate and a high adverse effect rate compared with docetaxel monochemotherapy for non-small-cell lung cancer. Non-small-cell lung cancer (NSCLC) is common and accounts for up to 85% of lung cancers . Most pa2 administered once every 3 weeks could lead to objective response rates of approximately 30% in untreated patients with advanced NSCLC [Docetaxel (Taxotere), a semi-synthetic taxoid derived from the rare pacific yew tree Taxus Baccata, has demonstrated significant antitumor activity. It is one of the most active single agents in both previously untreated patients and in those who have relapsed or progressed following cisplatin-based chemotherapy , 5. Doceed NSCLC , 8.Cisplatin-based doublets are recommended for the adjuvant or neoadjuvant treatment of potentially operable NSCLC and as a first-line therapy for advanced or metastatic NSCLC . ExtensiSeveral RCTs were performed to evaluate the activity and toxicity of the DP combination as a first-line treatment of chemotherapy-naive patients with metastatic or unresectable locally advanced NSCLC –20. HoweAccordingly, in this paper, we conducted a meta-analysis to compare the clinical profile of docetaxel monotherapy with that of DP combination chemotherapy in terms of response rate, overall survival and toxicity in patients with NSCLC.The following electronic databases were independently and extensively searched by two investigators from their inception through May 2016: EMBASE, Medline, the Cochrane Library, Web of Science, the China National Knowledge Internet (CNKI), and the Wan-fang database. The search strategy was based on a combination of three concepts adjusted to each database, when necessary. Concept one included all of the terms for docetaxel, and Concept two included the terms for cisplatin; Concept three included all of the terms for non-small-cell lung cancer. We only accepted one set of data on the same topic. The bibliographies of the included studies and dissertations were also searched for additional publications. All of the eligible studies were identified by two independent authors , and any disagreements were settled by consensus or consultation with a third author (HD).In order to be included in this analysis, the trials had to fulfill the following inclusion criteria: 1) contain patients with histologically proven NSCLC; 2) previous surgery was allowed if it had been completed at least 4 weeks before inclusion; 3) prior radiotherapy, except for that intended for the primary lesion, was permitted if it had been completed at least 2 weeks before inclusion; 3) randomized controlled clinical trials; 4) docetaxel monotherapy and DP doublet regimens were compared as chemotherapy regimens without the addition of confounding agents or interventions; 5) both groups could receive some foundation therapy or supportive care such as granulocyte colony-stimulating factor (G-CSF), antiemetic treatment with ondansetron and dexamethasone. The exclusion criteria were as follows: 1) an evaluation of the activity, efficacy and toxicity of docetaxel versus DP was absent in the studies; 2) agents were used as pre- or post-operative adjuvant chemotherapy; 3) the study featured comparisons of other types of chemotherapy regimens; 4) Early studies published as a series of articles from the same institution or author that contained significant overlapping data were excluded for fear of multiple publication bias; 5) case reports, editorials, experimental studies, conference articles and other studies that failed to provide detailed results were excluded.After duplicates were removed and the study selection process was completed, the titles and abstracts were scanned by two independent investigators  according to predefined selection criteria, and potentially relevant RCTs were selected. The relevant data were extracted by adopting a predetermined standardized procedure, which involved the first authors, year of publication, country, demographic characteristics of the participants, and the treatment regimen for each group. All data were verified for internal consistency, and controversies were settled by consensus or discussion with a third author. Whenever possible, the first authors were contacted to obtain and clarify the relevant data, when appropriate, as specified by the standardized protocol.The methodological quality of the included trials was assessed by the Cochrane Collaboration's tool . This toThe overall survival (OS) was defined as the time that elapsed from random assignment until death from any cause and was censored at the last follow-up date. Response evaluation was performed according to the Response Evaluation Criteria In Solid Tumors . The ove2 index, which express, as a percentage, the proportion of variability of the results due to heterogeneity as opposed to sampling error [2 was > 75 % and if P < 0.10 [The Cochrane Collaboration's Review Manager Software  was used to perform the meta-analyses. The overall effect size of each regimen was calculated as a weighted average of the inverse variance and 95 % confidence intervals (95 % CI) for study-specific estimates. The statistical heterogeneity among the individual studies was evaluated based on Cochrane's Q test and the Ing error . The preP < 0.10 . A variaP < 0.10 . If apprP < 0.10 . A P-valTable Detailed baseline characteristics of the patients included in the nine trials are listed in Table According to the Cochrane Collaboration recommendation, randomization methods were reported in four trials , 30–32. 2 = 12.73, I2 = 37 %, P = 0.12) . CR and PR were reported in detail in eight trials [2 = 7.16, P = 0.41, I2 = 2 %)   compared with the docetaxel regimen . Additionally, no considerable heterogeneity was found  . Moreove2 = 0 %) . The ove2 = 10.72, P = 0.01), and the I2 index indicated that 72 % of the variability across trials was due to heterogeneity rather than chance .The one-year survival rate was stated in four trials , 30, 34.Toxicity profile results with respect to the frequency of NCI-CTC grade 3 – 4 side effects were available for all trials. The number of trials with data available for anemia, thrombocytopenia, nausea/vomiting, nephrotoxicity, hyponatremia and treatment-related deaths was 7, 7, 6, 3, 2 and 4, respectively. The reporting of side effects was heterogeneous among trials. Patients who were treated with the DP regimen were more likely to experience anemia , thrombocytopenia , and nausea/vomiting  compared with patients who were treated with docetaxel. Moreover, the DP regimen led to more frequent grade 3 or 4 nephrotoxicity , hyponatremia , and treatment-related deaths , and this difference was statistically significant. Almost all treatment-related deaths occurred in the DP treatment group with the exception of one patient who died of febrile neutropenia in the docetaxel group in one trial . In addi2 = 75.60, P < 0.00001, I2 = 96 %), and the random effects model was applied to perform the data analysis. Otherwise, no statistically significant difference in the morbidity associated with neutropenia was observed  . The results were also consistent in the morbidity associated with febrile neutropenia . Data on leucopenia were available in six trials. Similarly, pooled data showed that no statistically significant difference existed with respect to leucopenia  . Four studies assessed the occurrence of neutropenia. Considerable heterogeneity existed in the morbidity associated with neutropenia among the 4 studies . A summary of hematological and non-hematological events is presented in Table Diarrhea, fatigue and pneumonitis were evaluated separately in 5, 3, and 2 trials, respectively. Overall, the meta-analysis did not reveal that patients in the DP chemotherapy group experienced a greater incidence rate of the above-mentioned side effects compared with the docetaxel group. Mucositis was reported in two trials , 36. PooThree trials , 29, 30 Overall, many clinical trials have confirmed the activity, efficacy and toxicity of the DP combination in patients with advanced NSCLC –39. It wCisplatin-based doublet regimens were associated with a higher response rate (PR plus CR) and lower occurrence of stable disease compared with non-platinum-based doublet regimens . On the 2 administered on a single day. Certainly, many variations exist in dose management [2 plus cisplatin 80 mg/m2 on day 1 every 21 days in an open label, randomized phase 3 trial that compared gefitinib versus DP for NSCLC [2 plus P 75 mg/m2 in one cycle in two trials [2 plus P 80 mg/m2 in one trial [2 on a single day in only one study [The DP regimen has been studied as an initial therapy for advanced, metastatic and recurrent NSCLC. The acknowledged and recommended total dose/cycle for the two drugs is 75 mg/mnagement . Mitsudoor NSCLC . It was or NSCLC . In the o trials , 30 and ne trial . Out of ne study . Dosing ne study . The redne study  found thne study . It was ne study . Otherwine study .Dosage reductions or therapy adjustments need to be implemented after the occurrence of grade 3 or 4 toxicities, but not for grade 1 or 2 toxicities. Therefore, the data on grades 3 or 4 toxicities were quantitatively synthesized in the meta-analysis. Hematologic adverse events were the most common major toxicities because of myelosuppression. Accepted practice guidelines suggested that prophylactic use of colony stimulating factors (CSFs) could lead to a greater than 20 % reduction in the incidence of febrile neutropenia when given with antineoplastic regimens . The useEfficacy may not be the only factor that might affect a physician's decision with regard to the choice of chemotherapy regimen for NSCLC. The principal goals of treatment should be palliation, an acceptable quality of life and prolonged survival. Consequently, clinicians should carefully define the best anticancer drug, schedule of administration, and treatment strategy, depending on potential toxicity and the individual patient's wishes. Some new therapies have been explored in recent years. It has been suggested that matrix metalloproteinase (MMP) inhibitors could significantly reduce vascular density around lung tumors and that the tumor growth inhibition rate could reach 88 % . ThalidoThe limitations of this systematic review involve the uniformity of the administration program and the small size of the included RCTs. Given the special features of lung cancer, imbalances in baseline prognostic factors and post-protocol treatment, such as epidermal growth factor receptor (EGFR) mutations, pathological type and comorbid illnesses, may be responsible for unexpectedly large differences in some measures between treatment arms. More patients with non-squamous histology were included in the DP arm than in the docetaxel arm in the trial conducted by Tsukada . Active The DP regimens led to a higher overall response rate in comparison with docetaxel regimens. In addition, unlike the promising survival and favorable toxicity profile seen in many other studies with the DP regimen , 57, a s


Spinal epidural abscess (SEA) is a rare disease which is often rapidly progressive. Delayed diagnosis of SEA may lead to serious complications and the clinical findings of SEA are generally nonspecific. Paraspinal abscess should be considered in the presence of local low back tenderness, redness, and pain with fever, particularly in children. In case of delayed diagnosis and treatment, SEA may spread to the epidural space and may cause neurological deficits. Magnetic resonance imaging (MRI) remains the method of choice in the diagnosis of SEA. Treatment of SEA often consists of both medical and surgical therapy including drainage with percutaneous entry, corpectomy, and instrumentation. A 13-year-old girl presented to our clinic with a 10-day history of low back pain, muscle tenderness, fever, and skin rash. Lumbar MRI showed abscess formation in the paravertebral area at the level of L4-L5 Figures . Initial Salmonella tests: negative Brucella tests: negative and ASO: N. Blood biochemistry and urine analysis were normal. The second thoracic and lumbar MRI scans demonstrated that the paravertebral abscess had spread to the epidural space extending between the levels of S1 and T12.Laboratory parameters were as follows: WBC: 18,500, HB: 5.13, HCI: 34, sedimentation: 80/h, CRP 95/2 h: 115 mg/L, RF: negative, Staphylococcus aureus (MRSA) was detected in the pus culture of the patient. Depending on the culture-antibiogram results and the consultation with the Department of Infectious Diseases, imipenem was stopped and the antibiotic therapy was restarted with Vancomycin 4 × 500 mg (2 weeks), Penicillin 4 × 1 g, third-generation ceftriaxone 1 g/flk 2 × 1 (14 days), Metronidazole 500 mg flk 2 × 1 (5 days), and Paracetamol suspension (60 days). Rapid clinical improvement was observed within the first days after surgery. In the control lumbar MRI, no abscess was detected in the epidural and paravertebral areas and several scar tissues were seen in the paravertebral area  is not common in neurosurgical practice. The incidence of SEA is reported to be 1/100,000 individuals, whereas some other studies have reported higher rates . SEA was S. aureus, followed by Streptococci, anaerobic bacteria, and Gram-negative bacilli [ S. aureus was the most common bacterium detected in our patient.SEA is mostly characterized by the fluid collection and inflammatory process on the surrounding dura mater and adipose tissue . The mos bacilli . SimilarSEA presents three clinical manifestations: acute, subacute, and chronic . The acuSEA is mostly seen at the thoracic area, followed by lumbar and cervical areas. Common clinical findings of SEA include pain, inflammation, radicular symptoms, spinal cord compression, and the symptoms of cauda equina syndrome . SEA mayIn 1986, three different pathogenic mechanisms were described for paraparesis regarding bacterial infections: (I) with nonspecific polyarthritis, (II) with mass effect of epidural abscess or vertebral collapse related to spondylitis, and (III) with ischemic spinal cord lesion as a result of the abdominal aorta septic thromboembolism . In our Magnetic resonance imaging (MRI) remains the method of choice in the diagnosis of SEA , 12. WheThe primary aims in the treatment of SEA are to identify microorganisms, ensure the drainage of abscess, perform the debridement of granulation tissue, and, if needed, perform spinal stabilization. Treatment of SEA often consists of both medical and surgical therapy including drainage with percutaneous entry, corpectomy, and instrumentation . SEA oftSEA is a rapidly progressive disease resulting in severe morbidity and mortality in children. Therefore, SEA should be considered in the children presenting with tenderness in the spinal area and pain with or without fever. As in our case, empirical antibiotic therapy is required in SEA patients. In the patients presenting with paravertebral abscess, blood sample should be obtained via abscess drainage and the patient should be strictly monitored during the antibiotic therapy. If neurological deficits or a worsening clinical status appears, radiological imaging should be immediately performed  and if neural compression is detected, surgical procedure should be promptly performed. Otherwise, SEA may progress rapidly and may consequently lead to sequela. Paraparesis should be kept in mind in the patients presenting with lumbosacral SEA.