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Anti-gp210-positive primary biliary cholangitis: The dilemma of clinical treatment and emerging mechanisms
Xiaoyi Wanga,#, Zhen Yanga,#, Ying Rana,#, Long Lib, Bangmao Wanga, Lu Zhoua,c,
Corresponding author
lzhou01@tmu.edu.cn

Corresponding author.
a Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
b Department of Immunology, School of Basic Medical Sciences, Tianjin Medical University, Tianjin, China
c Department of Gastroenterology and Hepatology, People's Hospital of Hetian District, Xinjiang Uygur Autonomous Region, China
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          "en" => "<p id="spara001" class="elsevierStyleSimplePara elsevierViewall">The structural diagram of nuclear pore membrane protein gp210&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0001" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">1</span><span class="elsevierStyleSectionTitle" id="cesectitle0004">Introduction</span><p id="para0002" class="elsevierStylePara elsevierViewall">Primary biliary cholangitis &#40;PBC&#41; is a chronic&#44; progressive autoimmune liver disease characterized by non-suppurative inflammation of small- and medium-sized bile ducts in the liver&#44; which causes cirrhosis&#46; Serum antimitochondrial antibody &#40;AMA&#41; is the major hallmark of PBC <a class="elsevierStyleCrossRef" href="#bib0001">&#91;1&#93;</a>&#46; However&#44; AMA is absent or present only in low titers in approximately 5&#37;&#8211;10&#37; of PBC patients <a class="elsevierStyleCrossRef" href="#bib0002">&#91;2&#93;</a>&#46; More than 30&#37; of AMA-negative PBC patients have PBC-specific anti-nuclear antibodies &#40;ANA&#41;&#44; including anti-gp210 and anti-sp100 antibodies <a class="elsevierStyleCrossRef" href="#bib0003">&#91;3&#93;</a>&#46; Moreover&#44; anti-gp210 can be detected in 13&#46;8&#37;&#8211;48&#46;2&#37; of PBC patients&#44; with high specificity &#40;&#62;98&#37;&#41; for the diagnosis <a class="elsevierStyleCrossRefs" href="#bib0004">&#91;4&#8211;17&#93;</a>&#46; Since 2017&#44; anti-gp210 has become a diagnostic marker for the diagnosis of AMA-negative PBC&#44; improving the diagnostic rate and thus avoiding unnecessary liver biopsy in some patients &#91;<a class="elsevierStyleCrossRef" href="#bib0002">2</a>&#44;<a class="elsevierStyleCrossRef" href="#bib0018">18</a>&#93;&#46;</p><p id="para0003" class="elsevierStylePara elsevierViewall">Anti-gp210 is not only a highly specific antibody for the diagnosis of PBC but also a prognostic marker&#46; Anti-gp210-positive PBC patients had worse responses to ursodeoxycholic acid &#40;UDCA&#41; &#40;39&#46;3&#37; vs&#46; 16&#46;7&#37;&#41;&#44; higher levels of biochemical liver tests&#44; more severe histopathological presentation&#44; and worse prognosis as compared to anti-gp210-negative patients &#91;<a class="elsevierStyleCrossRefs" href="#bib0004">4-6</a>&#44;<a class="elsevierStyleCrossRef" href="#bib0019">19</a>&#93;&#46; The therapeutic effects of different drugs&#44; including obeticholic acid &#40;OCA&#41;&#44; fibrates&#44; glucocorticoids&#44; and immunosuppressants in anti-gp210-positive and -negative PBC patients have been compared&#44; and it has been found positivity remains a risk factor for poor treatment response &#91;<a class="elsevierStyleCrossRef" href="#bib0008">8</a>&#44;<a class="elsevierStyleCrossRef" href="#bib0019">19</a>&#93;&#46; Thus&#44; anti-gp210 is a risk factor for poor response to UDCA and poor prognosis in PBC patients&#44; and thus clarifying the production of anti-gp210 and its mechanism in PBC is very important for the development of effective therapeutic targets&#46;</p><p id="para0004" class="elsevierStylePara elsevierViewall">Currently&#44; studies on the molecular mechanisms of anti-gp210 in PBC are still limited&#46; The antigen of anti-gp210 is gp210&#44; one of the constitutive proteins of the nuclear pore complex <a class="elsevierStyleCrossRef" href="#bib0020">&#91;20&#93;</a>&#46; Two antigenic epitopes of gp210 protein have been identified&#44; which laid a theoretical basis for the detection of anti-gp210 and the exploration of antigen expression as well as antibody production &#91;<a class="elsevierStyleCrossRef" href="#bib0021">21</a>&#44;<a class="elsevierStyleCrossRef" href="#bib0022">22</a>&#93;&#46; Notably&#44; Nickowitz <span class="elsevierStyleItalic">et al</span>&#46; <a class="elsevierStyleCrossRef" href="#bib0006">&#91;6&#93;</a> found that the gp210 expression in biliary epithelial cells &#40;BECs&#41; in the liver of PBC patients was significantly increased compared to that in the patients of AIH and hepatitis C&#44; however&#44; it did not correlate with the production of anti-gp210 antibody&#46; Thus&#44; it is suggested that gp210 antigen may be involved in the bile duct injury of PBC&#46; In addition&#44; in terms of the potential mechanism for anti-gp210 production&#44; molecular mimicry is the major hypothesis at present <a class="elsevierStyleCrossRef" href="#bib0021">&#91;21&#93;</a>&#46; However&#44; whether or not anti-gp210 is directly involved in the occurrence and development of PBC still requires more exploration or merely represents epiphenomenon&#46; Collectively&#44; the clinicopathological characteristics of anti-gp210-positive PBC patients&#44; the production of anti-gp210 antibodies&#44; and the possible pathogenic mechanism are reviewed to deeply understand the role of anti-gp210 in PBC&#46;</p></span><span id="sec0002" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">2</span><span class="elsevierStyleSectionTitle" id="cesectitle0005">Anti-gp210-positive PBC patients have poor treatment response and prognosis</span><p id="para0005" class="elsevierStylePara elsevierViewall">Anti-gp210-positive PBC patients have a lower UDCA response rate than their anti-gp210-negative counterparts&#46; In a cohort of 499 PBC patients from the UK&#44; Haldar et al&#46; <a class="elsevierStyleCrossRef" href="#bib0004">&#91;4&#93;</a> reported that anti-gp210-positive patients treated with UDCA did not respond sufficiently to treatment as compared to anti-gp210-negative patients &#40;39&#46;3&#37; vs&#46; 16&#46;7&#37;&#41;&#46; The study further confirmed that anti-gp210 could be used as an index to predict poor response to UDCA treatment&#44; with sensitivity and specificity of 26&#46;8&#37; and 89&#46;8&#37;&#44; respectively&#46; Chen Q <span class="elsevierStyleItalic">et al</span>&#46; <a class="elsevierStyleCrossRef" href="#bib0023">&#91;23&#93;</a> conducted a retrospective cohort study of 180 UDCA-treated Chinese PBC patients to assess the prognostic value of anti-gp210 and found that positivity for anti-gp210 was independently associated with a higher risk of liver-related death and transplantation&#46; In summary&#44; anti-gp210-positive PBC patients have low UDCA response rates and poor prognosis&#46;</p><p id="para0006" class="elsevierStylePara elsevierViewall">Second-line therapeutic drugs&#44; such as OCA&#44; fibrates&#44; and corticosteroids are available for UDCA-refractory PBC patients&#44; however&#44; the treatment efficacy remains unsatisfactory for anti-gp210-positive patients&#46; Nakamura <span class="elsevierStyleItalic">et al</span>&#46; <a class="elsevierStyleCrossRef" href="#bib0008">&#91;8&#93;</a> enrolled 50 and 114 anti-gp210-positive and -negative PBC patients&#44; respectively&#44; &#40;115 PBC patients of UDCA monotherapy and 49 UDCA-refractory PBC patients of UDCA combined with prednisolone and&#47;or bezafibrate&#41; in a retrospective study&#46; This study showed that the liver function of both groups had improved after 2 years of treatment&#44; however&#44; anti-gp210-positive patients presented with higher levels of aspartate aminotransferase &#40;AST&#41;&#44; alkaline phosphatase &#40;ALP&#41;&#44; and immunoglobulin M &#40;IgM&#41; after treatment than anti-gp210-negative patients&#46; Then&#44; Qian <span class="elsevierStyleItalic">et al</span>&#46; <a class="elsevierStyleCrossRef" href="#bib0019">&#91;19&#93;</a> respectively compared the responses of 29 and 51 anti-gp210-positive and -negative PBC patients who received UDCA or UDCA&#44; prednisolone&#44; and immunosuppressant &#40;AZA or MMF&#41; triple therapy&#44; and reported that the incidence of poor prognosis &#40;such as increasing rate of PBC related complications&#44; liver transplantation&#44; and mortality&#41; was higher in anti-gp210-positive PBC patients than in anti-gp210-negative patients&#46;</p><p id="para0007" class="elsevierStylePara elsevierViewall">Anti-gp210 is closely associated with poor prognosis in PBC patients&#46; In 1998&#44; Itoh <span class="elsevierStyleItalic">et al</span>&#46; <a class="elsevierStyleCrossRef" href="#bib0011">&#91;11&#93;</a> initially reported that anti-gp210-positive PBC patients had a three times higher mortality rate &#40;40&#46;0&#37; vs&#46; 13&#46;6&#37;&#41;&#44; and 3&#46;5 times higher probability of death from liver failure &#40;32&#46;0&#37; vs&#46; 9&#46;1&#37;&#41; than anti-gp210-negative patients&#46; The liver transplantation free survival time of anti-gp210-positive PBC patients was significantly shorter than their anti-gp210-negative PBC counterparts&#46; Meanwhile&#44; Yang F <span class="elsevierStyleItalic">et al</span>&#46; <a class="elsevierStyleCrossRef" href="#bib0007">&#91;7&#93;</a> found that anti-gp210-positive patients had remarkably higher UK-PBC scores and poorer long-term prognoses than anti-gp210-negative patients&#46; Previous investigators have reported that the presence of fatigue and pruritus during diagnosis is associated with poor responsiveness to UDCA treatment&#44; and more inclined to evolve to cirrhosis and its complications in PBC <a class="elsevierStyleCrossRef" href="#bib0024">&#91;24&#93;</a>&#46; Thus&#44; anti-gp210 may help together with clinical features to identify the subgroup of PBC patients with more severe prognoses&#46;</p><p id="para0008" class="elsevierStylePara elsevierViewall">Nakamura M <span class="elsevierStyleItalic">et al</span>&#46; <a class="elsevierStyleCrossRef" href="#bib0025">&#91;25&#93;</a> further studied the relationship between the titer of anti-gp210 and disease severity and prognosis&#46; They found that patients with reduced anti-gp210 titers showed milder disease and better prognosis than patients whose anti-gp210 titers were unchanged or elevated after UDCA treatment <a class="elsevierStyleCrossRef" href="#bib0005">&#91;5&#93;</a>&#46; Furthermore&#44; they concluded that the change of anti-gp210 titers in serum had great significance for the prognosis of the disease <a class="elsevierStyleCrossRef" href="#bib0005">&#91;5&#93;</a>&#46; However&#44; the issue of whether or not the titer of anti-gp210 is variable remains controversial because some studies have pointed out that anti-gp210 titers in PBC patients did not change over a long follow-up period of 3&#8211;10 years &#91;<a class="elsevierStyleCrossRef" href="#bib0011">11</a>&#44;<a class="elsevierStyleCrossRef" href="#bib0012">12</a>&#93;&#46; Therefore&#44; we summarized the detection methods&#44; substrates&#44; and the changes of anti-gp210&#8217;s serum antibody titers in previous studies to figure out why those research results differ &#40;<a class="elsevierStyleCrossRef" href="#tbl0001">Table 1</a>&#41; &#91;<a class="elsevierStyleCrossRef" href="#bib0005">5</a>&#44;<a class="elsevierStyleCrossRef" href="#bib0008">8</a>&#44;<a class="elsevierStyleCrossRefs" href="#bib0011">11-13</a>&#93;&#46; We found that the change of antibody titer can be detected when the carboxy-terminal tail of gp210 was used as the detection substrate&#44; whereas the studies reporting that the titer was unchanged did not indicate what detection substrate was used&#46; Therefore&#44; we speculated that the variability of anti-gp210 titers is related to different substrates in antibody detection&#46; Currently&#44; UDCA-refractory anti-gp210-positive PBC patients lack effective therapeutic strategies and have worse prognoses as compared to anti-gp210-negative patients&#46; Thus&#44; exploring new therapeutic targets is urgently needed&#46;</p><elsevierMultimedia ident="tbl0001"></elsevierMultimedia></span><span id="sec0003" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">3</span><span class="elsevierStyleSectionTitle" id="cesectitle0006">Anti-gp210-positive PBC patients have severe biochemical liver tests and histological indexes</span><p id="para0009" class="elsevierStylePara elsevierViewall">In biochemical liver tests&#44; anti-gp210-positive PBC patients have higher levels of ALP&#44; bilirubin&#44; globulin and IgM than their anti-gp210-negative counterparts&#46; In 1998&#44; Itoh <span class="elsevierStyleItalic">et al</span>&#46; <a class="elsevierStyleCrossRef" href="#bib0011">&#91;11&#93;</a> compared the biochemical liver tests in 25 and 88 anti-gp210-positive and -negative PBC patients at the first diagnosis&#44; respectively&#44; and found that the levels of ALT and total bilirubin were significantly higher in anti-gp210-positive PBC patients than that in anti-gp210-negative patients&#46; Subsequently&#44; anti-gp210-positive PBC patients had significantly higher liver biochemical and immunological indicators than their anti-gp210-negative counterparts &#40;<a class="elsevierStyleCrossRef" href="#tbl0002">Table 2</a>&#41; &#91;<a class="elsevierStyleCrossRef" href="#bib0004">4</a>&#44;<a class="elsevierStyleCrossRef" href="#bib0005">5</a>&#44;<a class="elsevierStyleCrossRef" href="#bib0007">7</a>&#44;<a class="elsevierStyleCrossRef" href="#bib0011">11</a>&#44;<a class="elsevierStyleCrossRef" href="#bib0012">12</a>&#44;<a class="elsevierStyleCrossRef" href="#bib0017">17</a>&#93;&#46; Therefore&#44; anti-gp210-positive PBC patients had higher serum levels of bile duct injury-related indicators at the initial diagnosis as compared with anti-gp210-negative patients&#44; thereby suggesting more severe bile duct injury at the early stage of the disease&#46;</p><elsevierMultimedia ident="tbl0002"></elsevierMultimedia><p id="para0010" class="elsevierStylePara elsevierViewall">Currently&#44; the histological studies of anti-gp210 related are limited&#46; Nakamura <span class="elsevierStyleItalic">et al</span>&#46; <a class="elsevierStyleCrossRef" href="#bib0005">&#91;5&#93;</a> enrolled 23 anti-gp210-positive PBC patients and found that anti-gp210 titers were sustained at high levels in 10 patients after UDCA treatment&#44; and showed more severe interface hepatitis and higher activity score than the patients with reduced titer&#46; Subsequently&#44; Nakamura <span class="elsevierStyleItalic">et al</span>&#46; <a class="elsevierStyleCrossRef" href="#bib0006">&#91;6&#93;</a> had done immunohistochemical staining using gp210 monoclonal antibody in the liver tissue&#44; and for the first time&#44; they proposed that the expression of gp210 antigen was increased on the nuclear envelope of BECs of small bile ducts in PBC patients as compared to healthy controls&#46; Furthermore&#44; in this study&#44; gp210 immunostained BECs were generally surrounded by inflammatory cells or fibrous tissues&#44; and the degree of gp210 expression was positively correlated with portal inflammation&#44; interface hepatitis&#44; and lobular inflammation&#44; thereby suggesting that the expression of gp210 antigen may be involved in the chemotactic process of lymphocytes infiltrating to BECs in PBC&#46; However&#44; there was no correlation between the high expression of gp210 antigen in the BECs and the positivity of anti-gp210 in the serum&#44; thus further studies are needed to elucidate the relationship between the gp210 antigen production in BECs and anti-gp210 production in serum&#46;</p></span><span id="sec0004" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">4</span><span class="elsevierStyleSectionTitle" id="cesectitle0007">Molecular structures of anti-gp210 and gp210 antigen and the application in PBC</span><p id="para0011" class="elsevierStylePara elsevierViewall">Anti-gp210 is a reliable indicator for the diagnosis of PBC&#46; The anti-gp210 positivity rates were 14&#46;3&#37;&#8211;48&#46;2&#37; and 15&#46;4&#37;&#8211;46&#46;7&#37; in PBC patients and AMA-negative PBC patients&#44; with specificity of over 99&#37; and sensitivity of approximately 25&#37; &#91;<a class="elsevierStyleCrossRefs" href="#bib0004">4&#8211;17</a>&#44;<a class="elsevierStyleCrossRef" href="#bib0024">24</a>&#93;&#46; The study addressing the diagnostic accuracy of anti-gp210 for PBC diagnosis was performed in more than 4000 sera from patients suspected of having liver and non-liver autoimmune and non-autoimmune diseases&#44; thereby demonstrating a very high specificity and positive predictive value for the diagnosis of PBC <a class="elsevierStyleCrossRef" href="#bib0026">&#91;26&#93;</a>&#46; This suggests that anti-gp210 is highly correlated with the pathogenesis of PBC&#46;</p><p id="para0012" class="elsevierStylePara elsevierViewall">In 1985&#44; Ruffati <span class="elsevierStyleItalic">et al</span>&#46; <a class="elsevierStyleCrossRef" href="#bib0020">&#91;20&#93;</a> discovered that anti-gp210 was an antinuclear membrane antibody that labeled the nucleus of Hep-2 cells with a rim-like pattern&#46; The anti-gp210 antibody belonged to IgG&#44; a specific antibody against the antigens including DNase I&#44; RNase&#44; and trypsin &#91;<a class="elsevierStyleCrossRef" href="#bib0027">27</a>&#44;<a class="elsevierStyleCrossRef" href="#bib0028">28</a>&#93;&#46; The sensitivity of anti-gp210 and the corresponding immunofluorescence pattern is higher when the detection of autoantibodies is performed at the level of IgG isotype &#40;in particular IgG1 isotype&#41; because it determines a wide gain in terms of sensitivity without a loss of specificity <a class="elsevierStyleCrossRef" href="#bib0029">&#91;29&#93;</a>&#46; Anti-gp210 has high specificity but low sensitivity for the diagnosis of PBC&#46; Therefore&#44; other antinuclear antibodies in AMA -negative PBC cases are been investigated&#46; Antibodies to hexokinase 1 &#40;HK1&#41; and kelch-like 12 &#40;KLHL12&#41; were described as additional biomarkers in these patients &#91;<a class="elsevierStyleCrossRef" href="#bib0030">30</a>&#44;<a class="elsevierStyleCrossRef" href="#bib0031">31</a>&#93;&#46;</p><p id="para0013" class="elsevierStylePara elsevierViewall">Gp210 protein can be found in most nucleus cells&#44; located on the nuclear membrane as one of the constituent proteins of the nuclear pore complex&#46; Gp210 is a 210&#8239;kDa type I integral membrane protein that assembles nuclear pore protein after mitosis and fixes nuclear pore complex to the pore membrane&#46; More importantly&#44; gp210 protein mediates nuclear pore expansion and macromolecular transport between the nucleus and the cytoplasm <a class="elsevierStyleCrossRef" href="#bib0032">&#91;32&#93;</a>&#46; In addition&#44; gp210 consists of three domains&#44; including a 1808 amino acid amino-terminal domain situated in the perinuclear space&#44; a 20 amino acid transmembrane segment&#44; and a 58 amino acid carboxy-terminal tail domain &#40;<a class="elsevierStyleCrossRef" href="#fig0001">Fig&#46; 1</a>&#41; &#91;<a class="elsevierStyleCrossRef" href="#bib0033">33</a>&#44;<a class="elsevierStyleCrossRef" href="#bib0034">34</a>&#93;&#46; Collectively&#44; these studies elucidated the localization&#44; function&#44; and structure of the gp210 antigen&#44; thereby laying the foundation for the subsequent antibody detection and the production mechanism of anti-gp210&#46;</p><elsevierMultimedia ident="fig0001"></elsevierMultimedia><p id="para0014" class="elsevierStylePara elsevierViewall">Regarding the antigen-antibody interaction&#44; two gp210 epitopes have been identified by serum anti-gp210 of PBC patients&#46; One is the 15 amino acids located at the carboxy-terminal tail and the other one is in the glycosylation regions at the amino-terminal domain &#91;<a class="elsevierStyleCrossRef" href="#bib0021">21</a>&#44;<a class="elsevierStyleCrossRef" href="#bib0022">22</a>&#93;&#46; Thus&#44; these two structural regions are important molecular regions to study gp210 and anti-gp210 as well as their roles in PBC&#46; In 1993&#44; Nickowitz <span class="elsevierStyleItalic">et al</span>&#46; <a class="elsevierStyleCrossRef" href="#bib0021">&#91;21&#93;</a> detected serum antibodies of 25 anti-gp210-positive PBC patients using bacterial gp210 fusion proteins and demonstrated that 15 amino acids in the carboxy-terminal tail domain between 1869 and 1883 can bind to anti-gp210&#46; Subsequently&#44; Bandin O <span class="elsevierStyleItalic">et al</span>&#46; <a class="elsevierStyleCrossRef" href="#bib0016">&#91;16&#93;</a> demonstrated that 97&#46;2&#37; &#40;70&#47;72&#41; of the serum antibodies of anti-gp210-positive PBC patients identified the same carboxy-terminal epitope&#46; Thus&#44; the carboxy-terminal epitope of gp210 protein has been widely recognized in previous studies&#46; Moreover&#44; Wesierska-Gadek <span class="elsevierStyleItalic">et al</span>&#46; <a class="elsevierStyleCrossRef" href="#bib0022">&#91;22&#93;</a> confirmed that the recognition epitopes to anti-gp210 existed in the glycosylation domain of the amino-terminal of gp210&#46; In this study&#44; 12 anti-gp210-positive PBC patients were enrolled&#44; and antibodies against an epitope within the glycosylation domain of the amino-terminal and in the carboxy-terminal tail were detected in the sera of 8 and 4 patients&#44; respectively&#46; Howeve&#44; the above studies suggest that the detection of antibodies with bacterial gp210 fusion proteins has certain limitations&#46; Therefore&#44; in the future&#44; it is necessary to develop a detection kit for dual epitopes of anti-gp210 and explore additional detection sites to improve the sensitivity of antibody detection and avoid the delay of diagnosis and timely treatment in PBC patients&#46;</p></span><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">5</span><span class="elsevierStyleSectionTitle" id="cesectitle0008">Pathogenesis of anti-gp210-positive PBC patients</span><p id="para0015" class="elsevierStylePara elsevierViewall">The rate of anti-gp210 positivity among PBC patients in different studies varies in different countries and human species &#40;<a class="elsevierStyleCrossRef" href="#tbl0003">Table 3</a>&#41; <a class="elsevierStyleCrossRefs" href="#bib0004">&#91;4&#8211;16&#93;</a>&#46; The detection rate of anti-gp210 in Chinese and German is higher than that in other countries&#44; ranging from 35&#46;7&#37; to 48&#46;2&#37;&#46; This difference suggests that genetic and environmental factors play an important role in the production of anti-gp210 in PBC&#46;</p><elsevierMultimedia ident="tbl0003"></elsevierMultimedia><p id="para0016" class="elsevierStylePara elsevierViewall">However&#44; the mechanism of anti-gp210 in the development of PBC remains unclear&#46; Regarding genetics&#44; Wang <span class="elsevierStyleItalic">et al</span>&#46; <a class="elsevierStyleCrossRef" href="#bib0014">&#91;14&#93;</a> conducted genome-wide association studies &#40;GWAS&#41; in 930 Chinese PBC patients based on their autoantibody status &#40;anti-gp210 and anti-sp100&#41;&#44; of which 350&#47;912 &#40;38&#46;4&#37;&#41; were anti-gp210-positive patients&#44; and no specific human leukocyte antigen &#40;HLA&#41; allele or single-nucleotide polymorphism &#40;SNP&#41; associated with anti-gp210 was found&#46; In terms of environmental factors&#44; Tang R <span class="elsevierStyleItalic">et al</span>&#46; <a class="elsevierStyleCrossRef" href="#bib0035">&#91;35&#93;</a> analyzed the gut microbiome of 116 Chinese PBC patients and found that the gut microbiome of anti-gp210-positive patients showed relatively lower species richness and <span class="elsevierStyleItalic">Faecalibacterium spp</span> abundance than the anti-gp210-negative patients&#44; thereby indicating that the gut microbiota may play a role in the pathogenesis of anti-gp210-positive PBC patients&#46;</p><p id="para0017" class="elsevierStylePara elsevierViewall">Therefore&#44; for the epitopes of anti-gp210 to be deeply investigated&#44; some studies have found that molecular mimicry&#44; induced by proteins with similar amino acid sequences to epitopes&#44; may be one of the main mechanisms in anti-gp210 production&#46; Molecular mimicry is the process by which exogenous antigens activate autoreactive T or B cells in susceptible individuals because of the similarity between exogenous peptides and self-peptides <a class="elsevierStyleCrossRef" href="#bib0036">&#91;36&#93;</a>&#46; Before the 1990s&#44; the transmembrane topology of gp210 closely resembled the envelope glycoproteins topology of various animal viruses <a class="elsevierStyleCrossRefs" href="#bib0037">&#91;37&#8211;39&#93;</a>&#46; Subsequently&#44; Nickowitz <span class="elsevierStyleItalic">et al</span>&#46; <a class="elsevierStyleCrossRef" href="#bib0021">&#91;21&#93;</a> demonstrated that the cytoplasmic carboxy-terminal tail epitope of anti-gp210 had six consecutive amino acids which were homologous to the protein products of the <span class="elsevierStyleItalic">Escherichia coli mutY</span> and <span class="elsevierStyleItalic">Salmonella typhimurium mutB</span> genes&#46; In addition&#44; Haruta <span class="elsevierStyleItalic">et al</span>&#46; <a class="elsevierStyleCrossRef" href="#bib0040">&#91;40&#93;</a> found that <span class="elsevierStyleItalic">Streptococcus intermedius</span> &#40;<span class="elsevierStyleItalic">S&#46;i&#46;</span>&#41; could induce the generation of anti-gp210 and cellular infiltration around the bile ducts in BALB&#47;c mice&#46; Moreover&#44; the antibody against histone-like DNA-binding protein of <span class="elsevierStyleItalic">Streptococcus intermedius</span> &#40;<span class="elsevierStyleItalic">S&#46;i&#46;</span>-HLP&#41; could bind to synthetic gp210 peptide&#46; Thus&#44; these studies suggest that bacteria or viruses may induce the production of anti-gp210 through molecular mimicry &#40;<a class="elsevierStyleCrossRef" href="#fig0002">Fig&#46; 2</a>&#41;&#46; Clinical studies also found that anti-gp210 could persist for more than 10 years after liver transplantation in some PBC patients <a class="elsevierStyleCrossRefs" href="#bib0009">&#91;9&#8211;11&#93;</a>&#44; thereby further suggesting that the antigen inducing the generation of anti-gp210 might not be derived from the liver&#46; Bacteria-induced molecular mimicry in the production of anti-gp210 may provide new insights into the pathogenesis of anti-gp210-positive PBC patients&#46; In addition to exogenous peptides such as bacteria and viruses&#44; molecular mimicry exists between endogenous peptides such as mitochondria and gp210 in PBC&#46; Shimoda <span class="elsevierStyleItalic">et al</span>&#46; <a class="elsevierStyleCrossRef" href="#bib0041">&#91;41&#93;</a> discovered that the selected specific T cell clones of a peptide corresponding to the mitochondrial pyruvate dehydrogenase complex E2 subunit could cross-react with the synthetic peptide of gp210&#44; thereby indicating a possible cross pathway existed between AMA and the production process of anti-gp210&#46; Furthermore&#44; T cell clones selected by recombinant gp210 protein simultaneously reacted with the mimicry peptide of amino acid 188&#8211;201 in gp210&#44; thereby indicating that the amino acid 188&#8211;201 in gp210 was one of the immunodominant T cell epitopes&#46;</p><elsevierMultimedia ident="fig0002"></elsevierMultimedia><p id="para0018" class="elsevierStylePara elsevierViewall">Current research on the relationship between anti-gp210 and the pathogenesis of PBC is very limited&#46; Notably&#44; anti-gp210 can be detected in the serum of the dominant-negative form of TGF-&#946; receptor type II &#40;dnTGF-&#946;RII&#41; mice&#44; one of the main model mice of PBC&#46; In addition&#44; Yang CY <span class="elsevierStyleItalic">et al</span>&#46; <a class="elsevierStyleCrossRef" href="#bib0042">&#91;42&#93;</a> found that the titer of anti-gp210 was significantly reduced by deleting specific cytokines &#40;including IL-12p40&#44; IL-23p19&#44; IL-17&#44; IL-6&#44; and TNF-&#945;&#41; in dnTGF-&#946;RII mice&#44; thereby suggesting that these cytokines may be involved in the production of anti-gp210&#46; In recent years&#44; studies on immune cells and the pathogenesis of PBC are actively underway&#44; and thus clarifying the pathogenesis of anti-gp210-positive PBC is essential to explore new therapeutic intervention targets for these patients&#46; Collectively&#44; current research on the pathogenesis of anti-gp210-positive PBC primarily focuses on aspects including genetic and environmental factors&#44; molecular mimicry&#44; and cytokines&#46; Therefore&#44; an in-depth investigation of the interrelationship among the above three aspects could provide direction for further study on anti-gp210-positive PBC&#46;</p></span><span id="sec0006" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">6</span><span class="elsevierStyleSectionTitle" id="cesectitle0009">Discussion and prospect</span><p id="para0019" class="elsevierStylePara elsevierViewall">Anti-gp210-positive PBC patients present with more severe biochemical indexes&#44; severe bile duct injury and liver inflammation in histology&#44; poorer response to treatment drugs&#44; faster disease progression&#44; and a worse prognosis than anti-gp210-negative patients&#46; It is of clinical importance to identify the pathogenesis of anti-gp210-positive PBC and find preventive measures against the etiology to guide the diagnosis and treatment of the disease&#46;</p></span><span id="sec0007" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">7</span><span class="elsevierStyleSectionTitle" id="cesectitle0010">Conclusions</span><p id="para0020" class="elsevierStylePara elsevierViewall">Anti-gp210 is an autoantibody against the nuclear membrane protein gp210&#44; and thus the study of anti-gp210 and the antigen is essential for the pathogenesis of anti-gp210-positive PBC&#46; Moreover&#44; the species richness of gut microbiome in anti-gp210-positive PBC patients was lower than that in anti-gp210-negative patients&#44; thereby suggesting that intestinal microecology may participate in disease development and progression&#46; Molecular mimicry by bacteria is currently the main hypothesis for the pathogenesis&#44; which still needs to be further explored&#46; The study on the localization&#44; structure&#44; and epitope of gp210 antigen has laid a certain theoretical foundation for the study of anti-gp210-positive PBC pathogenesis&#46; With the development of epidemiology&#44; genetics&#44; and animal models&#44; further elucidation of the generation and molecular mechanism of anti-gp210 in PBC will be crucial for clinical prevention and treatment&#46;</p></span></span>"
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          "titulo" => "Introduction"
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          "titulo" => "Anti-gp210-positive PBC patients have poor treatment response and prognosis"
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          "titulo" => "Anti-gp210-positive PBC patients have severe biochemical liver tests and histological indexes"
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        6 => array:2 [
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          "titulo" => "Molecular structures of anti-gp210 and gp210 antigen and the application in PBC"
        ]
        7 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Pathogenesis of anti-gp210-positive PBC patients"
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          "titulo" => "Discussion and prospect"
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        9 => array:2 [
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            1 => "Primary biliary cholangitis"
            2 => "Treatment response"
            3 => "Pathogenesis"
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        1 => array:4 [
          "clase" => "abr"
          "titulo" => "Abbreviations"
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          "palabras" => array:12 [
            0 => "PBC"
            1 => "AMA"
            2 => "ANA"
            3 => "UDCA"
            4 => "OCA"
            5 => "BECs"
            6 => "AST"
            7 => "ALP"
            8 => "IgM"
            9 => "GWAS"
            10 => "HLA"
            11 => "SNP"
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        "resumen" => "<span id="abss0001" class="elsevierStyleSection elsevierViewall"><p id="spara009" class="elsevierStyleSimplePara elsevierViewall">Anti-gp210 is the disease-specific anti-nuclear antibody &#40;ANA&#41; of primary biliary cholangitis &#40;PBC&#41;&#46; Anti-gp210-positive PBC patients have worse responses to ursodeoxycholic acid &#40;UDCA&#41; as compared with anti-gp210-negative patients&#46; Moreover&#44; anti-gp210-positive patients always present with more severe histopathologic features including lobular inflammation&#44; interfacial hepatitis&#44; and bile duct injury&#44; and have a worse prognosis than their anti-gp210-negative counterparts&#46; Previous studies have identified two antigenic epitopes recognized by anti-gp210&#46; Although the pathogenetic mechanism of anti-gp210 production remains unclear&#44; evidence suggests that the autoimmune response to anti-gp210 production might be due to molecular mimicry induced by bacteria or endogenous peptides&#46; T cells and related cytokines play a critical role in the pathogenesis of PBC&#44; however&#44; the mechanism hasn&#39;t been fully understood&#46; Thus&#44; this review focuses on the clinicopathological characteristics of anti-gp210-positive PBC patients&#44; the fundamental research of gp210 antigen&#44; and the possible mechanism of anti-gp210 production to clarify the mechanism of anti-gp210-positive PBC and provide potential molecular targets for disease prevention and treatment in the future&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="notep0001">Xiaoyi Wang&#44; Zhen Yang&#44; Ying Ran contributed equally to this work&#46;</p>"
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          "en" => "<p id="spara001" class="elsevierStyleSimplePara elsevierViewall">The structural diagram of nuclear pore membrane protein gp210&#46;</p>"
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          "leyenda" => "<p id="spara004" class="elsevierStyleSimplePara elsevierViewall">IIF&#44; indirect immunofluorescence&#59; ELISA&#44; enzyme-linked immunosorbent assay&#59; IB&#44; immunoblot&#46;</p>"
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                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Country of cases&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Detection of substrate&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Variable titers &#40;Follow up number&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><a name="en0007"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">IIF &#40;Rim-like&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0008"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1998 <a class="elsevierStyleCrossRef" href="#bib0011">&#91;11&#93;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0009"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Japan&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0010"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">HepG2 cells&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0011"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">NO &#40;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0012"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">87&#46;5&#8239;&#177;&#8239;56&#46;0 m&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0013"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0014"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2003 <a class="elsevierStyleCrossRef" href="#bib0012">&#91;12&#93;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0015"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Italy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0016"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">HEp-2 cell lines&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0017"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Not investigated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0018"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0019"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">ELISA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0020"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2003 <a class="elsevierStyleCrossRef" href="#bib0012">&#91;12&#93;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0021"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Italy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0022"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Purified gp210 ELISA kits &#40;IMTEC&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0023"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">NO &#40;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0024"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">3&#8211;10 y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0025"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0026"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2005 <a class="elsevierStyleCrossRef" href="#bib0005">&#91;5&#93;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0027"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Japan&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0028"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">gp210 C-terminal peptide&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0029"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">YES &#40;23&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0030"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">73&#46;4&#8239;&#177;&#8239;54&#46;3 m&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0031"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0032"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2007 <a class="elsevierStyleCrossRef" href="#bib0013">&#91;13&#93;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0033"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Japan&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0034"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">gp210 C-terminal peptide &#40;25 amino acids&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0035"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">YES &#40;217&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0036"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1&#8211;292 m&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0037"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0038"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2014 <a class="elsevierStyleCrossRef" href="#bib0008">&#91;8&#93;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0039"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Japan&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0040"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">gp210 C-terminal peptide &#40;25 amino acids&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0041"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">YES &#40;50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0042"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">6&#8211;12 m&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab3255935.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spara003" class="elsevierStyleSimplePara elsevierViewall">The substrate used in detection anti-gp210 and the variability of anti-gp210&#46;</p>"
        ]
      ]
      3 => array:8 [
        "identificador" => "tbl0002"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "alt0004"
            "detalle" => "Table 2&#58"
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spara006" class="elsevierStyleSimplePara elsevierViewall">TP&#44; total protein&#59; ALB&#44; albumin&#59; GLB&#44; globulin&#59; ALT&#44; alanine aminotransferase&#59; AST&#44; aspartate aminotransferase&#59; ALP&#44; alkaline phosphatase&#59; GGT&#44; &#947;-glutamyl transferase&#59; TBIL&#44; total bilirubin&#59; DBIL&#44; direct bilirubin&#59; TC&#44; total cholesterol&#59; Ig&#44; immunoglobulin&#59; Plt&#44; platelet&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><a name="en0043"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Clinical research&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0044"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Time&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0045"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Country&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0046"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Number of patients&#37; &#40;gp210&#43;&#47;PBC&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0047"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Indicators with statistical difference&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><a name="en0048"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Itoh S et al&#46; <a class="elsevierStyleCrossRef" href="#bib0011">&#91;11&#93;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0049"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1998&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0050"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Japan&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0051"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">22&#46;1 &#40;25&#47;113&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0052"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">ALP&#44; TBIL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0053"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Paolo et al&#46; <a class="elsevierStyleCrossRef" href="#bib0012">&#91;12&#93;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0054"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2003&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0055"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Italy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0056"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">15&#46;6 &#40;15&#47;96&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0057"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">ALP&#44; GGT&#44; TC&#44; ALB&#44; &#947;-GLB&#44; IgA&#44; IgM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0058"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Minoru et al&#46; <a class="elsevierStyleCrossRef" href="#bib0005">&#91;5&#93;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0059"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2005&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0060"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Japan&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0061"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">32&#46;4 &#40;23&#47;71&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0062"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">IgM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0063"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Dimitrioa et al&#46; <a class="elsevierStyleCrossRef" href="#bib0017">&#91;17&#93;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0064"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2007&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0065"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Spain and Greece&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0066"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">10&#46;5 &#40;38&#47;362&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0067"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">ALP&#44; DBIL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0068"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Yang et al&#46; <a class="elsevierStyleCrossRef" href="#bib0007">&#91;7&#93;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0069"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2017&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0070"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">China&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0071"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">48&#46;2 &#40;133&#47;276&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0072"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">GGT&#44; TBIL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0073"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Haldar et al&#46; <a class="elsevierStyleCrossRef" href="#bib0004">&#91;4&#93;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0074"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2021&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0075"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">UK&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0076"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">16&#46;7 &#40;81&#47;486&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0077"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">AST&#44; ALT&#44; TBIL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab3255937.png"
              ]
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spara005" class="elsevierStyleSimplePara elsevierViewall">Biochemical liver Indicators of anti-gp210-positive PBC patients are higher than anti-gp210-negative PBC patients&#46;</p>"
        ]
      ]
      4 => array:8 [
        "identificador" => "tbl0003"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "alt0005"
            "detalle" => "Table 3&#58"
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spara008" class="elsevierStyleSimplePara elsevierViewall">IIF&#44; indirect immunofluorescence&#59; ELISA&#44; enzyme-linked immunosorbent assay&#59; IB&#44; immunoblot&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><a name="en0078"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Methods of detection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0079"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Time&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0080"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Country of cases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0081"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Positivity&#37; &#40;Anti-gp210&#43;&#47;PBC&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0082"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Positivity&#37; &#40;Anti-gp210&#43;&#47;AMA- PBC&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><a name="en0083"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">IIF &#40;Rim-like&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0084"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1996 <a class="elsevierStyleCrossRef" href="#bib0016">&#91;16&#93;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0085"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">France&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0086"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">30&#46;5 &#40;87&#47;285&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0087"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">46&#46;7 &#40;7&#47;15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0088"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0089"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1998 <a class="elsevierStyleCrossRef" href="#bib0011">&#91;11&#93;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0090"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Japan&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0091"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">27&#46;4 &#40;31&#47;113&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0092"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">18&#46;2 &#40;2&#47;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0093"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0094"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2003 <a class="elsevierStyleCrossRef" href="#bib0012">&#91;12&#93;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0095"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Italy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0096"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">10&#46;0 &#40;9&#47;91&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0097"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">33&#46;0 &#40;5&#47;19&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0098"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">ELISA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0099"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1996 <a class="elsevierStyleCrossRef" href="#bib0016">&#91;16&#93;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0100"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">France&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0101"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">25&#46;5 &#40;73&#47;285&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0102"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">46&#46;8 &#40;7&#47;15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0103"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0104"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2003 <a class="elsevierStyleCrossRef" href="#bib0012">&#91;12&#93;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0105"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Italy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0106"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">16&#46;0 &#40;15&#47;96&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0107"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">15&#46;4 &#40;2&#47;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0108"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0109"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2005 <a class="elsevierStyleCrossRef" href="#bib0005">&#91;5&#93;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0110"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Japan&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0111"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">32&#46;4 &#40;23&#47;71&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0112"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0113"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0114"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2006 <a class="elsevierStyleCrossRef" href="#bib0006">&#91;6&#93;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0115"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Japan&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0116"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">38&#46;5 &#40;20&#47;52&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0117"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0118"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0119"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2007 <a class="elsevierStyleCrossRef" href="#bib0013">&#91;13&#93;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0120"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Japan&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0121"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">26&#46;1 &#40;72&#47;276&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0122"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0123"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0124"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2014 <a class="elsevierStyleCrossRef" href="#bib0008">&#91;8&#93;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0125"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Japan&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0126"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">30&#46;5 &#40;50&#47;164&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0127"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0128"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0129"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2019 <a class="elsevierStyleCrossRef" href="#bib0014">&#91;14&#93;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0130"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">China&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0131"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">38&#46;4 &#40;350&#47;912&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0132"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0133"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">IB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0134"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1996 <a class="elsevierStyleCrossRef" href="#bib0016">&#91;16&#93;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0135"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">France&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0136"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">25&#46;3 &#40;72&#47;285&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0137"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0138"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0139"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1997 <a class="elsevierStyleCrossRef" href="#bib0010">&#91;10&#93;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0140"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">USA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0141"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">25&#46;7 &#40;9&#47;35&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0142"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0143"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0144"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1998 <a class="elsevierStyleCrossRef" href="#bib0011">&#91;11&#93;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0145"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Japan&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0146"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">22&#46;1 &#40;25&#47;113&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0147"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">20&#46;0 &#40;1&#47;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0148"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0149"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1998 <a class="elsevierStyleCrossRef" href="#bib0009">&#91;9&#93;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0150"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Germany&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0151"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">35&#46;7 &#40;15&#47;42&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0152"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0153"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0154"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2003 <a class="elsevierStyleCrossRef" href="#bib0012">&#91;12&#93;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0155"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Japan&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0156"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">26&#46;3 &#40;46&#47;175&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0157"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">18&#46;5 &#40;10&#47;54&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0158"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0159"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2003 <a class="elsevierStyleCrossRef" href="#bib0015">&#91;15&#93;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0160"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Japan&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0161"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">28&#46;2 &#40;46&#47;163&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0162"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0163"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0164"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2017 <a class="elsevierStyleCrossRef" href="#bib0007">&#91;7&#93;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0165"></a><td class="td" title="\n
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