Background: Studies have investigated the lipid profile in amyotrophic lateral sclerosis (ALS), including the levels of total cholesterol (TC), triglyceride (TG), high-density lipoprotein (HDL), and higher low-density lipoprotein (LDL), and the associations with mortality of ALS, but the results were inconsistent. Therefore, we conducted this meta-analysis to systematically answer this unsolved question.Methods: We searched all the related studies that probed into the association between serum lipid levels and ALS based on PubMed, EMBASE, and Cochrane library from January 1990 to July 2020. The quality of the included studies was evaluated by using the Newcastle–Ottawa Scale (NOS). All the statistical analyses of this meta-analysis were performed using the Stata version 12.0 software.Results: Fourteen studies with a total of 3,291 ALS patients and 3,367 controls were included. Among them, 10 studies compared the lipid profile between ALS patients and controls. The results indicated that compared with controls, ALS patients from both Europe and Asia had lower levels of TG and HDL, but the levels of TC and LDL were higher in ALS patients from Europe. However, after systemic analyses, the altered TC level was significant only in Asian ALS patients; the differences of other lipids were not significant. Concerning the effect of lipid profile on mortality of ALS, analyses of four cohort studies showed that the levels of all lipids were not associated with overall mortality in ALS.Conclusion: The results of the present study showed that Asian ALS patients had lower TC levels than controls, and the levels of all lipids were not associated with mortality of ALS. Amyotrophic lateral sclerosis (ALS) is a progressive and heterogeneous disease characterized by the degeneration of the upper and lower motor neurons, leading to muscle atrophy, paralysis, and death within 3–5 years . The patAlthough a previous meta-analysis had analyzed the associations of serum lipid levels with ALS, it only included six studies and did not investigate the role of lipid profile in ALS survival. In the present study, we enlarged the number of studies and conducted a deeper systematic review and meta-analysis to examine the serum lipid profile in ALS and assess the association between lipid levels and the prognosis of ALS.* disease,” “amyotrophic lateral sclerosis,” “MND,” “ALS,” or “Lou Gehrig* disease.” To avoid missing literatures, we also looked through the references of all the relevant articles. Studies were screened independently by two investigators (JL and XL) using the aforementioned criteria. Any disagreements among investigators were resolved by a discussion to reach a conclusion. Our meta-analysis was registered with PROSPERO (registration number CRD42019117926).We performed a literature search within three main computerized databases, including PubMed, EMBASE, and Cochrane Library, to collect all the studies regarding the association between lipid levels and ALS from January 1990 to July 2020. The following search keywords were used: “lipid,” “cholesterol,” “triglyceride,” “low-density lipoprotein,” and “high-density lipoprotein” combined with “motor neuronin vitro or animal studies, (3) case reports, reviews, or meta-analysis, and (4) necessary data were not available.The flowchart of selection process was exhibited in The following data were extracted from each included study: first author, publication year, country of origin, sample size of ALS cases and HCs, ALS definition criterion, adjusted variables, and duration of follow-up in ALS patients. To avoid mistakes and bias, two authors extracted data separately, and a third investigator verified the data abstracted by the two authors. If the articles did not provide complete data, we sent an email to the author asking for the necessary data –13. StudI2 statistic. I2 > 50% or P < 0.1 represented substantial heterogeneity, and random effects model was chosen. Otherwise, fixed effects model was utilized  with 95% CI was used. To evaluate the association between serum lipid levels and all-cause mortality risk in ALS patients, the HR with 95% CI was used. TC, HDL, and LDL concentrations were converted from mmol/L to mg/dl using a ratio of 38.67 (1 mmol/L ≈ 38.67 mg/dl), and TG concentration was converted from mmol/L to mg/dl using a ratio of 88.545 (1 mmol/L ≈ 88.545 mg/dl). Heterogeneity analysis was assessed using the Cochrane Q test and utilized . To asseutilized . ProbabiThe literature research identified 4,951 papers from computerized databases according to the search strategy . After rP < 0.05, I2 = 77.8%) and TG  in Asian ALS patients. Thus, a random effects model was used. Compared with the HCs, both European and Asian ALS patients had lower concentrations of TG and HDL. The TC and LDL levels were lower in Asian ALS patients, but higher in European ALS patients. However, only the decreased TC level in Asian ALS patients was significant. In addition, there is no significance when we took TC levels in both European and Asian ALS patients into consideration, and the differences of other lipids were not significant , and a fixed effects model was used to pool the risk estimate. The results showed that the levels of TC, TG, LDL, and HDL in ALS patients were not associated with mortality (P > 0.05)  –13. SensA previous meta-analysis did not identify a statistical difference in the lipid levels between ALS patients and HCs . The incWe found that the serum TC levels in Asian ALS patients were significantly lower than those in HCs. Different from the previous meta-analysis, our study explored the lipid levels between ALS patients and HCs by dividing the included studies into Asian and European groups. Moreover, it is well known that dietary habits in Asian and European groups are dramatically different, which might be relevant with our positive findings.However, the differences between male and female were not highlighted in our study for lack of all the related data collected in the included studies. The detailed information we needed could not be obtained from the mails sent to the corresponding author. Original studies gave the whole data of TC, TG, HDL, and LDL levels in the entire population, but without the data of lipids in male and female ALS patients, we could not perform the adjust analysis for gender. One study from Asia collected serological data from 92 ALS patients and 92 age-, sex-, and body mass index-matched HCs and found significant increases of serum TC, TG, and LDL levels in female ALS patients, but not in male ALS patients . ConversStudies focusing on serum lipid levels and ALS survival were increasing in recent years, but the association between them was controversial. Huang et al. found that ALS patients with higher serum TG levels had a longer survival time than those with lower serum TG levels . SimilarThere were several unavoidable limitations in the present study. First, this meta-analysis only included studies published in English, which could inevitably lead to selection bias. Second, serum lipid levels can be affected by many factors, such as dietary habits and the use of cholesterol-lowering medication, which were not mentioned in some included studies. Third, we only included 14 studies at last because some studies did not give the completed data, though we had sent emails to the authors.In summary, our meta-analysis indicated that compared with the HCs, ALS patients from both Europe and Asia had lower TG and HDL levels, and ALS patients from Europe had higher levels of TC and LDL. However, only the difference in TC levels in Asian ALS patients was significant. Moreover, the overall survival of ALS patients was uncorrelated with the levels of TC, TG, LDL, and HDL. Therefore, meticulous designed randomized comparison studies with longitudinal follow-up are required to verify the exact role of lipid profile in ALS.All datasets presented in this study are included in the article/XC and HS conceived this study. JL and XL did the literature review and the statistical analysis. JL wrote the manuscript while all the authors revised and discussed the final edition.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.


Children with neurodevelopmental disabilities experience many unmet healthcare needs. Care coordination is one critical solution to addressing the substantial strain on families, local communities, and the larger healthcare system. The purpose of this study was to implement a care coordination program in an interdisciplinary pediatric neurodevelopmental evaluation clinic and examine care coordinator and caregiver outcomes. Following neurodevelopmental diagnosis, children were provided with either care coordination (CC) or care as usual (CAU). For those receiving CC, the care coordinator documented family goals and care coordination activities, outcomes, and time spent. Caregivers in both groups completed a survey measuring access to needed services and caregiver stress and empowerment following their child's evaluation (T1) and 4–6 months post-evaluation (T2). Care coordinator findings demonstrated that over 85% of family goals focused on understanding the child's diagnosis, getting needed interventions and educational support, and accessing healthcare financing programs. More than half of care coordination activities were spent on engaging and educating the family; similarly, the most time-consuming care coordination efforts were in helping families understand their child's diagnosis and meeting family's basic needs. For those children referred to needed services, 54% were enrolled in one or more service at T2. Caregivers in both the CC and CAU groups reported an increase in stress related to interactions with their child as well as increased empowerment from T1 to T2. Contrary to our hypotheses, there were no significant group-by-time interactions across caregiver-report measures. While these findings further our understanding of care coordination delivery, they diverge from previous evidence demonstrating care coordination efficacy. This study paves the way for future opportunities to evaluate what kinds of care coordination supports family need at varying times in their child's healthcare journey and how the outcomes important to all stakeholders are measured to reflect true evaluation of efficacy. Dispacal home , 11 haveCare coordination is one critical solution to addressing the substantial strain that children's unmet healthcare needs place on families, local communities, and the larger healthcare system . Care coThe concept of care coordination is often applied differently across various settings. To address this challenge, McAllister  developeResearch has explored the effectiveness of implementing various types of care plans and care coordination programs for children with special healthcare needs, largely in the setting of the medical home. Results of these studies have shown that care coordination has consistently led to improvements in family–professional partnership , 17 and McAllister and colleagues , 24 evalThe purpose of the current study was to implement McAllister's  SPoC modThis study was approved by the university Institutional Review Board. Participants were recruited from an outpatient interdisciplinary evaluation clinic at a large Midwestern children's hospital. This clinic is funded by the Maternal and Child Health Bureau's Leadership Education in Neurodevelopmental Disabilities (LEND) program. Children and adolescents, ages 2 through 20 years, are referred to this clinic by their community primary care provider or subspecialist for assessment of neurodevelopmental disabilities . The clinic is staffed by an interdisciplinary team of licensed professionals and trainees, including a developmental behavioral pediatrician, clinical psychologist, speech language pathologist, and licensed clinical social worker; an occupational and physical therapist, audiologist, dentist, and dietician are also available.All children and adolescents receiving neurodevelopmental evaluation in the LEND clinic from fall 2017 through summer 2018 were eligible for participation with the exception of the following exclusionary criteria: (1) children with caregivers who were not fluent in English language, (2) children who were in an unstable caregiving environment at the time of evaluation , and (3) children who were receiving care coordination services through an outside agency at the time of evaluation.A total of 105 children and adolescents were evaluated in this clinic during the study recruitment period. Fifty-four participants were assigned to the care coordination (CC) intervention, and 51 participants were assigned to receive CAU. The final descriptive care coordinator and quantitative caregiver report analysis included 17 participants in the CC group . Thirty-five participants in the CAU group were included in the final quantitative caregiver report analysis   via a quasi-random process. Specifically, children scheduled into two designated clinic slots per week were provided with the care coordination (CC) intervention, and children scheduled into the remaining two designated clinic spots were provided care as usual (CAU). Selection of clinic slots was based on availability and caregiver scheduling preferences; clinic schedulers and participants' caregivers had no knowledge of the study (including group assignment process) at the time of scheduling. However, the evaluation team (including care coordinator) was not blind to intervention group assignment or to the aims of the research study.An observational approach was utilized to gather descriptive data on family goals and care coordination activities, outcomes, and time spent on intervention implementation (as documented by the care coordinator) for those receiving CC. A quantitative repeated measures design was employed in order to compare caregiver-reported changes from evaluation (T1) to 4–6 months follow-up (T2) in unmet service needs, stress, and perceptions of empowerment related to the child's disability between those who received CC and those who received CAU.Together, the caregiver(s) and care coordinator set care coordination goals during the neurodevelopmental evaluation and throughout the intervention period. Each goal was coded by the care coordinator into one of seven categories: Getting Needed Interventions, Understanding the Diagnosis, Getting Needed Education Plan, Accessing Needed Healthcare, Complex Care Access/Communication, Family Quality of Life, and Meeting Basic Needs ?” and “Did child receive all the  he/she needed?” No known published psychometric data on this NS-CSHCN item set is available. Variables calculated included: total services needed, total services received, and percent unmet needs (sum unmet needs/sum needs).The PSI-4-SF is a 36-item measure of parenting stress. Items are scored on a five-point scale and grouped into three subscales: Parental Distress, Parent–Child Dysfunctional Interaction, and Difficult Child. A Total Stress score is also derived. PSI-4-SF T-scores were used for the current analysis. The PSI-4-SF has demonstrated strong psychometric properties , 28 and The FES is a 34-item rating scale developed to measure empowerment in families of children with disabilities. Items are scored on a five-point scale. Two subscales of the FES were included in this study: About Your Family  and About your Child's Services . The FES has demonstrated sound psychometric properties  and has McAllister's  Shared PPrior to a child's neurodevelopmental evaluation, the SPoC was prepopulated by an evaluation team member  with information obtained from medical and collateral records. This information was presented to the interdisciplinary team during a weekly meeting where the child's case was reviewed, and preplanning for potential care coordination needs occurred with cross-discipline input. The SPoC included (1) a Medical Summary detailing information about the child and family  spoken, family stressors, and preferences), significant developmental history, insurance and related healthcare financing programs, educational programs and supports, primary and specialty care providers, medical diagnoses and conditions, hospitalizations, surgeries and procedures, and family medical history, and (2) Family Goals with information detailing the action steps and overall plan for addressing identified unmet needs.During the evaluation, the care coordinator conducted a biopsychosocial interview with the child's caregiver(s) to establish rapport and trust, orient them to the process of care coordination, learn about the child and family, and identify unmet needs and develop initial care coordination goals. Goals were derived from needs identified by caregivers via a collaborative discussion between the child's caregivers and the care coordinator. Reflective listening, motivational interviewing, and solution-focused strategies were employed by the care coordinator during the interview, as well as during the follow-up period of active care coordination. Families received the SPoC with initial family goals as well as clinical recommendations and printed resources pertinent to the results of the neurodevelopmental evaluation at the conclusion of the evaluation.Caregiver(s) received an initial phone contact by the care coordinator within 2 weeks following their child's evaluation during which family goals were reviewed, amended, and prioritized, and action steps were set. The coordinator contacted the child's primary care provider's office to review the SPoC and results of the neurodevelopmental evaluation as well as communicate any requests for the PCP. Often this communication occurred between the care coordinator and a medical assistant or nurse at the PCP's office. While the primary care team was invited to provide feedback about the SPoC and make requests of the coordinator, often this contact resulted in the care coordinator educating the primary care team about how to meet the common needs of children with neurodevelopmental disabilities . When indicated, resources and educational materials specific to the needs of the individual child or general to individuals with neurodevelopmental disabilities were provided to the primary care team.The frequency and intensity of care coordination varied depending on family engagement and capacity, urgency of the unmet need(s), responsivity of the care neighborhood, and availability of needed services. Most contact with families and the care neighborhood was completed by phone, email, and fax, though some families did return to the hospital for other medical needs, and in-person meetings with the coordinator were conducted. The coordinator also worked with members of the child's neurodevelopmental evaluation team to gather clinical recommendations and information, as well as problem solve around barriers to meeting needs. The SPoC was updated by the care coordinator and disseminated to each family and their child's relevant care providers as goals were achieved, amended, and/or added.The care coordinator conducted a biopsychosocial interview with the child's caregivers during the course of the child's neurodevelopmental evaluation. Families were provided with the Medical Summary portion of the SPoC as well as clinical recommendations and printed information and resources relevant to the child's diagnosis at the conclusion of the evaluation. Caregivers were contacted by phone by a member of the study team within 3 weeks following their child's evaluation to answer any questions about the diagnosis or recommendations made during the evaluation. No further support was offered.On the day of each child's neurodevelopmental evaluation, caregivers were asked if they were interested in participating in a study about children's neurodevelopmental needs and services. If interested, they were provided with verbal information about the study as well as an IRB-approved Study Information Sheet detailing the study purpose, procedures , risks and benefits to participation, and participant reimbursement procedures. All participating caregivers, regardless of intervention group assignment, received a caregiver report survey  on the evaluation day (T1) as well as 4–6 months following their child's initial neurodevelopmental evaluation (T2). Surveys were completed via paper/pencil (and returned via paid envelope) or link to an individual, confidential online data collection tool . Participants received a $20 gift card for each completed survey.The care coordinator systematically documented information about provision of the care coordination intervention for each participant receiving this service  in a secure online research database throughout the data collection period . No information was documented by the care coordinator for those in the CAU group.t-test for continuous variables and Fisher's exact or chi-square test for categorical variables. A linear mixed model was employed to examine main effects and group by time interactions  for caregiver report measures. This model not only incorporated the correlation of repeated measures for the same participant but also accounted for missing values with the assumption of missing at random. Statistical analyses were performed in SAS version 9.4.For observational care coordinator report outcomes, descriptive statistics  were calculated. For the quantitative analysis, group differences in demographic variables were analyzed using a two-sample Together, families and the care coordinator generated a mean of 7.06 (SD = 4.62) goals during the care coordination period. Getting Needed Interventions (27.87%), Accessing Needed Healthcare (21.31%), Understanding the Diagnosis (21.31%), and Getting a Needed Education Plan (15.57%) accounted for over 85% of family goals. Improving Family Quality of Life accounted for 6.56% of goals, while Complex Care Access/Communication accounted for 4.10% and Meeting Basic Needs accounted for 3.28% of goals see .Together, Engagement (23.71%) and Education (22.00%) of the Family accounted for half of care coordination activities. Nearly 18% of activities focused on Research and Information Gathering (17.43%), while 16.86% of activities focused on Team Communication , 13.71% of activities focused on Identification of Needs and Goal Setting, and 6.29% of activities focused on Education of the Care Neighborhood see .n = 13), 53.80% (n = 7) of the children were enrolled in a needed service by T2. Seventy percent  of children were enrolled in one or more healthcare financing programs, and 11.8% of the children received safety resources  received formal psychoeducation or educational materials to support achievement of care coordination goals. Similarly, 76.50% of children were referred to one or more needed services and, of those children referred to a service  was spent in care coordination per child for the 4- to 6-month duration of the intervention. The most time-consuming care coordination activities were focused on goals related to Understanding the Diagnosis , Meeting Basic Needs , Complex Care Access/Communication , and Getting Needed Interventions . The care coordinator spent nearly 1 h in activities to support each of the other goal categories: Getting Needed Education Plan ; Family Quality of Life ; and Accessing Needed Healthcare  see .p-values are provided for comparisons of difference in change from T1 to T2 between CC and CAU groups.p > 0.05). Similarly, there were no significant group by time interactions for total number of services needed, F = 2.26, p = 0.14, total number of services received, F = 0.39, p = 0.53, or percentage unmet needs, F = 1.26, p = 0.28, as measured by the adapted NS-CSHCN Unmet Needs items. However, caregivers who received the CC intervention  reported an increase in services needed from T1 to T2 relative to those in CAU .There were no significant main effects for group or time for any of the three unmet needs outcome variables, including the total number of services needed, total number of services received, and percentage of unmet needs  = 4.96, p = 0.03, such that caregivers in both groups evidenced higher stress related to challenging interactions with their child at T2. No additional main effects of time or group were found for any other PSI-4-SF outcomes . There were no significant group by time interactions for any of the PSI-4-SF outcomes, including Parental Distress T-score, F = 0.91, p = 0.35, Parent–Child Dysfunctional Interaction T-score, F = 1.94, p = 0.17, Difficult Child subscales T-score, F = 0.61, p = 0.44, and Total Stress T-score, F = 1.41, p = 0.24.There was a significant main effect of time for PSI-4-SF Parent–Child Dysfunctional Interaction T-scores, F = 4.71, p = 0.04, indicating that all caregivers perceived an increase in knowledge and agency about the services their child received from T1 to T2. There were no additional significant main effects for time or group for other FES outcomes . There were no significant group by time interactions for FES outcomes, including About Your Family, F = 0.59, p = 0.45, and About Your Child's Services, F = 0.00, p = 0.95.There was a significant main effect of time for FES About Your Child's Services scores, Our objective was to integrate a model care coordination program into an interdisciplinary pediatric neurodevelopmental evaluation clinic and to (1) describe family goals and care coordinator reported activities, outcomes, and time spent implementing the care coordination intervention and (2) examine whether those provided with care coordination following McAllister's  Shared PResults of care coordinator report outcomes revealed that over 85% of family care coordination goals following neurodevelopmental evaluation focused on understanding the child's diagnosis, getting needed interventions and educational support, and accessing healthcare financing programs to support these needs. Despite the differential timing of when care coordination was initiated , our findings align with those of McAllister and colleagues  in that To our knowledge, this is the first study to measure care coordination activities and time spent for children with neurodevelopmental disabilities. Care coordination is a time-consuming intervention. While there was significant variability in time spent across families, likely related to family psychosocial complexity , on averall the needed services in that domain. As such, our care coordinator report data may have captured a broader range of services. Further, although a similarly adapted NS-CYSHCN item-set [e.g., . Although our neurodevelopmental clinic has a long history of building cross-sector partnerships that support care access for the families that we serve, the systems are overburdened and underresourced, and it is likely that local and regional services were often not available and/or waitlists for enrollment exceeded the 4- to 6-month follow-up period. It must be also considered that, even when provided referrals for needed services, not all families may be emotionally ready to seek recommended interventions immediately following their child's diagnosis. Moreover, similar to prior studies , 40, famWhile previous studies have shown that care coordination is associated with reduced caregiver worry , we did Care coordination aims to build caregiver capacity  to addreSeveral important limitations to the study warrant discussion. First, while the care coordinator had a high level of experience in delivering McAllister's  SPoC modIn conclusion, an emerging body of research has demonstrated the effectiveness of care coordination for a broad array of important family and health outcomes, including improvement in family–professional partnership and satisfaction, reduction in family time and financial burdens, reduction in unmet needs, and inappropriate use of the healthcare system. Despite these positive benefits, care coordination is a complex, time- and skill-intensive process for which measuring outcomes proves challenging. Our findings suggest that families of children with neurodevelopmental disabilities prioritize accessing and financing needed interventions. Yet, the activities of care coordination, at least immediately following initial neurodevelopmental evaluation, must largely focus on providing support and education to the child's family and care neighborhood before more directly measurable benefits may be realized. Four to 6 months is not long enough for most children with neurodevelopmental disabilities to access needed services in a geographic area with substantial service shortages. Further, it may not be enough time to support the reduction of caregiver stress and meaningfully bolster empowerment and advocacy skills. While care coordinator report findings further our understanding of the delivery of care coordination for children with neurodevelopmental disabilities, our caregiver report findings diverge from the emerging body of strong evidence for the efficacy of care coordination. However, we believe they pave the way for future opportunities to further evaluate what kinds of care coordination supports families need at varying times in their child's healthcare journey and how the outcomes important to all stakeholders are measured to reflect true evaluation of efficacy. Future studies should focus on the use of a randomized controlled trial design and development of sensitive tools to measure the outcomes important to all involved in the process: families, providers, and the systems that they operate within and across.mcnallyr@iu.edu).The data analyzed in this study are not publicly available due to Human Subjects protections. Requests to access the datasets should be directed to Rebecca McNally Keehn (The studies involving human participants were reviewed and approved by The Indiana University IRB. Patient's/participant's written informed consent to participate was not required for this study in accordance with institutional guidelines.RM and BE conceptualized and designed the study, contributed to designing the data collection instruments, data collection, analysis, and interpretation. MR contributed to designing the data collection instruments and data collection and interpretation. ZY and MG contributed to data analysis and interpretation. MC and AC provided critical intellectual feedback at all stages of the study. All authors reviewed and revised the manuscript for important intellectual content, approved the final manuscript, and agreed to be accountable for all aspects of the work.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.


MSTN gene and to analyze effects of the detected alleles/genotypes on growth and carcass traits in Colored Polish Merino sheep. In total, 23 traits were analyzed, i.e., seven describing lamb growth and 16 carcass traits. Single nucleotide polymorphisms (SNPs) in the first intron and the c.*1232 position were identified using polymerase chain reaction single-strand conformation polymorphism (PCR-SSCP) and PCR-restriction fragment length polymorphism (PCR-RFLP) methods, respectively. The MIXED procedure of the SAS software package was used to analyze allelic and genotypic effects of the MSTN gene on growth and carcass traits. Polymorphisms were only detected in the first intron of the MSTN gene. All investigated sheep were monomorphic G in the c.*1232 position. The MSTN genotype was found to have significant effect on body weight at 2nd day of life (BW2) and loin and fore shank weights. Significant allelic effects were detected with respect to BW2, scrag, leg, fore, and hind shank weights. These results suggest that polymorphisms in the first intron of the MSTN gene are relevant with respect to several carcass traits and BW2 in Colored Polish Merino sheep.Myostatin acts as a negative regulator of muscle growth; therefore, its role is important with regard to animal growth and meat production. This study was undertaken with the objective to detect polymorphisms in the first intron and c.*1232 position of the  Constant improvement of lamb growth and meat yield of lamb carcasses is of high interest for sheep breeders due to direct benefits from breeding of faster growing animals with higher final body weight as well as carcass weight. Nowadays, sheep breeding is supported by various molecular genetics tools. One of them is a marker-assisted selection, which seems to be convenient choice, especially for less numerous indigenous sheep populations. This relatively cheap approach has a potential to increase rates of genetic gain for certain growth and carcass traits in different sheep populations.Among many genes, which are involved in animal growth and which affect final carcass weight, the one coding for myostatin is an excellent candidate for the marker-assisted selection due to its crucial role in muscle development and growth. Indeed, myostatin, being a member of the transforming growth factor-β super-family, acts as a negative regulator of muscle growth. This protein is a homodimer, which is primary synthesized in skeletal muscle as a 375-amino acid propeptide. Subsequently, this propeptide is proteolytically processed at the RSRR 263) site to give rise to a 26-kDa active processed peptide, which binds to receptor to elicit biological function ,2.63 site tMSTN) is expressed both in developing and adult skeletal muscles. It is located on the second chromosome in sheep and consists of three coding exons. Whole gene length is 6757 bps (GenBank no NC_040253.1), whereas transcript consists of 1128 bps and codes for a protein with 375 amino acids in its final configuration [MSTN gene, inhibits production of mature, functional myostatin leading to increase in muscle mass caused by enhanced muscle development [MSTN gene only in Norwegian White sheep, which resulted in completely non-functional protein. Additionally, Boman and Våge [MSTN gene was identified in two Indian sheep breeds [The myostatin gene  family, critical for many aspects of animal morphogenesis .MSTN gene, very limited number of association studies between these polymorphisms and growth as well as carcass traits in sheep have been undertaken. The majority of studies have focused on the G/A substitution in the 3′UTR region (c.*1232); however, this substitution has not been found in Merino sheep [MSTN gene and to estimate their effects on growth and carcass traits in Colored Polish Merino sheep. The presence/absence of the G/A transition in the c.*1232 position of this gene was also investigated. With respect to carcass traits, the novelty in this study was the first extensive analysis of allelic and genotypic effects in the first intron of MSTN gene on lamb carcass traits, involving weights of 10 different meat cuts, weights of 3 parts of a carcass as well as tissue composition of a leg. The importance of this study lies also in comprehensive analysis of association between polymorphisms in the first intron of the MSTN and growth traits in Merino sheep based on first results obtained in Colored Polish Merino sheep.Despite the abovementioned potential significant functionality of the SNPs located in the first intron of the no sheep ,15 despino sheep . For thiThe studies were carried out on 264 purebred Colored Polish Merino lambs of both sexes, which were produced over three experimental years on a farm owned by the National Research Institute of Animal Production (NRIAP) Experimental Station Kołuda Wielka (Poland). Lambs were sired by nine different rams. Each sire was used for breeding during two or three experimental years. Sheep were raised indoors and at the pasture, where they grazed six times a week. Suckling lambs were fed dry, granulated mash and a meadow hay ad libitum.The Colored Polish Merino is a variety of the Polish Merino sheep breed, which was produced by selecting the Polish Merino sheep for colored wool. Similarly to the Polish Merino sheep, the Colored Polish Merino sheep are used both for their meat and wool. Adult ewes and rams weight on average 55–65 kg and 80–100 kg, respectively . ProlifiAll procedures that involved animals were approved by the Local Animal Research Ethics Committee and the Local Veterinary Service.Growth data regarding body weights at second (BW2), 30th (BW30), 56th (BW56), and 78th (BW78) day of life were collected for 264 male and female lambs. Based on these data the average daily gains between second and 30th (ADG2-30), 30th and 56th (ADG30-56), as well as 56th and 78th (ADG56-78) were calculated for each individual under investigation. Moreover, birth rank and sex were recorded for each lamb at birth.In total, 106 ram lambs at mean age 105 days  were chosen for slaughter during the three years of the study. Slaughtering, carcass cutting, and leg dissection were done in the abattoir of the NRIAP Experimental Station Kołuda Wielka as described previously by Grochowska et al. ,24 accorMSTN gene polymorphisms were performed on 264 sheep as described previously by Grochowska et al. [TM DNA Purification Kit for Blood Version II . Polymorphisms in the first intron as well as the c.*1232 position, that is located in the 3′UTR region, of the MSTN gene were analyzed. Genotypes in the first intron were identified using the PCR-SSCP method according to the methodology of Hickford et al. [®  and sequenced in both directions in Genomed, Poland. Moreover, the A/G substitution at the c.*1232 position of the ovine MSTN gene was detected using PCR-RFLP method as presented by Clop et al. [DNA extraction and the identification of the a et al. . Brieflyd et al.  with latd et al. . Thereafp et al.  with latp et al. .http://bioinfo.life.hust.edu.cn/AnimalTFDB/) [MSTN gene in sheep.The AnimalTFDB (version v3.0)   was usedMSTN locus were calculated. Moreover, the observed and expected heterozygosity as well as the Hardy–Weinberg equilibrium test calculations were performed in Arlequin 3.5.1.2 [Allele and genotype frequencies in the  3.5.1.2 .MSTN genotypes or a number of copies of a certain MSTN allele on growth traits were estimated using the MIXED procedure. The following mixed-effect model was applied:ijkl is the performance of the nth individual lamb for each trait of interest, μ is the general mean for each trait of interest, ai is the fixed effect of the ith MSTN genotype  or the fixed effect of the ith number of copies of a certain MSTN allele , bj is the fixed effect of the jth litter size (j = 1 (single), 2 (twin)), ck is the fixed effect of the kth year of observation , dl is the fixed effect of the lth sex , fm is the random effect of the mth sire , and eijklm is the random error.SAS software package  . With regard to carcass traits, which were recorded for male lambs, only two genotypes excided the sample size of 10, i.e., MSTN-A/MSTN-A and MSTN-A/MSTN-E. Effects of a number of copies of a certain MSTN allele on growth traits were estimated separately for each of four alleles , which fulfilled the criterium of minimal sample size (n = 10). With respect to carcass traits only three alleles, i.e., MSTN-A, MSTN-E, and MSTN-E1 reached the sample size of at least n = 10; therefore, allelic effects were tested only for them.Analyses of relationships between the MSTN gene revealed four alleles, i.e., MSTN-A, MSTN-C, MSTN-E, and MSTN-E1, and four genotypes , whereas the MSTN-C allele occurred with the lowest frequency of 2.3%. Consequently, the MSTN-A/MSTN-A homozygotes were the most frequent (75.4%) individuals in the investigated flock, while MSTN-A/MSTN-C sheep were the rarest ones (4.5%). With the regard to polymorphisms in the first intron of the MSTN gene, the value of observed heterozygosity (Ho = 0.25) was found to be slightly higher than the value of expected heterozygosity (He = 0.23). The population was in the Hardy–Weinberg equilibrium (p = 0.83).In the studied Colored Polish Merino sheep, the SSCP analysis of polymorphisms in the first intron of the enotypes , which wMSTN gene . The MSTN-A/MSTN-E1 heterozygous lambs were on average 10% heavier than homozygotes MSTN-A/MSTN-A. With regard to BW2 it was found that this difference was due to effect the MSTN-E1 allele, but was not related with the number of copies of the MSTN-A allele. The presence of the MSTN-E1 allele was highly significantly related (p = 0.006) with higher BW2, whereas the MSTN-A allele was not associated with this trait . MSTN-A/MSTN-E lambs had 6.2% heavier fore shank cuts when compared with MSTN-A/MSTN-A (p = 0.005) effect of a number of copies of the MSTN-A allele, whereas animals carrying one copy of this allele had heavier fore shank cut (3.9%) than those ones with two copies. In contrast, the presence of the MSTN-E allele in the lamb genotype resulted in highly significantly (p = 0.009) higher fore shank weight when compared with counterparts without this allelomorph  when compared with lambs without this allele  on economically important traits in lamb production, i.e., growth traits and meat cuts weights. To our knowledge, it is the first so extensive study of the associations between polymorphism in the first intron of the MSTN gene and growth traits as well as meat cuts weights in a merino sheep breed not only in Europe, but also worldwide. The better understanding of the impact of polymorphisms in the first intron of the MSTN gene on growth and carcass, especially in sheep breeds lacking G/A transition in the c.*1232 position, is of high interest due to its potential effect on lamb production. Importantly, significant associations between alleles and/or genotypes in this region of the MSTN gene and growth as well as carcass traits, could offer the potential to improve meat production in sheep breeds without beforementioned substitution in the 3′UTR region.In this study we presented allelic and genotypic effects of the MSTN gene polymorphisms, together with analyses performed by Kijas et al. [MSTN gene. Other authors, e.g., [MSTN gene was highly polymorphic in different sheep breeds. Indeed, we confirmed these observations in Colored Polish Merino sheep in our present and previous study [MSTN gene [MSTN gene, i.e., the first intron, could have functionality as regulatory elements. For instance, the G nucleotide in the c.373+18 position, which is only present in the MSTN-A allele in Colored Polish Merino sheep, initiates processes that could potentially increase the transcription and splicing efficiency of the c.373+18G sequence variant compared to the c.373+18T alleles . Consequently, Sjakste et al. [MSTN-E1 allele [MSTN-C allele have cytosine in the c.373+323. Sjakste et al. [HOX) family. SMAD proteins are involved in muscle mass regulation in adulthood [HOX) family is critical for many aspects of animal morphogenesis  generates new GATA1 site on the plus strand and controls the affinity to the nonspecific transcriptional activator of the GATA family involved in muscle growth regulation [Our present and previous  study ofs et al. , showed s, e.g., ,14,17,18us study  detectinSTN gene . Interes1 allele , creates1 allele  as well 1 allele , could pdulthood . The MEIiewed by ). On thegulation .MSTN-A allele and consequently the MSTN-A/MSTN-A genotype were the most frequent ones in Colored Polish Merino sheep. We reported similar results in our previous study [MSTN gene in a Merino sheep; therefore, it is hard to compare them with other studies in Merino sheep worldwide. Only Hickford et al. [In the preset study, the us study . To our d et al.  reportedd et al. , Gan et d et al. , Trukhacd et al. ,32 proviMSTN-A allele (51.1%) in Kamieniec sheep breed and higher occurrence of this allele in Pomeranian sheep breed in Poland [MSTN-B allele, not detected in the preset study, occurred with the frequency of 46.5%. On the other hand, Farhadian et al. [MSTN gene is polymorphic, whereas both the number of alleles/haplotypes as well as their frequencies vary with respect to sheep breed, its purpose, and region of an origin. Moreover, breeding history together with genetic background of the breed play important roles in modulating the polymorphism in the first intron of the MSTN gene. Considering the fact, that a great number of sheep breeds from all around the world have not been investigated in terms of polymorphism in the first intron of the MSTN gene, information about nucleotide variations in this part of the MSTN gene in different sheep breeds all around the world could be very valuable.With respect to the first intron, we observed considerably lower frequency of the n Poland  as compan et al.  observedMSTN-A/MSTN-E1 heterozygous lambs were significantly heavier on the second day of life than MSTN-A/MSTN-A homozygotes. Subsequent analysis of the allelic effect showed that this difference was due to effect of the MSTN-E1 allele. Similarly, Farhadian et al. [MSTN gene on birth weight, but not on other growth traits, in Iranian Makoei sheep. Additionally, our previous results showed both genotypic and/or allelic effects of the MSTN intronic polymorphisms on several carcass and meat quality traits in Colored Polish Merino sheep [MSTN gene and growth traits in New Zealand Romney sheep.Myostatin acts as a negative regulator of muscle growth. Growth traits are of great interest for breeders because they influence the profit form lamb production. It is well known, that polymorphisms in non-coding regions can have a significant effect on a regulation of the gene expression. Therefore, they can finally affect a phenotype. Indeed, in the current study we showed effect of intronic polymorphisms on one out of seven analyzed growth traits, i.e., BW2. We found that n et al.  found thno sheep  as well no sheep . In contno sheep  did not MSTN gene than the first intron [MSTN gene; however, they did not find any relationships between these nucleotide substitutions and several lamb growth traits, e.g., birth weight, in different sheep breeds. These results partially correspond with findings of Masri et al. [MSTN gene (c.-2379) and birth, tailing and weaning weights. Moreover, Han et al. [MSTN gene and they observed highly significant (p = 0.006) and significant (p = 0.02) effects of the H1 haplotype on tailing weigh (approximately 3 weeks after birth) and growth rate to weaning, respectively.Several authors have also focused on the effects of nucleotide variations in other non-coding regions of the t intron ,35,36,37t intron ,10 on grt intron  analyzedi et al. , who alsi et al. . Moreovei et al.  found asMSTN [MSTN gene (rs417816017) and several growth traits, among them birth weight, in Tan sheep. Boman et al. [MSTN gene (c.960delG) on weaning weight and live weight gain in Norwegian White Sheep. Ranjan et al. [MSTN gene with body weights in 9 and 12 months old Madras Red sheep, whereas birth weight was not affected by this SNP.SNPs in coding regions are even of higher interest than those ones in non-coding fragments of the gene due to their direct effects on the structure of a protein. According to Ensembl database there are 8 SNPs in coding region of the ovine MSTN   counterparts (using CRISPR/Cas9 technology), did not find evidence on the effect of the myostatin gene on prenatal lamb growth. They observed that homozygous MSTN KO lambs were not significantly different than WT animals in terms of body weight at birth. Moreover, conversely to our results Crispo et al. [MSTN KO lambs in postnatal growth and development. Results of Crispo et al. [MSTN gene on birth weight. Conversely, several authors, e.g., [MSTN gene polymorphisms on postnatal growth. In the MSTN KO lambs the myostatin is completely inactive; therefore, the effects are more profound when compared them to lambs with different MSTN genotypes. Lambs having the MSTN gene in their genomes differ in terms of genotype in the locus of this gene and the differences between genotype groups are often not significant due to functions of other gene fragments, which simultaneously play a role in gene function and expression.As mentioned before, in the present study the s et al.  and Shors et al.  observedo et al. , who stuo et al.  and Li eo et al.  showed so et al.  are witho et al. ,16,34, ws, e.g., ,38, did MSTN gene polymorphisms on growth traits vary on type of polymorphism and sheep breed. Like many other production traits, growth characteristics belong to complex traits, which are affected by polygenes as well as environmental factors. Consequently, different results of association analyses obtained for certain sheep breeds are probably due to divergent genetic background of the breeds of interests, which may affect the magnitude and, perhaps, even the mode of action of the MSTN gene effects on lamb growth [MSTN gene on lamb growth. Moreover, different results of the aforementioned association analyses are probably caused by differences in the MSTN gene polymorphism as well as in allele/haplotype frequencies between investigated sheep breeds in the present study as well as studies of other authors.Taking into consideration both our results and those reported by other authors, it could be concluded that the effect of the b growth . AdditioMSTN gene are associated with the meatiness and fatness of lambs . ,24. MSTNMSTN-A/MSTN-A homozygous lambs had 6.6% higher weight of one of the most valuable cuts, i.e., loin. Despite the fact that the effect of this genotype was not very large, on average 32 g, with regard to the weight of whole carcass, it could be relevant for a breeder in terms of profit from lamb production when considering a whole flock. As it is the first report on the association between alleles and genotypes in the first intron of the MSTN gene and lamb carcass cuts weighs both in Merino sheep and European sheep, it is hard to compare our results with those of other authors. To our knowledge only Hickford et al. [MSTN gene and yields of three lamb carcass cuts, i.e., leg, loin and shoulder; however, the research was performed in New Zealand on Romney sheep. Despite the fact that Hickford et al. [MSTN-A allele; see [MSTN gene haplotypes and various carcass traits, showed that the presence of the H1 haplotype increased yields of such as valuable cuts as loin and leg as well as total yield. The H1 haplotype is similar to the MSTN-A allele detected in present study. Interestingly, Han et al. [MSTN-A allele from our current study  on leg ele; see  observedele; see , who invn et al.  reportedudy (see ) in termA allele ,24. ThesMSTN-A/MSTN-E heterozygotes had significantly heavier fore shank cuts (6.2%). Subsequent analysis of the effect of the presence or the absence of certain MSTN alleles, showed that this increase was due to effect the MSTN-E allelic variant, because the occurrence of both additional copy of the MSTN-A allele or one copy of the MSTN-E1 allele in the genotype of a lamb caused reduction in fore shank cut weight. Furthermore, we also found, that additional copy of MSTN-A was not advantageous in terms of its effect on weight of scrag and leg weight, whereas hind shank weight were higher due to the effect of the MSTN-E allele. Since other authors have performed their analyses on different lamb cuts  ater alia ,34,38), ter alia ,38). Forter alia , who invter alia  analyzedter alia . Complexter alia , who invs et al.  did not MSTN gene are associated with increased muscle mass and decreased fatness [MSTN gene on selected growth and slaughter traits in the Colored Polish Merino, the sheep breed, which is monomorphic in the c.*1232 position. A total of 7 growth and 16 carcass traits were investigated. The novelty in the present study was that 10 different meat cuts were separately subjected to association analysis. Significant genotypic effects of the polymorphisms in the first intron of the MSTN gene were found for BW2, loin and fore shank weights. Moreover, the MSTN alleles in the first intron of this gene significantly affected BW2, scrag, leg, fore and hind shank weights. Obtained results suggest that polymorphisms in the first intron of the MSTN gene are associated with abovementioned carcass traits and BW2 in Colored Polish Merino sheep; therefore, may be considered as genetic marker of carcass traits in this breed. Our results provide a foundation for further analysis of polymorphisms and association analyses of the MSTN gene with production traits as well gene expression study both in Merino and other sheep breeds worldwide, which regardless of monomorphism in the c.*1232 position, exhibit phenotypic variance in carcass traits.Polymorphisms in the  fatness ,15; ther


Personality traits are relevant in understanding substance use disorders (SUD) and schizophrenia (SZ), but few works have also included patients with dual schizophrenia (SZ+) and personality traits. We explored personality profile in a sample of 165 male patients under treatment, using the Temperament and Character Inventory-Revised. The participants were assigned to three groups of 55 patients each, according to previous diagnosis: SUD, SZ- and SZ+ (without/with SUD). We analyzed their clinical characteristics, relating them to personality dimensions. The SUD and SZ+ groups scored higher than SZ- in Novelty/Sensation Seeking. SZ- and SZ+ presented higher Harm Avoidance and lower Persistence than the SUD group. SZ+ patients showed the lowest levels of Self-directedness, while SZ- and SZ+ had higher scores in Self-transcendence than the SUD group. Several clinical characteristics were associated with personality dimensions depending on diagnosis, and remarkably so for psychiatric symptoms in the SZ- and SZ+ groups. The three groups had a maladaptive personality profile compared to general population. Our results point to different profiles for SUD versus SZ, while both profiles appear combined in the SZ+ group, with extreme scores in some traits. Thus, considering personality endophenotypes in SZ+ could help in designing individualized interventions for this group.  Personality can be broadly defined as the pattern of a person’s thoughts, behaviors, and feelings in different contexts throughout their life. From a dimensional perspective, some research supports the existence of a series of features that follow a normal distribution along a continuum, whose extremes would imply some vulnerability for the development of psychopathology . StudyinOn the other hand, substance use disorders (SUD) constitute a public health problem given their high prevalence and consequences on individuals, their environment, and society as a whole . SchizopAlthough much of the research on personality in DD has followed a categorical perspective in the analysis of relationships between personality disorders and SUD ,20, studFurthermore, the evidence points to some personality traits acting as endophenotypes or risk factors for SUD development, the most relevant being Impulsivity ,33 and NResearch on personality has also highlighted the existence of possible endophenotypes for SZ, with Harm Avoidance, measured using Cloninger’s model, receiving the most attention ,48. SomeThe scarce data published on SZ+ patients suggest that they have a character and temperament profile different from that observed in other groups with DD ,30. In sWe consider that research on personality traits and possible behavioral endophenotypes is of special interest, since such knowledge can improve the design of strategies aimed at prevention as well as personalized interventions. For this reason, we decided to investigate the possible differences in temperament and character profiles among groups of SUD, SZ+, and SZ- patients under treatment, following Cloninger’s psychobiological model, and then compared them with the corresponding normative data. In addition, we analyzed whether personality traits are associated with some clinical characteristics of these disorders. To our knowledge, this is the first work focused on studying the temperament and character profile in these three diagnostic groups, and one of the few that also analyzes their personality profile.The total sample of our study consisted of 165 patients, all of them males, assigned to three groups of 55 patients each, according to their previous diagnosis. All the participants were under treatment in different public or private centers in the province of Barcelona . In the SUD and SZ+ groups, abstinence was verified by urinalysis in the referral centers.The inclusion criteria were: (1) male sex ; (2) aged 18 to 55; (3) under treatment and stabilized; (4) with a SUD diagnosis in initial remission for the SUD and SZ+ groups, according to Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria ; (5) witFirst, the reference professionals from the collaborating centers screened those patients who met our inclusion criteria. Then, we contacted each participant, provided more detailed information, and obtained their informed and signed consent. Participation in the study was voluntary, and the only compensation the participants received was an individualized return of their results. The Research Committee of the University of Barcelona approved our study (IRB00003099), which complied with the ethical principles of the Declaration of Helsinki . A psychad hoc structured interview, in order to collect data regarding age, marital status, cohabitation, educational level, and employment situation, among others. In addition, through contact with the reference professionals in each center, we obtained information on the diagnoses, age of onset, family psychiatric history, suicide attempts, medical comorbidities, and relevant prescribed medication (the doses of antipsychotic drugs were converted to milligrams of chlorpromazine). Regarding substance use, we recorded the quantity and type of substances consumed, period of abstinence, and number of previous relapses. In addition, we administered the Structured Clinical Interview (SCID-I) for the DSM-IV [For our study, we designed an e DSM-IV  to confie DSM-IV  to assesWe used the Spanish version of the Positive and Negative Syndrome Scale (PANSS)  to assesWe administered the Temperament and Character Inventory-Revised (TCI-R) , based oMain descriptive data  were obtained for all the measured variables. For the clinical and sociodemographic data, we explored possible differences among the three groups with univariate analyses of variance (ANOVA) for continuous data, and with Kruskal-Wallis tests for non-continuous or categorical data. When the variables affected only two groups (data relating to SZ or SUD diagnoses), we applied the Student´s t-test (t) if the quantitative data fulfilled the necessary conditions; otherwise, we used the Mann-Whitney U test. Chi-Square contrast was applied for categorical variables. Regarding internal consistency, we calculated Cronbach´s alpha coefficient for the seven TCI-R dimensions. pη2) statistic was used to measure the effect size, with the cut-off points being 0.01 , 0.06 (moderate), and 0.14 (large) [p ≤ 0.05) found in the previous bivariate correlation analysis performed between each TCI-R dimension and the clinical data.We also performed multivariate analyses of covariance (MANCOVA), introducing the TCI-R dimensions as dependent variables, the group as independent variable, and age as a covariate, since it could act a confounding factor . Post ho (large) . FinallyAll the data were analyzed using the SPSS software  for Windows, version 25, and tests were two-tailed with the type I error set at 5%. p = 0.013). In the SUD group, a higher proportion of patients were married or had a stable partner. Furthermore, this group presented a higher proportion of working patients than the other two groups (p ≤ 0.010 in both cases). p ≤ 0.031 in both cases). No differences were observed in the number of comorbid organic pathologies.Regarding the clinical data in p = 0.011), with no differences among the rest of the contrasts, although the SUD group had the lowest rate of previous suicide attempts. Furthermore, the SUD group presented a higher GAF than the two groups with SZ (p < 0.001 in both cases). Regarding medication, the SUD group had fewer prescribed drugs compared to the other two groups (p < 0.001 in both cases), with no differences between the groups with SZ. When we analyzed the prescription of antipsychotic drugs, no patient in the SUD group had received typical antipsychotics, and only 3.6% of these patients had received atypical antipsychotics. Thus, we found differences in the type of antipsychotic drug prescribed between the SUD group and the two groups with SZ , while there were no differences between the SZ+ and SZ- groups. However, when we looked at the doses of antipsychotics converted to milligrams of chlorpromazine , the SZ- group had been prescribed almost twice as many milligrams than the SZ+ group (p < 0.001). In the SZ+ group, there were more participants who had been prescribed an interdictory drug compared to the SUD group (p = 0.049).The SZ+ group presented a higher number of suicide attempts than the SUD group (p = 0.004). Considering the clinical characteristics of SZ, we found no differences between groups in age of onset or duration of the disorder. We also found no differences in positive or negative symptoms measured with the PANSS, but the SZ+ group had a higher score than the SZ- group on the general psychopathology scale (p = 0.019), as well as a longer duration of the disorder (p = 0.049). Furthermore, the SZ+ group had consumed a greater number of substances on average (p = 0.033), but we found no differences in the main type of substance, with a majority of polyconsumers in both groups. Most of the participants had been cocaine and alcohol users, with no differences found between the SUD and SZ+ groups. Neither did we find differences in the consumption of hallucinogens or opioids, although in both cases the rates were higher in the SZ+ group. In contrast, use of cannabis (p = 0.010), and of hypnotics and anxiolytics (p = 0.008), were higher in the SZ+ group compared to the SUD group. We also found no difference in abstinence time or severity of addiction. Finally, the SZ+ group presented a greater number of previous relapses than the SUD group (p = 0.002).With respect to the clinical characteristics of SUD, we observed that the SZ+ group presented an earlier onset of the disorder with respect to the SUD group (p ≤ 0.001 in both cases). In contrast, the two groups with SZ (SZ+ and SZ-) obtained higher scores in Harm Avoidance (p < 0.001 in both cases) and lower Persistence scores (p ≤ 0.024 in both cases) with respect to the SUD group.p < 0.001 in both cases). Finally, the two groups with SZ presented higher scores in Self-transcendence compared to the SUD group (p ≤ 0.002 in both cases). For the Character dimensions, the MANCOVA contributed differences in Self-directedness and Self-transcendence. Post hoc contrasts showed a lower score for Self-directedness in the SZ+ group compared to the other two groups  = 9.227; p = 0.004), while the GAF was positively linked to Reward Dependence, and explained 24.9% of the variance  = 18.885; p < 0.001). Regarding the SZ+ group, general psychopathology (PANSS) was positively associated to Harm Avoidance, accounting for 11.7% of the variance  = 6.156; p = 0.018). Abstinence period measured in months (p = 0.015) was positively related to Self-directedness, whereas general psychopathology (PANSS) (p = 0.028) was negatively linked to this dimension, and both of them accounted for 31.3% for the variance  = 9.867; p < 0.001) in Self-directedness. Likewise, 28.2% of the variance  = 8.058; p < 0.001) in Cooperativeness was explained by number of relapses (p = 0.001), which were negatively related, duration of SZ (measured in years) (p = 0.005) and onset age of SUD (p = 0.036), which were positively related to Cooperativeness in this group. In addition, positive symptoms (PANSS) were positively associated to Self-transcendence and accounted for 8.4% of the variance  = 4.554; p = 0.039). Finally, for the SZ- group, positive symptoms (PANSS) were positively related to Harm Avoidance and explained 9.1% of the variance  = 5.096; p = 0.019). Similarly, 18.7% of the variance  = 6.627; p = 0.003) in Reward Dependence was explained by the GAF (p = 0.008) and the PANSS negative symptoms (p = 0.032). The former was positively associated to Reward dependence, whereas the latter was negatively associated. General psychopathology was negatively linked both to Self-directedness, and explained 16.1% of the variance  = 10.37; p = 0.002), and to Cooperativeness, accounting for 22.8% of the variance in this dimension  = 15.473; p < 0.001). General psychopathology was also positively related to Self-transcendence, explaining 11.7% of the variance  = 11.569; p = 0.001). Our work focused on studying the temperament and character profile of patients with SZ+, SZ- and SUD, comparing them among themselves as well as with respect to the normative reference data, in order to elucidate the existence of a possible endophenotype of SZ+. Furthermore, we tried to study the possible associations among personality traits and the clinical characteristics of each diagnosis.Regarding the clinical and sociodemographic characteristics, our results are in line with the data provided by previous works analyzing similar groups of patients ,63,64. TThe two groups with consumption presented more family history of SUD, which is consistent with the idea that such history is a risk factor for developing an addiction . This reRegarding personality results, patients in the groups with consumption (SUD and SZ+) showed a greater tendency to present intense responses to novel stimuli, as well as to respond impulsively and to try to avoid monotony and routine (higher Novelty Seeking), compared with the SZ- group and with population data. This is consistent with the data pointing at Novelty/Sensation Seeking as a possible risk factor for addiction ,68, regaGroup members diagnosed with SZ tended to experience negative affect frequently, be pessimistic, have multiple concerns, and some behavioral inhibition (high Harm Avoidance). In line with that observed in other studies, which point to Harm Avoidance as a possible endophenotype for SZ ,48, patiIn addition, the three groups were characterized as being less sentimental and more solitary and resistant to social pressure, compared to population data (lower Reward Dependence). This trend was especially marked in the SZ+ group, while the SUD group was more similar to the general population, although there were no differences among the groups in direct scores. These data are consistent with those provided by previous studies, especially regarding the groups with SZ ,70. In tRegarding the Character dimensions, and in line with previous studies ,44,70, tMoreover, the three groups showed difficulties in adapting to society, a tendency to ignore other people’s needs, and to show little or no interest in social relations (low Cooperativeness) ,46,48. TFinally, according to previous data ,30,31, tTaken as a whole, our results support the idea that there is a character and temperament profile more associated with SUD, and a different one more associated with SZ, and that both differ from the profile reflected by the population data. Thus, patients with SZ would present a specific profile ,31 charaThis study has some strengths and limitations. One of the strengths is having studied these three groups of patients, thus allowing us to overcome the limitation of extrapolating data on patients with SZ+ from patients with SUD, on the one hand, and with SZ- on the other. Furthermore, we consider that the sample is representative of consuming patients, since the main pattern was that of poly-consumption, both with SZ and without psychiatric comorbidity. However, this point may also be a limitation, as it does not allow us to study the differential effects of each substance, nor study if certain personality profiles are associated with the consumption of a specific substance. In this sense, we consider it of special interest to explore further the possible implications of cannabis consumption, which was the largest in the SZ+ group. Moreover, our results are only generalizable to persons with a SUD diagnosis in initial remission, and we have not controlled for the possible effect of time of abstinence. Additionally, the fact that it is a multicenter study confers some external validity to our results. The fact that the sample is made up only of men means that the differences found are not due to sex but, in turn, does not allow us to generalize the results to the female population. This may be a future line of research, despite the greater difficulty of obtaining women undergoing treatment for SUD (around 20%). Furthermore, the study of personality traits has the specific limitations of self-reported measurements. Finally, the cross-sectional and retrospective design does not allow us to establish causal relationships or determine to what extent the results observed in personality traits reflect the effects of treatment. This aspect is of special relevance in the study of personality traits, since, as it has been already commented, several works point to the possibility that these traits may be endophenotypes for SUD and/or SZ. In this sense, we think that it is necessary to carry out longitudinal studies in order to study these aspects in greater depth.To the best of our knowledge, this is the first work to study the temperament and character profiles of these three groups of patients, and to relate these dimensions to clinical characteristics of interest. In addition, it allows exploring the specific weight of the characteristics of each of the disorders (SUD and SZ) in SZ+.The three diagnostic groups presented a different profile from that observed in the general population, with more maladaptive personality characteristics. Our results support the idea of the existence of a personality profile associated with SUD, a different one associated with SZ, and both emerging in combination in the SZ+ group. Thus, the groups with consumption issues presented higher scores in Novelty Seeking, while the groups with SZ presented higher scores in Harm Avoidance and Self-transcendence. In addition, the SZ+ group presented a character and temperament profile with more extreme scores. Regarding the therapeutic approach for these patients, it could be useful to work on their self-esteem, providing specific resources so that they feel capable of taking responsibility for their behavior, implementing strategies to improve their social skills, empathy and collaboration, and working on the interpretation of psychotic symptoms and the content of thoughts. On the other hand, the association of certain personality traits with clinical characteristics  seems to us of special relevance based on the diagnosis, and we consider it a promising line of research, given its clinical applicability. Thus, future studies that overcome the limitations of this work could provide data of great interest in order to design personalized prevention and treatment strategies.


For sFC, compared with SI– and HC groups, SI+ group showed decreased sFC from habenula to the precuneus and the inferior frontal gyrus. Patients with MDD displayed increased sFC from habenula to the putamen but decreased sFC to the precentral gyrus. For dFC, SI+ group showed increased dFC from habenula to the superior temporal gyrus, the precuneus, but decreased dFC to the lingual gyrus, the postcentral gyrus, when comparing with SI– and HC groups. Patients with MDD, regardless of SI, displayed decreased dFC from the habenula to the angular gyrus. These findings provide evidence that SI in first-episode, drug-naïve patients with MDD may be related to an abnormality in habenula neural circuitry, which may provide the theoretical basis of novel treatments.Investigating the neurobiological mechanism of suicidal ideation (SI) in major depressive disorder (MDD) may be beneficial to prevent the suicidal behavior. Mounting evidence showed that habenula contributed to the etiology of MDD. The habenula is a key brain region that links the forebrain to midbrain, crucial for the processing of reward and aversion. The aim of the present study was to identify whether first-episode, drug-naive MDD patients with SI displayed altered habenula neural circuitry. Forty-three and 38 drug-naïve patients with first-episode MDD with or without SI (SI+/– group) and 35 healthy control subjects (HC) underwent resting-state functional magnetic resonance imaging. The whole-brain habenula static (sFC) and dynamic functional connectivity (dFC) were calculated to identify regions showing significant difference among these three groups followed by region of interest to region of interest  Major depressive disorder (MDD) is a leading cause of global disease burden and disability, which is not only associated with severe mental and physical disabilities in individuals but also carries a high risk of suicide , 2. SuicNeurobiology mechanisms of SI are closely related to abnormal levels of monoamine metabolites in the brain , 8. The A growing body of evidence suggests that the habenula is involved in the pathophysiological mechanisms of a variety of psychiatric disorders, especially MDD , 18. To Functional magnetic resonance imaging (fMRI) based on the blood-oxygen-level-dependent (BOLD) signal is widely used to record the neural activity in the brain . More inTaken together, the present study addressed these knowledge gaps by comparing sFC and dFC of the habenula in a sample of first-episode, drug-naive MDD patients, with and without SI, and healthy control subjects. We hypothesized that, compared to MDD patients without SI and healthy control participants, those with SI would generally exhibit weaker correlational strength and less dynamic variability in correlations from the habenula to other brain regions over time, particularly in regions involved in cognitive and emotional processing, and that such abnormalities may underline SI in MDD and could be used as features to distinguish MDD patients with SI from those without SI.The study included 116 subjects aged 18–56 years: 81 drug-naïve patients with first-episode MDD and 35 HC individuals. The drug-naive, first-episode MDD participants were recruited from the Department of Psychiatry, First Hospital of Shanxi Medical University, Taiyuan, China. The HC subjects were recruited from Taiyuan, China, using advertisement in the community. All participants were evaluated by two trained psychiatrists independently to determine the presence or absence of Axis I psychiatric diagnoses using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) Axis I Disorders (SCID).Inclusion criteria for the patients included the following: (1) met the DSM-IV diagnostic criteria of MDD and did not meet to the criteria for any other Axis I disorder, (2) in their first episode, (3) no history of any form of antidepressant treatment, (4) no history of suicide attempt, and (5) right-handedness. HC subjects with no history of any psychiatric diagnosis and suicide attempt were included. Exclusion criteria for both patients and HC controls included the following: (1) history of head injury or any neurological disorder, (2) any serious symptom of major medical disorder, (3) history of any Axis I disorder in their first-degree relatives, and (4) any MRI contraindications.This study was approved by the Ethics Committee of the First Hospital of Shanxi Medical University. All participants were right-handed and signed informed consent.Participants completed a comprehensive diagnostic evaluation within 24 h prior to the functional MRI (fMRI) scan. Suicidal ideation was assessed using the Chinese version of the Beck Scale for Suicidal Ideation (BSI-CV) , 27, a 1For correlations between clinically related variables and neural measures, we used the Hamilton Depression Rating Scale for Depression 24 item (HAMD-24) , a struc2, acquisition matrix = 256 × 240, slice thickness = 1.2 mm, gap = 0.6 mm, voxel size = 1 × 1 × 1 mm3, 160 sagittal slices, and a total of 9 min 14 s. The resting state fMRI (rs-fMRI) was performed using an echo planar imaging (EPI) sequence with the following parameters: TR = 2,000 ms, TE = 30 ms, FA = 90°, FOV = 240 × 240 mm2, acquisition matrix = 64 × 64, slice thickness = 3 mm, gap = 3.99 mm, 212 sagittal slices, and a total of 8 min 6 s.All structural and fMRI data were acquired on an A MAGNETOM Trio Tim 3.0T  with a 12-channel birdcage head coil located at the First Hospital of Shanxi Medical University. The participants were required to keep their eyes closed but remain awake and relaxed throughout the entire scan. Restraining foam pads and rubber earplugs were used to minimize head motion and noise interference. A 3D-FLASH sequence was used to obtain high-resolution T1-weighted structure images with the following parameters: repetition time (TR) = 2,300 ms, echo time (TE) = 2.95 ms, inversion time (TI) = 900 ms, flip angle (FA) = 9°, field of view (FOV) = 225 × 240 mmhttp://rfmri.org/dpabi) (3); fourth, spatial smoothing with a Gaussian kernel of 4 mm full width at half maximum (FWHM) to decrease noise; fifth, linear detrending; sixth, temporal band-pass filtering (0.01–0.08 Hz); and seventh, nuisance covariates regression, including Fristion 24 motion parameters, cerebrospinal fluid, and white matter signals.The rs-fMRI data preprocessing was carried out using Data Processing and Analysis for Brain Imaging software  . The firThe habenula was selected as the region of interest (ROI) for both sFC and dFC analysis. Each ROI was drawn as a sphere with a radius of 3 mm around a coordinate  for the left habenula and  for the right habenula according to a previous computational fMRI study .We performed a seed-based whole-brain approach to examine sFC stemming from the bilateral habenula using DPABI. The mean BOLD time course from each seed ROI was extracted, and the Pearson's correlation coefficients with the time course of all other voxels of the brain were calculated. Then, we transformed the correlation coefficients to Z values using the Fisher's r-to-z transformation.fmin, which is deemed the minimum frequency of the time series .The demographic and clinical characteristics of the participants were analyzed using IBM SPSS Statistics for Windows, Version 22.0. We conducted one-way analyses of variance (ANOVA) to estimate the differences among the three groups in age, years of education, and chi-square tests to detect differences in gender. For the score of HAMD-24, two-sample P < 0.001 with cluster P < 0.05 [using Gaussian random field (GRF) correction]. Significant clusters identified in this analysis were then imported as target ROI in the post hoc ROI to target ROI analysis. We extracted mean sFC and dFC values between the left/right habenula and significant clusters for each group and conducted post hoc pairwise comparisons. The results were considered significant if P < 0.05, corrected by Bonferroni test.In order to compare sFC and dFC and identify abnormalities among three groups , one-way analysis of covariance (ANCOVA) was performed with age, gender, years of education, and head motion included as covariates, using DPABI. Connectivity group differences were considered significant for voxel P < 0.05, Bonferroni correction).To further identify the dimensional correlations between clinical symptoms and neural patterns in MDD patients with SI, Pearson's partial correlation analyses (two tailed), controlling for age, gender, and years of education, were conducted between FC (sFC/dFC) values with significant group differences and the total score of HAMD-24, and BSI-CV .Besides, the results were reanalyzed by regressing out HAMD scores to test the difference between the SI+ and SI– groups with respect to sFC and dFC.F = 0.265, P = 0.768), gender , years of education , or head motion . For clinical symptoms, the total score of HAMD-24 in the SI+ group were higher than in the SI– group .F = 8.280, P = 0.000), the left cerebellum , and the right precentral gyrus , as well as altered sFC between the right habenula and the right precuneus  and the left inferior frontal gyrus (IFG)  , and the left IFG , as well as increased sFC between the left habenula and the left cerebellum , compared with both the SI– and HC groups, but no difference was observed in sFC between the SI– and the HC groups. Compared with the HC group, both the SI+ and SI– groups showed increased connectivity between the left habenula and the left putamen  and decreased sFC between the left habenula and the right precentral gyrus , while no difference was observed in sFC between patient groups  , Table 2t groups .F = 10.790, P = 0.000), the left , and right precuneus . The three groups significantly differed also in dFC between the right habenula and the left superior temporal gyrus (STG) , the left angular gyrus , and the left postcentral gyrus   and between the right habenula and the left postcentral gyrus , as well as increased dFC between the left habenula and the left precuneus , and between the right habenula and the left STG , compared with both the SI– and HC groups, but no difference was observed in dFC between the SI– and the HC groups. Meanwhile, compared with the HC group, both the SI+ and SI– groups showed decreased dFC between the left habenula and the right precuneus  and between the right habenula and the left angular gyrus , but no difference was observed in dFC between patient group  , Table 2nt group .P > 0.05, Bonferroni correction).No significant correlations between the sFC and dFC in regions showing significant group differences, and clinical symptom measures were observed in the SI+ group , the abnormalities of sFC and dFC observed in post hoc analysis were also found between the SI+ and SI– groups after regressing out HAMD scores (Except the left cerebellum (D scores .The present study explored neuroimaging correlates of SI in a population of first-episode, drug-naive MDD patients. To the best of our knowledge, it represents the first study to investigate differences between patients with a diagnosis of MDD, with and without SI, and healthy controls in sFC and dFC of the habenular. We found that SI+ group had significantly decreased sFC between the right habenula and the right precuneus and the left IFG. As for dFC, SI+ group had significantly decreased dFC between the left habenula and the right lingual gyrus, between the right habenula and the left postcentral gyrus, as well as increased dFC between the right habenula and the left STG and between the left habenula and the left precuneus. Moreover, patients with a diagnosis of MDD, independently of SI, exhibited altered sFC between the left habenula and the left putamen and the right precentral gyrus, as well as abnormal dFC between the left habenula and the right precuneus, and between the right habenula and the left angular gyrus.As a key region within the reward circuit that regulates the midbrain monoamine system, the function of the habenula in humans is of great clinical relevance . Our datIn our sample, sFC between the right habenula and the left IFG was decreased in MDD patients with SI. The IFG is known to be involved in response inhibition, a component of executive function, and is essential for impulse control, while SI has a clear correlation with the increase in impulsivity and neurobehavior disinhibition . In thisTraditional sFC reflects average connectivity strength between regions, while dFC assesses functional connectivity variability over time. In our study, dFC provided additional information that was different from but complementary to the information for sFC. The greater the dFC, the more frequent the switching of the FC strength between the two regions. Regarding the dFC analyses, significantly decreased dFC between the habenula and the postcentral gyrus was found in first-episode MDD patients with SI compared to those without SI and normal controls. The postcentral gyrus is considered to be a region involved in somatosensory perception and representation of emotional response . FurtherIn addition, we observed greater dFC between the habenula and STG in SI+ group. Although there are few studies on the role of instability of FC of STG in SI, previous studies investigating morphological and functional abnormalities of brain in patients with SI have reported altered STG connections and gray volumes , 47. TheIt is also worth noting that in patients with SI, the habenula has shown remarkable lower sFC but greater dFC to the precuneus, which is closely related to fundamental cognitive functioning . In otheTaken together, these findings demonstrate that MDD patients with SI exhibits abnormal FC, especially from dynamic nature. These abnormal dynamic functional connections provide additional information about the status of brain functional circuits and are sensitive measures to detect changes in brain circuits in depressed patients with SI. In addition, a better understanding of the connection between SI and brain dynamic activity can further enhance our comprehension of how temporal variations in connectivity strength promoting development of SI in patients with depression. Specifically, dynamic attributes may be a powerful neuroimaging indicator to explore the pathological changes of SI in patients with MDD and is expected to provide a new way to distinguish MDD patients with and without SI.It is important to address several limitations in the present study. First, there was a relatively small sample size, which may affect the statistical power, but we are still to keep collecting the relevant samples for future research about SI. Second, the cross-sectional design of this study limited the ability to infer whether the altered FC of habenula was a preexisting abnormality or a consequence of SI. Longitudinal study is needed in the future to explore the direct causality of SI with related neural variables. Third, in our study, we did not collect the information about the duration and the age of first onset of patients, which also may affect the accuracy of our results. Besides, the optimal length of the sliding window for obtaining the dynamics of brain activity is still unclear, although validation analyses with different window sizes were conducted to increase consistency. Other correction models of dFC, such as the wavelet transformation coherence method , should In conclusion, the current study presented novel results linking SI to the abnormal functional connectivity of habenula using both sFC and dFC. As such, from a neurobiological point of view, the altered sFC and dFC of the habenula in drug naive, first-episode MDD patients with SI may mediate a dysfunction in the mechanism that links the habenula with self-referential processing, response inhibition, emotional response, and introspective integration processing. Nonetheless, additional research, especially longitudinal study, focused on the neural features of different suicide dimensions is needed to explore neural biomarkers for suicide risk and to facilitate early identification and intervention.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Ethics Committee of the First Hospital of Shanxi Medical University. The patients/participants provided their written informed consent to participate in this study.DQ, ZL, and KZ contributed to conception and design of the study. JL, TZ, YX, and YWe collected the samples and participants' characteristics. AZ, CY, and NS organized the database. DQ and YWa analyzed data and performed the statistical analysis. DQ wrote the first draft of the manuscript. All authors contributed to manuscript revision, read, and approved the submitted version.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.


Background: Upper lip appearance received major attention with the introduction of diverse treatment modalities, including lip augmentation, rhinoplasty surgery, and dental treatment designed to support the upper lip. Our objectives were to define the prevalence and characteristics of the upper lip horizontal line (ULHL), which is a dynamic line appearing during a smile, in relation to gender, malocclusions, aging, and facial morphology. Methods: First, the prevalence and gender distribution of ULHL was examined from standardized en-face imaging at full smile of 643 randomly selected patients. Second, cephalometric and dental cast model analyses were made for 97 consecutive patients divided into three age groups. Results: ULHL appears in 13.8% of the population examined, and prevailed significantly more in females (78%). The prevalence of ULHL was not related to age nor to malocclusion. Patients presenting ULHL showed shorter upper lip and deeper lip sulcus. The skeletal pattern showed longer mid-face, shorter lower facial height and greater prevalence of a gummy smile. Conclusions: Female patients with short upper lip, concavity of the upper lip, and gummy smile are more likely to exhibit ULHL. The ULHL is not age-related and can be identified in children and young adults. Therefore, it should be considered when selecting diverse treatment modalities involving the upper lip. Perceptions of facial beauty are multifactorial, with genetic, environmental, and cultural foundations . Yet, vaThe face can be divided into thirds, with the lips comprising of the key aesthetic feature of the lower third, where the upper lip is shown as having the greatest effect on beauty perception. Traditionally, fuller lips have been considered more beautiful and were associated with voluptuousness, sensuality, and youthfulness. Indeed, in the last century, there has been a gradual increase in the demand for lip prominence , startinThe transverse upper labial crease was recently described to be located in the mid-philtral area below the nose . It was Treatment of the upper lip region has received major attention lately, with the introduction of diverse modalities, such as injectable derivative of botulinum toxin , insertiIn the present study, we describe the upper lip horizontal line (ULHL), which is a dynamic line that appears only while smiling . AlthougWhen aesthetic treatment is planned, it is essential to match the expectations of the patient by having a complete diagnosis of all related parameters and to be aware of the clinician’s ability to affect the results. Even in cases in which the treatment plan does not include intervention , it is important to inform the patient.Since ULHL is mainly visible during smiling (dynamic line), and in the light of diverse exposure of dental and gingival units during smiling , it is pThe study was approved by the Ethical Committee of the Tel Aviv University. Each patient or parent signed an informed consent form following the criteria of the Ethical Committee.The study was divided into two stages. The first stage included a survey of a large sample to determine the prevalence of the ULHL in the population studied. The second stage aimed to evaluate the association of facial and dental features that were measured from cephalometric analyses  and studThe identification of the ULHL was based on standardized photographs of a full smile. Only patients who showed a clear fold in their upper lip during smile were categorized in the ULHL group. Malocclusion was analyzed based on the molar occlusion from dental study models following Angle classification—Class I molar occlusion, Class II molars with OJ greater than 2 mm (Class II/1), Class II molars with overjet (OJ) equal or smaller than 2 mm (Class II/2) and Class III. The presence or absence of a gummy smile was marked when exposure of more than 2 mm of gum above the upper central incisors was exposed while smiling . The incp < 0.05. To predict the presence of the ULHL, a stepwise logistic regression test was used.Cephalometric analyses of nine skeletal and soft tissue measurements  were perThe reliability Intra Class Correlation Coefficient (ICC) presented high correlations in all cephalometric measurements taken (ICC > 0.9).p < 0.001): 83% females (N = 74) and 17% males (N = 15) , the prevalence of the ULHL was 13.8% (N = 89). The ULHL was significantly more prevalent in females (based on Chi-square (N = 15) .There was no significant difference in the average age between the group presenting the ULHL (17.78 ± 9.54 years) and the group without this feature (18.72 ± 9.06 years) (based on T–Test).No significant difference was found in the prevalence of the ULHL between the three age groups   . The femNo significant difference was found between different malocclusions and the prevalence of ULHL . Most ULp = 0.004)  as compared to patients without a gummy smile (15.2%) (= 0.004) .p < 0.028), as well as greater sulcus depth was found in the ULHL group (p < 0.017), greater upper anterior vertical proportion (N-ANS/N-Me) (p < 0.028), and smaller lower anterior vertical proportion (ANS-Me/N-Me) (p < 0.026)  .p < 0.001). The parameters that were included in the analysis were: the upper lip height, sulcus depth, and gender , we would expect an increase in ULHL presence with aging. Surprisingly, this was not the case. No statistical difference was found between the age groups. On the contrary, there was a tendency of ULHL prevalence to decline with age. The almost plateau level of ULHL prevalence that remained between all age groups suggests that subjects who have ULHL at an early age will still display it at an elderly age. The slight decrease in ULHL prevalence with aging can be explained by the drop of the upper lip ,34,35 anHwang et al.  defined Alongside the hyperactivity of the mimic muscles, it was suggested that the superficial musculoaponeurotic system (SMAS) around the nasolabial fold, with its condensing fibro-muscular meshwork, is responsible for the nasolabial fold formation and other facial creases/lines ,39. The ULHL was found to be related to long mid-face (N-ANS/N-Me), short maxilla (height of maxilla), short lower face (ANS-Me/N-Me), short upper lip (upper lip height), and concavity of the upper lip (sulcus depth). The ULHL was more prevalent in females, which is supported by studies related to gender dimorphism in the lip region and unique characteristics to the female smile line ,41,42, aImprovement of the upper lip aesthetic should be considered as part of dental treatment plan. There are several approaches to correct a gummy smile or soft tissue asymmetry, such as administration of Botulinum toxin or rhinoplasty procedures . HoweverThe clinician should take into consideration that the presence of the ULHL can affect the satisfaction of the patient, similarly to the presence of a gummy smile or smile asymmetry. Therefore, we recommend including the diagnosis of the ULHL in smile analysis and, when needed, further intervention should be recommended.In the present study, we report on the presence of an upper lip horizontal line (ULHL), which appears in 13.8% of the sample while smiling. This line can be associated with morphological features, such as short upper lip and concavity of the lip in the philtrum region. The ULHL is found in a higher prevalence in females compared to males. It is not related to malocclusion, nor to aging.Patients exhibiting ULHL should be informed prior to dental treatment that the ULHL is a morphological feature and is not related to aging, and clinicians should be aware of the possible treatment modalities that can be presented to the patient to improve smile esthetics.