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Original article
Multiple system atrophy: Clinical, evolutive and histopathological characteristics of a series of cases
Atrofia multisistémica: características clínicas, anatomopatológicas y evolución de una serie de casos
M. Carmona-Abellana,
Corresponding author
marcarmonaabellan@gmail.com

Corresponding author.
, R. Del Pinoa, A. Murueta-Goyenaa, M. Aceraa, B. Tijeroa,b, K. Berganzod, I. Gabilondoa,b,c, J.C. Gómez-Estebana,b
a Neurodegenerative Diseases Division, Health Research Institute Biocruces, Barakaldo, Bizkaia, Spain
b Hospital Universitario de Cruces, Barakaldo, Bizkaia, Spain
c Ikerbasque, The Basque Foundation for Science, Spain
d Hospital Universitario de Basurto, Bilbao, Bizkaia, Spain
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Cumulative survival rate&#46; Kaplan&#8211;Meier curves illustrating survival rate in MSA cerebellar and parkinsonian phenotype&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Multiple System Atrophy &#40;MSA&#41; is a rare and rapidly progressive neurodegenerative disorder that is characterized by a combination of parkinsonism&#44; cerebellar impairment and autonomic dysfunction&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">1</span></a> Patients are divided into MSA-Parkinsonism &#40;MSA-P&#41; or MSA-Cerebellar &#40;MSA-C&#41; depending on the predominance of parkinsonism or cerebellar symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">2</span></a> The current diagnostic criteria also distinguish between levels of certainty&#44; differentiating definite MSA for subjects with autopsy demonstration&#44; probable MSA for patients with autonomic failure plus parkinsonism or cerebellar ataxia&#44; and possible MSA for people with sporadic&#44; progressive adult-onset disease including parkinsonism or cerebellar ataxia and one autonomic feature plus other clinical or neuroimaging abnormality&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In 1969&#44; Graham and Oppenheimer first introduced the term MSA to encompass the pathological entities of olivopontocerebellar atrophy&#44; striatonigral degeneration&#44; and Shy-Drager syndrome on the basis of the neuropathological findings in these disorders&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">3</span></a> The neuropathological hallmark of the disease is the presence of alpha-synuclein &#40;&#945;-synuclein&#41; aggregates in oligodendrocytes forming glial cytoplasmic inclusions<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">4&#44;5</span></a> &#40;Papp-Lantos bodies&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">4</span></a> observed in all types of oligodendroglia that contain aggregates of misfolded &#945;-Synuclein&#44; however GCIs are present not only in known atrophic areas but also in areas without atrophy such as the cortex&#46; Hence&#44; MSA is a oligodendroglial &#945;-synucleinopathy&#46; Macroscopically&#44; MSA is characterized by striatal atrophy and depigmentation of the substantia nigra&#46; In some cases&#44; striatal degeneration is histological without macroscopic atrophy&#46; These findings are associated with olivopontocerebellar atrophy&#44; which may be macroscopically evident&#46; The neuropathology of sporadic MSA also includes varying degrees of demyelination and atrophy&#44; especially in the cerebellum&#44; pons and medulla&#44; the loss of pigmented cells in the substantia nigra pars compacta and the classic MSA microscopic oligondendroglial inclusion pathology&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">6</span></a> The neuronal loss is mainly present in the putamen&#44; substantia nigra&#44; pons&#44; inferior olive&#44; and cerebellum&#44;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">7</span></a> which involves striatonigral or olivopontocerebellar structures&#46; Loss of Purkinje cells affects mainly the vermis and gliosis and neurodegeneration are observed in the pons and cerebellum&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The etiology is still unknown and the origin of &#945;-synuclein deposits and its role in the pathophysiology of the disease is still unclear&#46; Other relevant aspects regarding the pathogenesis of MSA are neuroinflammation&#44; mitochondrial dysfunction&#44; oxidative stress and impaired autophagy and insulin resistance&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">8</span></a> The diagnosis of MSA is based on a medical history and neurological examination&#46; Diagnostic criteria have been described<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">1&#44;9</span></a> and recently some of the critical issues have been reviewed in order to achieve a better sensitivity&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">10</span></a> Ancillary investigations help to support the diagnosis and complete the differential diagnosis&#44; but specificity and sensitivity of current diagnostic criteria are not high enough&#46; In this regard&#44; biomarkers could help as to increase sensitivity and specificity&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">11</span></a> Although Magnetic Resonance Imaging &#40;MRI&#41; can be normal in MSA&#44; especially in the early stages of the disease&#44;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">12</span></a> volume measures of different regions has been performed to discriminate MSA from PD with 100&#37; accuracy<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">13</span></a> and some signs such as the &#8220;hot cross bun&#8221; can be suggestive&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">14</span></a> Due to the heterogeneity of clinical phenotype and lack of specific biomarkers&#44; it is challenging to make a correct diagnosis of MSA&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">15</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">We here review the main features of a large retrospective series of cases with MSA&#44; with the aim of describing clinical and neuropathological findings of MSA&#44; to try to improve sensitivity and specificity of the current diagnostic criteria from early stages&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">We retrospectively studied 51 MSA patients&#44; who were referred to the Movement Disorders Unit&#44; Hospital Universitario de Cruces &#40;Barakaldo&#44; Vizcaya&#41;&#44; from 2000 to 2019&#44; with parkinsonism&#44; ataxia&#44; autonomic failure or multiple system atrophy diagnosis and met MSA criteria&#46; Established MSA criteria<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">1</span></a> were applied by senior investigators to include patients in the study&#46; Therefore&#44; patients with probable or possible MSA-P or MSA-C were included&#46; We also included three definite MSA who had post-mortem confirmed diagnosis&#46; Neuropathological study was performed following the standard protocol from the Biobank&#46; Other cases with adult onset ataxia or parkinsonism&#44; not meeting criteria at the end of follow-up&#44; despite of suspicion&#44; were excluded from the analysis&#46; The local Ethics Committee approved the research protocol &#40;CEIC E09&#47;25&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Data collection from the medical records included demographic and clinical data&#44; and assessments such as neurological examination&#44; UMSARS &#40;Unified Multiple System Atrophy Rating Scale&#41;&#44; and response to Levodopa &#40;<span class="elsevierStyleSmallCaps">l</span>-Dopa&#41;&#46; Clinical features were assessed by means of UMSARS&#44; including functional status &#40;UMSARS I&#41;&#44; neurological deficits &#40;UMSARS II&#41;&#44; autonomic examination &#40;UMSAR III&#41; and disability status &#40;UMSARS-IV&#41;&#46; We performed UMSAR scale at baseline in all patients and at 2 years follow-up in 28 patients&#46; The age at onset was defined as the age of the first symptom&#44; according to medical records&#46; In case of death&#44; date and cause of death was obtained&#46; At the autonomic disorders unit&#44; we systematically assess patients with MSA diagnosis by means of the UMSARS part I &#40;a functional subscale to score symptoms and ability to undertake activities of daily living&#41;&#44; UMSARS II &#40;neurological motor evaluation&#41;&#44; Autonomic examination and UMSARS IV &#40;global disability scale&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Conventional neuroimaging based on MRI was performed at baseline for all patients to rule out other diagnoses and complete differential diagnosis&#44; using a 3T scan&#46; MRI images were available in 40 patients&#46; In 31 patients with parkinsonism <span class="elsevierStyleSup">123</span>I-metaiodobenzylguanidine &#40;MIBG&#41; scintigraphy was performed to establish the differential diagnosis with idiopathic Parkinson&#39;s Disease &#40;PD&#41;&#46; We analyzed the early &#40;15<span class="elsevierStyleHsp" style=""></span>min&#41; and late &#40;4<span class="elsevierStyleHsp" style=""></span>h&#41; heart-to-mediastinum uptake ratios &#40;HMR&#41;&#46; We selected healthy controls who had undergone MIBG scintigraphy as routine screening for suspicion of neurovascular dysautonomia&#44; not confirmed&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Statistical analyses</span><p id="par0040" class="elsevierStylePara elsevierViewall">Demographics and clinical variables were described in order to characterize our population cohort&#46; Survival analysis was performed in both groups separately&#44; depending on the subtype &#40;parkinsonian vs cerebellar form of MSA&#41;&#44; and the Kaplan-Meier curves were used to estimate the cumulative survival probability&#46; All statistical analyses were performed using the Statistical Package for the Social Sciences &#40;SPSS&#44; version 24&#46;0&#44; Chicago&#44; Illinois&#44; USA&#41;&#46; We used Cox hazards models to calculate hazard radios for shorter survival&#46; Data are shown as mean and standard deviation&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0045" class="elsevierStylePara elsevierViewall">Fifty-one patients with a clinical diagnosis of possible &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>7&#41; or probable &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>44&#41; MSA according to the current diagnostic criteria<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">1</span></a> were evaluated&#46; Regarding subtype&#44; 32 patients &#40;62&#46;7&#37;&#41; were diagnosed as MSA-cerebellar and 19 patients &#40;37&#46;3&#37;&#41; were diagnosed as MSA-parkinsonian&#46; The mean age for all subjects included was 62<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8 years&#46; Overall&#44; there were 23 women&#44; with no differences in sex distribution when analyzing all the cases&#44; whereas by subtype there were significant differences in groups classification &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#44; as there were more women in the MSA-P group&#46; Globally&#44; disease duration was 6&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;9 years&#44; from the first symptom to death&#46; Both groups &#40;MSA-P and MSA-C&#41; had similar ages of disease onset &#40;60&#46;65<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;873 vs 62&#46;63<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;469 years old&#41; and similar disease duration &#40;7&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;1 vs 6&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;8 years&#41;&#44; with no statistically significant differences &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; As expected&#44; all MSA-C patients had cerebellar signs and 100&#37; of MSA-P patients had parkinsonism&#46; Nevertheless&#44; both groups of patients developed concomitant cerebellar and parkinsonian symptoms&#46; In detail&#44; 89&#46;5&#37; of MSA-P patients developed cerebellar signs&#44; whilst 63&#37; of patients from MSA-C group had at least one parkinsonian sign&#46; <span class="elsevierStyleSmallCaps">l</span>-Dopa therapy was given to all the subjects&#44; 56&#37; of MSA-C and 84&#37; of MSA-P had poor response to <span class="elsevierStyleSmallCaps">l</span>-Dopa treatment&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">In this series of MSA patients&#44; 54&#37; of the subjects died during the follow-up&#44; 10 from the MSA-P group and 17 MSA-C subjects&#46; Mean time &#40;months&#41; from diagnosis to death was 68&#46;65 &#40;&#177;30&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Regarding causes of death&#44; pneumonia was the most common cause of dead &#40;66&#37;&#41;&#44; specifically aspiration pneumonia &#40;33&#37;&#41;&#44; and other infectious diseases &#40;22&#37;&#41; were the main causes of death among patients with MSA&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">UMSARS</span><p id="par0055" class="elsevierStylePara elsevierViewall">Patients with MSA-P and MSA-C had similar status at baseline&#44; there were no differences in UMSARS score between MSA subtypes&#59; mean UMSARS I 26&#46;02 &#40;&#177;6&#46;9&#41;&#59; UMSARS II 25&#46;49 &#40;&#177;7&#46;1&#41;&#59; UMSARS IV 3&#46;26 &#40;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;4&#41;&#46; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; By items&#44; only rigidity &#40;increased tone in limbs&#41;&#44; rapid alternating movements of hands and posture were statistically significant different &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; between both subtypes&#44; with worse scores for MSA-P group in these items&#44; at baseline&#46; There were no differences between parkinsonian and cerebellar forms of MSA in terms of autonomic examination at baseline&#46; At this stage&#44; no correlations were observed between the magnitude of Systolic Blood Pressure Difference &#40;&#923;SBP&#41;&#44; and Diastolic Blood Pressure Difference &#40;&#923;DBP&#41;&#44; Heart Rate &#40;&#923;HR&#41; supine-standing&#44; and UMSARS-I&#44; -II or -IV &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">During the two-years follow-up&#44; a statistically significant worsening was observed &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; in both groups&#59; UMSAR I 34&#46;47 &#40;&#177;5&#46;1&#41;&#59; UMSAR II 31&#46;69<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;7&#41;&#59; UMSAR IV 4&#46;53 &#40;&#177;0&#46;6&#41;&#46; By items&#44; during follow-up&#44; we observed worse scores in all the UMSAR I items &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; except orthostatic symptoms and bowel function&#46; In UMSAR II there were statistically significant differences in all the items between baseline and after 24 months evaluation&#44; except for action tremor and rigidity &#40;<a class="elsevierStyleCrossRef" href="#sec0085">Fig&#46; 2 on Appendix A - supplementary data</a>&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">MRI results</span><p id="par0065" class="elsevierStylePara elsevierViewall">Results were compatible with MSA in 35&#47;40 patients and unspecific in 5 patients&#46; Slit like hyperintensity of the lateral putaminal border &#40;Hyperintense Putaminal Rim Sign&#41;&#44; hot cross bun sign&#44; mesencephalic&#44; putaminal or cerebellar atrophy was described in these cases&#46; It is remarkable that findings were compatible with MSA-C in 3 patients with parkinsonian phenotype and in 1 patient with cerebellar phenotype the MRI showed parkinsonian findings&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Quantitative neuroimaging with MRI volumetry at baseline was also performed&#46; Indices of neurodegeneration in the putamen&#44; middle cerebellar peduncle &#40;MCP&#41;&#44; pons&#44; and cerebellum were obtained&#46; MCP atrophy was present in 25&#37; MSA-C patients and was absent in MSA-P patients&#46; Putamen atrophy was detected only in 12&#46;5&#37; MSA-P patients&#44; whereas no MSA-C patients showed atrophy in the putamen&#46; Pons atrophy was described in 75&#37; patients with MSA-C but none of the MSA-P&#46; Mesencephalic atrophy was described in 25&#37; of MSA-P patients but none of the MSA-C patients&#46; Cerebellar atrophy was present in all MSA-C cases and also in 2 MSA-P cases&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">MIBG results</span><p id="par0075" class="elsevierStylePara elsevierViewall">MIBG turned out to be consistent with MSA diagnosis in 22 cases&#44; 15 patients with MSA-C and 7 with MSA-P&#46; MIBG analyses showed no differences between MSA patients and healthy controls &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; The mean value of late &#40;4<span class="elsevierStyleHsp" style=""></span>h&#41; HMR MIBG uptake was 1&#46;60<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;37&#46; A total of 9 patients showed cardiac sympathetic denervation&#44; 3 patients had MSA-C and 6 with MSA-P&#44; according to 1&#46;60 threshold for normality used in our hospital&#46; We observed that there was less sympathetic denervation in MSA patients than in PD patients &#40;late H&#47;M uptake ratio&#58; 1&#46;75<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;3 in MSA patients vs&#46; 1&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;3 in PD patients&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; These patients with cardiac denervation were diagnosed with MSA because they met MSA diagnostic criteria and MRI findings were compatible with MSA&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Neuropathology</span><p id="par0080" class="elsevierStylePara elsevierViewall">MSA-P patient presented a rapidly progressive rigid-akinetic syndrome&#44; with poor response to <span class="elsevierStyleSmallCaps">l</span>-Dopa and marked autonomic dysfunction&#46; DAT-SCAN showed asymmetric loss of dopamine transporter activity and MIBG uptake was normal&#46; Both MSA-C cases presented cerebellar ataxia with parkinsonism and autonomic features and cerebellar and striatal atrophy was found&#46; All cases had parkinsonian signs and striatonigral degeneration was observed&#46; As expected&#44; MSA-C phenotype had olivopontocerebellar predominant degeneration&#46; In this regard&#44; it is worth mentioning the fact that in MSA-P case striatonigral degeneration was isolated&#44; without macroscopically cerebellar atrophy&#46; Atrophy was predominant in the putamen and substantia nigra in the MSA-P case&#44; but also observed in the reticular formation&#44; periaqueductal gray and subthalamic nucleus&#46; Gliosis&#44; astrogliosis and atrophy was observed in all these areas accompanied by small iron deposits&#46; MSA-P showed striatal atrophy and substantia nigra and locus coeruleus denervation&#44; whereas both MSA-C cases had only slight striatal atrophy&#46; All cases had glial cytoplasmic inclusions&#44; observed in the cerebellum of MSA-C cases&#44; and in the striatum and substantia nigra in MSP-P cases&#44; with overstimulated astroglia and microglia&#46; Glial &#945;-synuclein inclusions were observed in subthalamic nucleus&#44; substantia nigra&#44; mesencephalon and lenticular nucleus&#44; being these aggregates ubiquitin and p62 immunoreactive&#46; Co-pathology can be present in some cases&#44; beta-amyloid deposits in MSA-C cases&#44; nevertheless it is important to note that both MSA-C cases were older than the MSA-P patient&#46; Finally&#44; in one of the MSA-C cases&#44; &#945;-synuclein deposits were present also in astrocytes and oligodendrocytes in the putamen and globus pallidus &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discussion</span><p id="par0085" class="elsevierStylePara elsevierViewall">Multiple system atrophy is a rare&#44; fatal&#44; neurodegenerative disorder with symptoms of autonomic failure associated with parkinsonism&#44; cerebellar ataxia&#44; or both&#46; According to the consensus criteria&#44; in our cohort 63&#37; of the patients were classified as cerebellar subtype&#46; The frequencies of cerebellar and parkinsonism-predominant cases in this population are different from the European registry &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#44; where the majority of patients have MSA-P&#44;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">16</span></a> whereas the olivopontocerebellar-predominant pathology was more frequent in Japanese MSA&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">17</span></a> The reason for this discrepancy could be that patients with cerebellar subtype are more commonly referred to our autonomic disorders unit&#44; whereas parkinsonian phenotype is less frequently referred&#46; The majority of patients with MSA-P were females&#44; whereas among MSA-C there were no differences in sex&#44; as described in other series&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">We here show that MSA-C and MSA-P patients have similar clinical characteristics&#44; with no differences at baseline in clinical evaluation by means of UMSARS total score&#46; At baseline&#44; patients with MSA-P showed worse scores in parkinsonian items compared to MSA-C patients&#46; It is interesting to highlight here that at least one parkinsonian sign was reported in 63&#37; of MSA-C patients&#44; being rigidity&#44; rapid alternating movements and posture statistically significate different when comparing MSA-P with MSA-C &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; MSA-P cases showed cerebellar signs in a large number of cases&#44; indicating that probably cerebellar features are less specific&#46; In this line&#44; cerebellar atrophy was present not only in MRIs from MSA-C cases but also in some MSA-P cases&#46; The neuropathological study in MSA-P cases showed subthalamic atrophy and gliosis in the substantia nigra and locus coeruleus although volumetric MRI imaging did not show alterations&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">We have found a similar natural history in both MSA-C and MSA-P&#44; with a wide overlap in signs and symptoms between both subtypes&#44; from baseline&#46; As previously described and expected&#44; parkinsonism and Cerebellar forms are characterized by a predominance of parkinsonism with striatonigral pathology and cerebellar ataxia with predominant olivopontocerebellar pathology&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">18</span></a> Nevertheless&#44; due to the overlap and the clinical heterogeneity in phenotypes the neuropathological study is still essential to make an accurate diagnosis&#46; One limitation of the study is the retrospective analyses that could have introduced some bias&#46; To minimize bias&#44; we have described clinical assessments based on diagnostic tests and specific neurological scales&#46; Data from the UMSARS-III &#40;autonomic examination&#41; are in concordance with previous descriptions&#44;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">19</span></a> highlighting the importance of autonomic tests when suspected diagnosis&#46; The clinical assessment was performed systematically and follow-up time was similar to that in other prospective studies&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">20</span></a> After two years of follow up&#44; we observed a mild&#44; but significant worsening&#44; indicating the fast progression of the disease in both subtypes &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; Interestingly&#44; MSA-C patients respond poorly to <span class="elsevierStyleSmallCaps">l</span>-Dopa but there was a 28&#37; of patients with mild <span class="elsevierStyleSmallCaps">l</span>-Dopa response&#46; In the MSA-P group only one patient had a good response to <span class="elsevierStyleSmallCaps">l</span>-Dopa&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">23</span></a> This could be explained by the fact that among MSA-C&#44; parkinsonian signs were mild&#44; it could be hypothesized that mild striatal atrophy among MSA-C patients would contribute to a better response to <span class="elsevierStyleSmallCaps">l</span>-Dopa in this group of patients&#46; MSA-P patients group&#44; showed more severe parkinsonian features&#44; accompanied by cerebellar signs in the majority of patients&#44; without improvement after <span class="elsevierStyleSmallCaps">l</span>-Dopa treatment was initiated&#46; Another limitation of the study could be the absence of genetic studies in this cohort&#44; in future studies it would be interesting to investigate which genes are related with the disease or predispose to the condition&#46; In our cohort there is a subgroup of patients with initially Pure Autonomic Failure &#40;PAF&#41; diagnoses and progression to MSA&#44; as previously reported approximately 8&#37; of patients developed MSA after 4 years follow-up&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">21</span></a> This group could increase the heterogeneity of the cohort&#44; but we should certainly include them in the natural history of MSA to better characterize the clinical spectrum of patients with MSA diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">10</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The mean time to death from diagnosis was 5&#46;6 years &#40;Median 5&#46;7 years<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;5&#41;&#46; Compared with other series&#44;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">20</span></a> time to death is shorter in this study&#46; A selection bias might be present because patients were referred when a probable diagnosis is reached&#46; Rate of mortality was the same among both subtypes&#44; with no differences between MSA-C and MSA-P &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Overall&#44; the main cause of death was pneumonia&#44; associated with bronco-aspiration in many cases&#44; due to early dysphagia&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">2</span></a> When analyzing hazard ratios for shorter survival&#44; we observed that patients with severe UMSAR-I and UMSAR-II score at baseline had a shorter median survival&#46; MSA-P has been reported as more aggressive in an European cohort<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">22</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#46; In our cohort median survival and clinical status were similar both in MSA-P and MSP-C&#44; as described in other cohorts&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">20</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Neuropsychological tests were performed&#44; but different tests were used over the years&#44; not being comparable&#46; This is one important aspect that we should include in future descriptions&#44; following a necessary general consensus&#46; Neuropsychological assessment should be included since the beginning of the disease in future prospective studies&#44; to better characterize this group of patients&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">24</span></a> Another important aspect is the lack of peripheral or fluid biomarkers&#44; not available at the moment&#44;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">25&#44;26</span></a> that could help to differentiate MSA cases from PD cases&#46; In the absence of other biomarkers&#44; MIBG scintigraphy is useful in some cases&#44; however&#44; MRI findings seems to provide higher accuracy to distinguish between PD and MSA&#46; In our series&#44; 9 patients with MSA diagnosis had cardiac sympathetic denervation&#46; In some cases MIBG did not match with clinical nor neuropathological phenotype&#44; as we previously described&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">27</span></a> In fact&#44; one of the MSA-C cases was neuropathologically confirmed and MIBG showed cardiac denervation&#46; In this case&#44; there was a massive loss of neurons in the substantia nigra&#44; with reactive gliosis and the cerebellum &#40;dentate nucleus&#41; was massively depopulated&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conclusion</span><p id="par0110" class="elsevierStylePara elsevierViewall">In conclusion&#44; in our cohort there is a substantial overlap of parkinsonian and cerebellar features&#44; from early stages of the disease&#46; In fact&#44; 89&#46;5&#37; of MSA-P patients developed cerebellar signs&#44; and 63&#37; of patients with MSA-C had at least one parkinsonian sign&#46; Existing diagnostic criteria have a low sensitivity at the early stages of the disease probably due to this overlap&#44; which agrees with mixed neuropathological findings&#46; Efforts should focus on early stages&#44; to increase sensitivity and specificity&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Rigidity&#44; alternating movements of hands and posture were significantly different between groups at baseline&#44; while there were no differences in autonomic examination&#46; After 2 years of follow-up there were differences in all the items between baseline and after 24 months evaluation&#44; except for action tremor and rigidity&#46; As we here report&#44; UMSARS performed at baseline and follow-up could be helpful to rate prognosis from early diagnosis&#46; Finally&#44; UMSARS&#44; including autonomic function testing&#44; could be useful to differentiate between MSA-C and MSA-P&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Authors&#8217; contributions</span><p id="par0120" class="elsevierStylePara elsevierViewall">MCA and JGE have contributed with conception and design of the research&#46; BT&#44; KB&#44; MA&#44; IG have contributed with acquisition of data&#46; RP&#44; AM and MCA have contributed with the analyses&#46; JGE supervised the manuscript&#46; All authors discussed the results and implications and commented on the manuscript at all stages&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Standard protocol approval</span><p id="par0125" class="elsevierStylePara elsevierViewall">Patients had been informed that their data may be used for scientific purposes and had given their informed consent&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Availability of data and materials</span><p id="par0130" class="elsevierStylePara elsevierViewall">The data that support the findings of this study are available from the corresponding author&#44; upon reasonable request&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Funding</span><p id="par0135" class="elsevierStylePara elsevierViewall">No funding has been received for this work&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Conflict of interest</span><p id="par0140" class="elsevierStylePara elsevierViewall">The corresponding author confirms on behalf of all authors that there have been no involvements that might raise the question of bias in the work reported or in the conclusions&#44; implications&#44; or opinions stated&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The authors declare that they have not conflict of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background and objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Multiple system atrophy is a rare and fatal neurodegenerative disorder&#44; characterized by autonomic dysfunction in association with either parkinsonism or cerebellar signs&#46; The pathologic hallmark is the presence of alpha-synuclein aggregates in oligodendrocytes&#44; forming glial cytoplasmic inclusions&#46; Clinically&#44; it may be difficult to distinguish form other parkinsonisms or ataxias&#44; particularly in the early stages of the disease&#46; In this case series we aim to describe in detail the features of MSA patients&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Unified MSA Rating Scale &#40;UMSARS&#41; score&#44; structural and functional imaging and cardiovascular autonomic testing&#44; are summarized since early stages of the disease&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">UMSARS proved to be useful to perform a follow-up being longitudinal examination essential to stratify risk of poor outcome&#46; Neuropathological diagnosis showed an overlap between parkinsonian and cerebellar subtypes&#44; with some peculiarities that could help to distinguish from other subtypes&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A better description of MSA features with standardized test confirmed by means of neuropathological studies could help to increase sensitivity&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Background and objective"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Material and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusion"
          ]
        ]
      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Antecedentes y objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La atrofia multisist&#233;mica es un trastorno neurodegenerativo raro y letal que se caracteriza por una disfunci&#243;n auton&#243;mica en asociaci&#243;n con parkinsonismo o signos cerebelosos&#46; La marca anatomopatol&#243;gica es la presencia de agregados de &#945;-sinucle&#237;na en los oligodendrocitos&#44; que forman inclusiones citoplasm&#225;ticas gliales&#46; Desde un punto de vista cl&#237;nico&#44; puede ser dif&#237;cil de distinguir de otros parkinsonismos o ataxias&#44; particularmente en las primeras etapas de la enfermedad&#46; En esta serie de casos&#44; nuestro objetivo es describir en detalle las caracter&#237;sticas de los pacientes con atrofia multisist&#233;mica&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se resumen los datos objetidos de la puntuaci&#243;n de la Escala de calificaci&#243;n unificada de la atrofia multisist&#233;mica &#40;UMSARS&#41;&#44; im&#225;genes estructurales y funcionales y las pruebas auton&#243;micas cardiovasculares realizadas desde las primeras etapas de la enfermedad&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La escala UMSAR demostr&#243; ser &#250;til para hacer un seguimiento&#58; el examen longitudinal esencial fue para estratificar el riesgo de peor evoluci&#243;n&#46; El diagn&#243;stico neuropatol&#243;gico mostr&#243; un solapamiento entre los subtipos parkinsoniano y cerebeloso&#44; con algunas peculiaridades que podr&#237;an ayudar a distinguir los subtipos&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Una mejor descripci&#243;n de las caracter&#237;sticas de la atrofia multisist&#233;mica en casos confirmados mediante neuropatolog&#237;a podr&#237;a ayudar a aumentar la sensibilidad del diagn&#243;stico&#46;</p></span>"
        "secciones" => array:4 [
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            "titulo" => "Antecedentes y objetivo"
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            "titulo" => "Material y m&#233;todos"
          ]
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            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusi&#243;n"
          ]
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      ]
    ]
    "apendice" => array:1 [
      0 => array:1 [
        "seccion" => array:1 [
          0 => array:4 [
            "apendice" => "<p id="par0160" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article&#58;<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary data"
            "identificador" => "sec0085"
          ]
        ]
      ]
    ]
    "multimedia" => array:7 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Cumulative survival rate&#46; Kaplan&#8211;Meier curves illustrating survival rate in MSA cerebellar and parkinsonian phenotype&#46;</p>"
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        "etiqueta" => "Table 1"
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          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">UMSARS&#44; Unified MSA Rating Scale&#44; section I&#58; disease-related impairments&#59; II&#58; motor examination&#44; IV global disability scale&#46;</p>"
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                  \t\t\t\t">25&#46;19<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">26&#46;52<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;82&nbsp;\t\t\t\t\t\t\n
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">UMSARS&#44; Unified MSA Rating Scale&#44; section III&#58; autonomic examination&#59; BPSSu&#44; Systolic blood pressure supine&#59; BPDSu&#44; diastolic blood pressure supine&#59; HRSu&#44; heart rate supine&#59; BPSSt&#44; Systolic blood pressure standing&#59; BPDSt&#44; diastolic blood pressure standing&#59; HRSt&#44; heart rate standing&#59; SBPD&#44; Systolic blood pressure drop on standing&#59; DBPD&#44; Diastolic blood pressure drop on standing&#59; Dif HR Su-St Difference of heart rate supine-standing&#46;</p>"
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">SBPD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;75<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab3332739.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Demographic data&#44; frequency of diabetes&#44; disease duration and MIBG uptake ratios for early and delayed scintigraphy images in healthy controls&#44; multisystem atrophy and idiopathic Parkinson&#39;s disease&#46;</p>"
        ]
      ]
      4 => array:8 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at4"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">STN&#44; subthalamic nucleus&#59; SN&#44; substantia nigra&#59; TDP&#44; TAR-DNA-binding protein-43&#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"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">MSA-C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">MSA-P&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Neuronal loss&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Olivopontocerebellar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Strionigral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Gliosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Cerebellum</span>&#44; <span class="elsevierStyleItalic">striatum</span>&#44; pons and dentate nucleus</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Depigmentation in the ventrolateral substantia nigra&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8730;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8730;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Neuronal loss and gliosis in the pontine nucleus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8730;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Neuronal loss with gliosis in the lateral putamen&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8730;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8730;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Iron deposits in the putamen&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8730;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Demyelination in the cerebellar white matter&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8730;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Glial cytoplasmic inclusions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cerebellum&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Striatum and substantia nigra&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Neuronal cytoplasmic inclusions in the hippocampus&#44; beta-amyloid deposits&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8730;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hippocampal atrophy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8730;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#945;-Synuclein immunoreactivity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">STN&#44; SN&#44; mesencephalon and lenticular nucleus</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">TDP-43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Negative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Negative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab3332737.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Neuropathological findings in MSA-C and MSA-P patients&#46;</p>"
        ]
      ]
      5 => array:8 [
        "identificador" => "tbl0025"
        "etiqueta" => "Table 5"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at5"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "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"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">US study<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">22</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">European study<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">18</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Present study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Study design&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Prospective&#46;175 participants&#46;Visits every 6 months for 5 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Prospective&#46;141 participants&#46;Visits every 6 months for 2 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Retrospective&#46;51 patients&#46;2 years follow-up&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Participants&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Probable MSA-P MSA-C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Possible and probable MSA-P and MSA-C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Possible and probable MSA-P and MSA-C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Variables&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">UMSARS I&#44; UMSARS II and COMPASS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">UMSARS I&#44; UMSARS II and COMPASS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">UMSARS I&#44; UMSARS II&#44; III and IV</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Survival&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Median 9&#46;8 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Median 9&#46;8 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Median 5&#46;75 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Predictors of outcome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Severe symptomatic autonomic failure at diagnosis associated with worse survivalMSA-P and MSA-C same median survival&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MSA-P shorter survival&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MSA-P and MSA-C same survivalSevere UMSAR-I and UMSAR-II at baseline had shorter survival&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Rate of progression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">UMSARS I increased 0&#46;3 points per month&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">UMSARS I increased by 0&#46;5 points per month&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">UMSAR I increased 0&#46;3 points per month&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Autopsy confirmation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">16&#47;16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#47;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#47;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Funding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">US NIH&#44; Mayo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">EU&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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ISSN: 02134853
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