Supplemental Information

Supplemental Information Supplemental Methods Principal Component Analysis (PCA) Every patient (identified by index k varying between 1 and n) was characterized by 4 cell-level measured features (quantitative properties of their primary myotubes, represented by xj, with j varying between 1 and 4). PCA transforms the original data to principal components cj. The cj are found by a linear transformation of the original data to a new set of the same dimension (4 in the present case). The transformation 32 33 is such that transformed data (components) are mutually independent (i.e. not correlated). The comparisons of patients are then made in the transformed space of components. The transformation is standard in terms of linear algebra. Data of patient k was grouped in a row vector k 1k 4k X x x (1) The Xk for all k constitute a 4 n matrix X, x X x x 11 41 x 1n 4n (2) M is the row vector of four feature means 1 4 x j, calculated over all patients M x x (3) Xc (for centered ) represents the matrix obtained by subtracting from every value in X its corresponding mean (equivalently, from every row in Xk the all-patients mean M). C represents the covariance of Xc, calculated as C = Xc T Xc/n, (4) where T represents matrix transposition. This 4 4 matrix has as diagonal elements the variances of the four measured variables. Page 1

The linear transformation used in the analysis is a multiplication of the original data by the diagonalization matrix P, a 4 4 matrix defined by the equation C = P D P -1, (5) where C is the covariance of the data set (Eq. 4) and D is the diagonal version of C, with principal component variances ( eigenvalues ) λj in the diagonal positions and zero elsewhere. The 4 columns of P are the eigenvectors of C. The transformed data are calculated as Z=Xc P (6) Z is a matrix of the same dimensions as the original dataset (i.e., 4 n in the present case); the principal components for patient k are in row k of Z. The 4 eigenvectors the columns of P are listed in text table 2, together with the variances (eigenvalues) of the principal components. Because the principal components are combinations of the original variables, they provide a joint assessment of the condition of an individual. This assessment in turn is used to determine whether the separation of groups is warranted. The principal components of interest are those of greatest variance. For this purpose, the columns of P are permutated and placed in decreasing order of eigenvalue (variance), which yields the matrix P* Then the columns of Z* = Xc P*, (6) Z * c c c 11 41 c 1n 4n which differ from those of Z in placement only, contain the transformed variables placed from left to right in order of decreasing variance. Note that in this technique groups or clusters may or may not be defined, but have no a-priori role in the analysis. Specifically, the CHCT classification (as HS, HH and HN) is irrelevant to the procedure. To summarize, for patient k, the four principal components are the four elements in row k of matrix Z*. Text Figure 5C is a plot of principal component 1 (c11 c1n, first column of Z*) vs. principal Component 2 (second column of Z*). Page 2

Supplemental Tables Median Avg. S.E.M. Range patients p vs HN p vs HS HN 0.00 0.51 0.18 0-8.3 59 < 0.01 HS 3.33 3.33 0.49 0-8.3 22 < 0.01 HH 3.33 3.83 0.47 0-10 40 < 0.01 > 0.69 Table S1. Statistics of the clinical index. The last columns list the probability of the results in the hypothesis of no difference between the HH and the group indicated, calculated from a Mann-Whitney rank sum test of difference of medians. The difference in clinical index between HH and HS groups is far from statistical significance. 1 2 3 4 5 6 7 8 I.D. CHCT RYR1 CACNA1S dbsnp rs # MAF, % ClinVar In silico prediction 5 HS G341R none rs121918592 n/a Pathogenic Damaging 28 HS K1393R none rs137933390 0.51 Likely benign Benign 41 HS T2206M none rs118192177 0.003 Pathogenic Damaging 45 HS none G258D rs35534614 0.74 Likely benign Uncertain, likely benign 51 HS none T1354S rs145910245 0.24 Likely benign Benign 68 HS none Y585C n/a n/a n/a Damaging 86 HS E176K none rs761616815 0.002 Uncertain Damaging 88 HS E176K none rs761616815 0.002 Uncertain Damaging 91 HS H2204Q none n/a n/a n/a Damaging 114 HS none S738L n/a n/a n/a Uncertain T1573M rs183195890 0.03 n/a Uncertain 30 HH R1679H none rs146504767 0.15 Uncertain Damaging 50 HH D3159N none n/a n/a n/a Uncertain 84 HH L2695R none n/a n/a n/a Damaging 97 HH V3088M none rs145044872 0.06 Uncertain Damaging 119 HH p.c810g none n/a n/a n/a Damaging 23 HN R1016Q none rs373541911 0.005 Uncertain Damaging 44 HN none T1354S rs145910245 0.24 Likely benign Benign 75 HN Y3540F none rs752477271 0.009 n/a Benign 94 HN V1447M none rs370851779 0.01 Uncertain Damaging 116 HN D4505H none rs150396398 0.61 Likely benign Damaging Table S2. RYR1 and CACNA1S variants found among the study patients, color-coded according to CHCT class. Column 1 lists a unique patient identifier. Column 2 lists patient classification by CHCT result. Columns 3 and 4 identify the gene for which the variant is listed. Cols. 5 and 6 list respectively the IDs and minor allele frequencies (MAF) of the variants, sourced from NCBI s dbsnp database. Cols. 7and 8 list respectively the ClinVar interpretation of clinical significance and the impact of the variant predicted by bioinformatics software tools (https://www.ncbi.nlm.nih.gov/clinvar). The MH-causative RYR1 variants are shown in boldface. None no variants found; n/a data not available. Genetic data to be deposited in dbgap, National Institutes of Health, USA. Page 3

ID # Age / Gender MH History CHCT max. (g) CHCT status Clinical index parameters Caff. Hal. CK Clinical Pathology 1 24 / M Self 0.1 0.5 HN 40 no symptoms type II atrophy, rare fiber degeneration Clinical Index Basal Calcium (nm) Calcium index parameters Spont. act. (%) Waves after stimulation (%) Spiking after stimulation (%) Ca Index 0 N/A N/A N/A N/A N/A 2 43 / F No 0.1 0.5 HN 20 no symptoms negative 0 N/A N/A N/A N/A N/A 3 20 / M FH 0 1.1 HH 47 fiber size 4 34 / F FH 0 0.3 HN 16 no symptoms Type II fiber atrophy 0 100 0 10.5 0 1.67 5 41 / F FH 4.2 10 HS 121 no symptoms negative 0 81 0 22.7 13.6 2.5 6 38 / F FH 0 0.6 HN 91 no symptoms Mild atrophy 0 N/A N/A N/A N/A N/A 7 45 / M FH 0.1 1 HH 21 no symptoms negative 0 N/A N/A N/A N/A N/A 8 30 / F FH 0.3 2.1 HS 81 no symptoms 9 70 / M FH 0.1 0.6 HN 200 no symptoms, fiber with focal splitting, and internal nuclei neurogenic 10 40 / F FH 0.4 1.5 HS 82 no symptoms negative 0 N/A N/A N/A N/A N/A 11 33 / F No 0 0.7 HH 64 severe muscle N/A 1.67 N/A 0 0 26.3 N/A 12 39 / F No 0 0.3 HN 39 no symptoms negative 0 N/A N/A N/A N/A N/A 13 56 / M FH 0 1.9 HH 350 muscle pain negative 3.33 N/A 11.1 22.2 40.7 N/A 14 34 / F No 0 0.6 HN 175 heat stroke x1 negative 1.67 N/A 0 0 0 N/A 15 19 / M FH 0 0.6 HN 9 no symptoms negative 0 N/A N/A N/A N/A N/A 16 49 / M FH 0 0.2 HN 100 muscle negative 17 26 / M Self 0 0.5 HN 77 no symptoms 18 31 / M FH 0.1 1.1 HH 168 no symptoms, 19 53 / F No 0.1 1.8 HH 210 muscle weakness, heat intolerance, fibromyalgia 20 29 / F Self 0.2 1.7 HH 40 no symptoms 21 26 / F FH 0.2 2.4 HH 387 heat sensitivity minor non-specific abnormalities, scattered atrophic fibers and focal small aggregates largely unremarkable muscle with scattered small fibers moderate in fiber size with some fibrosis non-specific mild myopathic mild myopathic 6.67 N/A N/A N/A N/A N/A Page 4

22 33 / M Self 0.5 2.6 HS 490 muscle 23 27 / M FH 0 0.3 HN 31 24 26 / M No 0.2 2.1 HH 360 severe muscle muscle cramp, exertional 25 30 / M FH 0 0.7 HH 48 no symptoms largely unremarkable skeletal muscle, mild fibrosis moderate capillary vascular thickening 3.33 110 87.5 0 62 6.7 5 N/A N/A N/A N/A N/A negative 6.67 99 26.7 15.3 30.7 5.8 occasional split fibers 26 28/ M FH 0 0.9 HH 34 no symptoms negative 0 N/A N/A N/A N/A N/A 27 19 / F No 0.1 1.4 HH 540 28 19 / M FH 1.4 7.2 HS 23 muscle weakness and heat sensitivity severe muscle 29 47/ F FH 0 0.6 HN 52 no symptoms 30 57 / F FH 0.1 2.2 HH 730 31 27 / M FH 0.2 3.3 HH 320 severe weakness and pain muscle cramp and heat sensitivity unremarkable skeletal muscle mild non-specific focal fibrotic in fiber size with focally grouped atrophic fibers- very mild (early) type 2 fiber atrophy 5 106 0 8.3 16.7 4.2 3.33 85 17.6 9.1 1.2 2.5 0 87 0 0 0 0 8.33 122 14.3 0 30 5.0 8.33 108 40 0 30 5.8 32 67 / F FH 0.2 1 HH 99 muscle cramp negative 33 29 / M FH 0.1 0.8 HN 183 no symptoms negative 0 N/A N/A N/A N/A N/A 34 20 / F No 0.1 1.5 HH 420 35 64 / M FH 0.1 3.1 HH 850 36 38 / F FH 0 1.6 HH 340 37 32 / F No 0 0.6 HN 453 38 47 / F FH 0.2 1.6 HH 591 heat intolerance, muscle muscle, heat sensitivity multiple heat strokes, muscle Muscle spasm, heat-induced, exercise intolerance no symptoms, family history of MH death 39 56 / F FH 0 0.6 HN 37 no symptoms 40 21 / M No 0.2 1.3 HH 2330 41 55 / M Self 3.8 10 HS 58 Severe, exercise-induced severe muscle negative 5 112 42.9 0 42.8 6.7 negative 5 141 10 0 60 5.8 large in fiber size 8.33 120 16.7 16.7 16.7 6.7 type-ii atrophy 8.33 N/A N/A N/A N/A N/A mild nonspecific myopathic, focal fibers splitting and occasional internal nuclei in some fibers mild non-specific type II atrophy, mild myopathic 3.33 144 100 0 50 7.5 1.67 108 7.1 0 7.1 0.83 10.00 128 100 0 25 6.7 negative 3.33 99 0 0 14.3 1.7 42 34 / F FH 0 0.6 HN 122 no symptoms negative 0 N/A N/A N/A N/A N/A 43 44 / F Self 0 1.8 HH 79 muscle moderate fiber size 5 128 N/A N/A N/A N/A 44 40 / M FH 0.1 0.5 HN 115 no symptoms negative 0 N/A N/A N/A N/A N/A 45 50 / F No 0.6 2.5 HS 719 muscle negative 3.33 105 0 7.7 23.1 3.3 46 66 / M FH 0 0.7 HH 100 no symptoms negative 0 80 50 0 20 4.2 Page 5

47 37 / F FH 0.2 0.3 HN 101 no symptoms negative 0 N/A N/A N/A N/A N/A 48 35 / M FH 0.1 1.2 HH 29 no symptoms N/A 0 N/A N/A N/A N/A N/A 49 22 / F FH 0 0.6 HN 25 no symptoms negative 0 103 0 0 0 0.83 50 35 / F Self 0.1 0.8 HH 409 muscle Negative 51 38 / F FH 0.5 1.8 HS 121 no symptoms moderate fiber size, and 1.67 95 0 0 0 0.8 type I hypertrophy 52 29 / M FH 0.1 0.6 HN 195 no symptoms negative 0 N/A N/A N/A N/A N/A 53 35 / M FH 0.3 1.8 HS 840 heat intolerance fiber size, type II dominance, and increase in collagen 5 84 33.3 33.3 16.7 5 54 42 / F FH 0 0.6 HN 67 no symptoms negative 0 N/A N/A N/A N/A N/A 55 18 / F No 0.1 0.3 HN 101 no symptoms negative 0 110 0 0 0 1.7 56 26 / M Self 2.2 4 HS 311 muscle spasm and negative 3.33 105 11.7 0 30 4.2 57 25 / F No 0.1 2.1 HH 110 no symptoms mild endomysial fibrosis and fiber size 1.67 126 0 0 0 2.5 58 34 / F FH 0 0.4 HN 20 no symptoms negative 0 N/A N/A N/A N/A N/A 59 38/ F FH 0 1.8 HH 220 muscle moderate in fiber 5 N/A N/A N/A N/A N/A size 60 27/ M Self 0.3 1.8 HS 94 no symptoms negative 0 119 0 0 28.6 3.3 61 47 / M FH 0 0 HN 33 no symptoms negative 0 N/A N/A N/A N/A N/A 62 33 / F FH 0.2 1.2 HH 212 no symptoms 1.67 200 44.4 11.1 66.7 8.3 63 64 / M FH 0 1.1 HH 102 no symptoms inflammatory myopathy 64 22 / F FH 0 2.5 HH 410 no symptoms negative 65 34 / F FH 0.3 2 HS 45 no symptoms slight in fiber size 66 58 / F FH 0 0 HN 55 no symptoms Page 6 1.67 112 0 0 0 2.5 67 46 / F FH 0.7 1 HS 342 no symptoms mild fiber degeneration and regeneration, mild 3.33 114 0 0 18.2 3.3 fibrosis 68 41 / F No 0.3 1.1 HS 421 no symptoms moderate in fiber size and focal type 3.33 111 0 7.1 14.3 3.3 2 fiber atrophy 69 32 / M No 0 0.6 HN 200 muscle scattered atrophic fibers 70 24 / F No 0 1.8 HH 94 no symptoms negative 0.00 151 N/A N/A N/A N/A 71 36 / M FH 0 0 HN 66 no symptoms, had heat stroke negative 72 47 / F FH 0.2 0.6 HN 119 no symptoms mild type II fiber predominance 73 17 / F FH 0 0.4 HN 141 heat sensitivity negative 74 19 / F FH 0 0.2 HN 80 no symptoms negative 0 N/A N/A N/A N/A N/A 75 38 / M FH 0 0.6 HN 111 no symptoms negative 0 75 11.2 0 0 0 76 39 / M FH 0 0 HN 185 no symptoms negative 0 94 0 0 6.7 0.8 77 38 / M Self 0.3 0.8 HS 206 muscle not adequate for diagnosis 1.67 100 0 0 0 0.8 78 42 / F FH 0.3 1.4 HS 100 no symptoms mild in fiber size, endomysial 1.67 85 N/A N/A N/A N/A fibrosis 79 44 / F FH 0.1 0.4 HN 96 no symptoms negative 0 105 0 0 0 0.8 80 38 / M FH 0 0.6 HN 84 no symptoms negative 0 N/A N/A N/A N/A N/A 81 33 / F FH 0 0.3 HN 35 no symptoms negative 0 85 N/A N/A N/A N/A 82 37 / M FH 0.3 1.1 HS 332 no symptoms increased fiber size,

83 35 / F Self 0.1 1.5 HH 696 84 27 / M FH 0.1 1.8 HH 1774 severe muscle pain and twitch after anesthesia; heat and exertional induced twitches exertional increased central nuclei polygonal atrophic muscle fibers moderate interstitial fibrosis and mild in fiber size 10.00 N/A N/A N/A N/A N/A 10.00 94 N/A N/A N/A N/A 85 42 / F FH 0 0 HN 332 no symptoms negative 0 120 0 0 0 1.7 86 24 / M No 0.6 2.2 HS 1848 exercise-induced negative 6.67 154 0 0 26.1 4.2 87 35 / M FH 0.1 0.3 HN 171 no symptoms negative 0 89 N/A N/A N/A N/A 88 23 / M No 2 10.6 HS 921 severe myopathy triggered by viral infection 6.67 173 0 0 14.3 3.3 89 44 / F FH 0 0.5 HN 100 no symptoms negative 0 N/A N/A N/A N/A N/A 90 27 / F FH 0.1 0.5 HN 414 91 33 / M Self 3.4 6.6 HS 120 no symptoms, MH death in the family muscle weakness and negative 0 N/A N/A N/A N/A N/A 5 129 0 6.7 13.3 4.2 92 40 / F FH 0.2 0.6 HN 92 no symptoms negative 0 97 0 0 20 2.5 93 40 / F FH 0 0 HN 38 no symptoms negative 0 N/A N/A N/A N/A N/A 94 43 / M FH 0 0 HN 69 no symptoms negative 0 N/A N/A N/A N/A N/A 95 41 / F Self 0.1 0.8 HH 354 heat sensitive mild myopathic with mild fibrosis 5 N/A N/A N/A N/A N/A 96 4 1/ M FH 0 0.6 HN N/A no symptoms negative 0 N/A N/A N/A N/A N/A 97 37 / M Self 0.2 3.7 HH 149 no symptoms mild in fiber size 98 39 / M FH 0 0.2 HN N/A no symptoms negative 0 N/A N/A N/A N/A N/A 99 36 / M FH 0 0.6 HN 39 no symptoms negative 0 N/A N/A N/A N/A N/A 100 39 / F FH 0 0.4 HN N/A no symptoms negative 0 N/A N/A N/A N/A N/A 101 52 / M FH 0.2 1.2 HH 104 no symptoms fiber size 1.67 190 0 14.3 0 3.3 102 43 / M FH 0 0 HN N/A no symptoms negative 0 110 0 0 7.7 2.5 103 35 / F FH 0 0 HN N/A no symptoms negative 0 118 0 0 0 1.7 104 36 / F FH 0 0 HN N/A no symptoms negative 0 104 N/A N/A N/A N/A 105 29 / M No 0 0.3 HN N/A no symptoms negative 0 111 N/A N/A N/A N/A 106 52 / F FH 0 0 HN N/A no symptoms negative 0 N/A N/A N/A N/A N/A 107 29 / F FH 0 0.5 HN N/A no symptoms negative 0 N/A N/A N/A N/A N/A 108 20 / M FH 0 1.5 HH 300 no symptoms negative 0 171 12.5 0 18.2 5 109 52 / F FH 0 0.2 HN N/A no symptoms negative 0 106 N/A N/A N/A N/A 110 21 / F No 0 0.4 HN 33 no symptoms negative 0 95 N/A N/A N/A N/A 111 39 / F No 0 0.1 HN 256 no symptoms negative 0 N/A N/A N/A N/A N/A 112 21 / F FH 1.2 2.5 HS 621 heat sensitive increased internal nuclei 6.67 114 0 0 20 3.3 113 47 / F Self 0 0 HN 84 no symptoms negative 0 N/A N/A N/A N/A N/A 114 30 / M Self 1 4 HS 602 exertional type 2 atrophy, increased internal nuclei 8.33 N/A N/A N/A N/A N/A Page 7

115 36 / M FH 0.1 1.5 HH 53 family history of MH related death severe type 2 atrophy 116 39 / F FH 0 0 HN 44 no symptoms negative 0 N/A N/A N/A N/A N/A 117 39 / F FH 0 0 HN 61 No symptoms negative 0 N/A N/A N/A N/A N/A 118 31 / M FH 0 0 HN 32 no symptoms negative 0 N/A N/A N/A N/A N/A 119 41 / M FH 0 1.5 HH 712 sensitivity to heat, and negative 5 139 50 0 62.5 7.5 120 39 / M Self 0 2.3 HH 295 exertional severe Type 2 atrophy 6.67 N/A N/A N/A N/A N/A 121 32 / M FH 0 2.7 HH 561 muscle negative 5 117 37.5 0 25 5.83 Table S3. Summary of patient clinical and cell-level data. Caff: contracture with 2mM caffeine; Hal: contracture to 3% halothane; FH: family history of MH; Self: own history of adverse anesthetic reaction. N/A: not available. Clinical index calculation is based on: weakness and myopathy (0-2: none, mild, severe), pain and (0-2: none, mild, severe interfering with daily activity), heat and exercise sensitivity (0-2: none, mild, ), hyperck (0-2: <300, 300-1500, >1500), histopathology (0-2: normal, mild, severe ). For example patient #36 has score of: 0 (no myopathy) +1 ()+ 1 (heat strokes) + CK:340 (1) +severe histopathology (2)=5. Once rescaled to range of 1-10 it becomes 8.33. Page 8