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Original article
Usefulness of cholestanol levels in the diagnosis and follow-up of patients with cerebrotendinous xanthomatosis
Utilidad de los niveles de colestanol en el diagnóstico y seguimiento de los pacientes con xantomatosis cerebrotendinosa
B. Pilo de la Fuentea,
Corresponding author
bpilodelafuente@yahoo.es

Corresponding author.
, M.J. Sobridob, M. Girósc, L. Pozod, M. Lustrese, F. Barrerof, J. Macarróng, M. Díazh, A. Jiménez-Escrigi
a Sección de Neurología, Hospital del Sureste, Arganda del Rey, Madrid, Spain
b Fundación Pública Galega de Medicina Xenómica, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain. CIBERER, Instituto de Salud Carlos III, Madrid, Spain
c Sección de Errores Congénitos del Metabolismo, Servicio de BGM, Hospital Clínico de Barcelona, Barcelona, Spain. CIBERER, Instituto de Salud Carlos III, Madrid, Spain
d Departamento de Investigación, Hospital Ramón y Cajal, Madrid, Spain
e Servicio de Neurología, Complejo Hospitalario de Orense, Orense, Spain
f Servicio de Neurología, Hospital San Cecilio, Granada, Spain
g Servicio de Neurología, Hospital General Yagüe, Burgos, Spain
h Servicio de Neurología, Hospital de Cabueñes, Gijón, Asturias, Spain
i Servicio de Neurología, Hospital Ramón y Cajal, Madrid, Spain
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        "titulo" => "Utilidad de los niveles de colestanol en el diagn&#243;stico y seguimiento de los pacientes con xantomatosis cerebrotendinosa"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">A&#58; Cholestanol levels on diagnosis in the group of deceased patients and in live patients&#46; B&#58; Cholestanol levels on diagnosis in the groups of patients with and without xanthomas&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Cerebrotendinous xanthomatosis &#40;CTX&#44; OMIM &#35; 213700&#41; is a recessive autosomal disease produced by a deficit in the mitochondrial enzyme sterol 27-hydroxylase &#40;CYP27A1&#41;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> described by van Bogaert et al&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> in 1937&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">From a clinical perspective&#44; patients with CTX usually present a history of chronic diarrhoea since infancy&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In the third decade of life&#44; they have bilateral cataracts and tendinous xanthomas&#46; Subsequently&#44; neurological symptoms appear and these may be extremely varied&#58; ataxia&#44; paraparesis&#44; cognitive impairment&#44; psychiatric disorders&#44; Parkinson&#39;s disease&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> polyneuropathy&#44;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> epilepsy and others&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3&#8211;5</span></a> Although tendinous xanthomas appear in the name of this illness&#44; they are frequently absent&#44; so this in no case excludes the diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The primary metabolic defect in CTX consists of an alteration in the synthesis of bile acids from cholesterol&#44; due to mutations in the gene <span class="elsevierStyleItalic">CY27A1</span>&#44; which encodes the mitochondrial enzyme sterol 27-hydroxylase&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;8&#44;9</span></a> A deficiency in CYP27A1 leads particularly to a reduction in the synthesis of chenodeoxycholic acid &#40;CDCA&#41; and an increase in intermediate products&#44; such as 7&#945;-hydroxy-4-cholesten-3-one and its oxidation product&#44; cholestanol&#46; Cholestanol is also produced directly from the oxidation of cholesterol and is accumulated in all tissues&#44; especially in the brain&#44; lungs&#44; the crystalline lens and the tendons of patients with CTX&#44; so it is used as a biochemical marker for this entity&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Low levels of cholestanol are present in most tissues of mammals and its absorption&#44; along with that of phytosterols&#44; is extremely low in humans&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">However&#44; an elevated level of cholestanol in plasma can be found in primary biliary cirrhosis and in cases of cholestasis<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;11</span></a> as a consequence of the alteration in cholesterol homeostasis&#46; On the other hand&#44; cholesterol levels in plasma and the lipoprotein profile in CTX patients are usually normal or below the range &#40;the lipoprotein profile is usually &#8220;anti-aterogenic&#8221;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Cranial magnetic resonance imaging &#40;MRI&#41; usually shows hyperintensity at the level of the dentate nuclei and the pyramidal tracts&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Some authors have described the potential usefulness of functional tests&#44; such as DATSCAN&#44; to evaluate the impact of this disease on the central nervous system&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Treatment with CDCA&#44; which inhibits the anomalous synthesis of bile acid&#44; is effective for correcting biochemical alterations<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> and&#44; according to some authors&#44; it slows down the progression of the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> This treatment is usually associated with hydroxymethylglutaryl-co-enzyme A &#40;HMG-CoA&#41; reductase inhibitors&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Although cholestanol levels have been used in the diagnosis of this disease for many years&#44; their possible prognostic value and usefulness for monitoring the course of the disease have not been greatly studied&#46; We present here a retrospective analysis of Spanish patients with CTX to evaluate the usefulness of cholestanol levels in this illness&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Patients and methods</span><p id="par0040" class="elsevierStylePara elsevierViewall">A total of 26 patients with CTX &#40;from 19 families&#41; were reviewed&#59; they all had a confirmed molecular diagnosis at the Galician Public Foundation for Genomic Medicine in Santiago de Compostela and at the Ram&#243;n and Cajal Hospital in Madrid between 1995 and 2008&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Their main demographic details &#40;gender&#44; family origin&#44; date of birth&#44; age at the onset of symptoms&#44; age at diagnosis&#44; age at death&#41; were all recorded&#44; along with clinical information &#40;cataracts&#44; xanthomas&#44; diarrhoea&#44; pyramidalism&#44; ataxia&#44; Parkinson&#39;s disease&#44; psychomotor delay&#44; cognitive impairment&#44; psychiatric alterations&#44; polyneuropathy&#44; epilepsy&#41;&#44; complementary tests &#40;cranial CT scan&#44; cranial MRI&#44; spinal MRI&#44; genetic study&#44; neurophysiological study&#41;&#44; as well as the treatment received and their progress&#46; Through the Expanded Disability Status Scale &#40;EDSS&#41; by Kurtzke<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> estimated at diagnosis&#44; it was possible to evaluate the degree of disability in these patients&#46; As this study has been conducted by neurologists and systemic symptoms such as diarrhoea are affected by memory bias&#44; the age of onset was established as of the date on which the first neurological symptoms were reported&#46; In patients who started with symptoms in infancy &#40;for example with backwardness at school&#41; and could not remember an exact age&#44; they were assigned 12 years old as the age of onset&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Of the 26 patients diagnosed&#44; only 14 cases &#40;5 males and 9 females&#41; were selected for the present study&#59; they were those from the 12 families in which a determination of cholestanol levels had been made at diagnosis&#46; Of these 12 families&#44; four came from the Galician area&#44; four from Castilla y Le&#243;n&#44; two from Andalusia&#44; one for Extremadura and one from Castilla La Mancha&#46; In only 5 cases &#40;36&#37;&#41; was the existence of consanguinity identified&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The cholestanol determinations were mostly performed at the Clinical Biochemistry Institute at the &#8220;Hospital Cl&#237;nico&#8221; in Barcelona&#46; Cholestanol&#44; together with the other plasma sterols&#44; was isolated following alkaline hydrolysis and extraction with organic solvent&#44; then analyzed using capillary gas chromatography in an Agilent 7890 chromatograph fitted with a flame detector&#44; such as trimethylsilyl-derivative &#40;BSTFA 1&#37;&#47;TMCS in pyridine Sigma&#41;&#46; The column used was a DB1701 &#40;S&#38;W&#41;&#46; Epi-coprostanol &#40;Sigma&#41; was used as the internal standard&#46; The reference values for cholestanol &#40;from 2 to 12&#46;6<span class="elsevierStyleHsp" style=""></span>&#956;mol&#47;L&#41; correspond to individuals between 1 and 60 years of age not affected by any alteration in the metabolism of cholesterol&#44; with levels of between 36 and 102<span class="elsevierStyleHsp" style=""></span>&#956;mol&#47;L being diagnostic for CTX&#46; In addition&#44; most of the patients had had analyses done for total cholesterol&#44; cholesterol fractions and triglycerides&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Due to the small sample size&#44; the Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> test was used to compare cholestanol levels between the different clinical groups&#46; Using Spearman&#39;s correlation&#44; the cholestanol levels were compared on the basis of the different quantitative variables&#46; Statistical significance was considered for <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#44; always using bilateral significance&#46; The SPSS programme &#40;version 15&#46;0 for Windows&#41; &#40;SPSS Inc&#41; was used for the statistical analysis</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><p id="par0065" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows details of the main demographic&#44; clinical&#44; genetic and biochemical data on the patients included in this series&#44; together with their treatment and progression&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">In the 14 patients with CTX&#44; the mean age of onset of their neurological symptoms was 20 years &#40;range from 7 to 50&#41;&#46; The mean age at diagnosis was 39 years of age &#40;range&#58; 14&#8211;54&#41;&#44; so the mean delay between onset of symptoms and their diagnosis was 19 years&#46; Four patients had died in the period between their diagnosis and the performance of this study&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The index symptoms most frequently encountered were backwardness at school &#40;43&#37;&#41;&#44; gait alterations &#40;29&#37;&#41; and epileptic seizures &#40;21&#37;&#41;&#46; Ataxia &#40;100&#37;&#41;&#44; pyramidalism &#40;93&#37;&#41; and cataracts &#40;93&#37;&#41; were the most frequent symptoms &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Only 50&#37; of the patients had xanthomas&#46; The mean EDSS calculated on diagnosis was 5&#46;1 &#40;range&#58; 3&#46;5&#8211;9&#41;&#44; representing severe disability&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">The two sequencing variants considered as the pathogenic mutations in each case were identified in the 12 families&#46; The most frequent mutation was p&#46;R395C&#44; which was found in up to 25&#37; of the alleles &#40;5 families&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The mean cholestanol levels found were 106<span class="elsevierStyleHsp" style=""></span>&#956;mol&#47;L &#40;range&#58; 56&#8211;238&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; A significant negative relationship &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#46;64&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>0&#46;013&#41; was found between the time during which people had suffered from the illness and their cholestanol levels&#44; in other words cholestanol levels were lower the longer the illness had been present &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; On the other hand&#44; no significant relationship was found between plasma cholestanol and age at onset&#44; at diagnosis or at death&#46; Higher levels of cholestanol &#40;116<span class="elsevierStyleHsp" style=""></span>&#956;mol&#47;L&#44; SD 65&#41; were found among females than in men &#40;87<span class="elsevierStyleHsp" style=""></span>&#956;mol&#47;L&#44; SD 28&#41;&#44; although the small sample size meant that this difference did not achieve statistical significance&#46; On the other hand&#44; it is noteworthy that the cholestanol levels found in the group of patients who had died by the time of the study &#40;63<span class="elsevierStyleHsp" style=""></span>&#956;mol&#47;L&#59; range&#58; 56&#8211;82&#41; were significantly lower than those obtained among those still alive at the same time &#40;123<span class="elsevierStyleHsp" style=""></span>&#956;mol&#47;L&#59; range&#58; 63&#8211;238&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>A&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Higher levels of cholestanol &#40;147<span class="elsevierStyleHsp" style=""></span>&#956;mol&#47;L&#59; SD 60&#41; were found among the 6 patients who had tendinous xanthomas&#44; versus 74<span class="elsevierStyleHsp" style=""></span>&#956;mol&#47;L &#40;SD 23&#41; than among the 8 who did not &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>B&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41;&#46; Only one patient out of the 14 had no cataracts&#44; and his levels of cholestanol were 57<span class="elsevierStyleHsp" style=""></span>&#956;mol&#47;L&#44; whereas the mean in the other 11 who did have cataracts was 109<span class="elsevierStyleHsp" style=""></span>&#956;mol&#47;L &#40;SE 56&#41;&#44; although it did not achieve statistical significance&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">With respect to neurological symptoms&#44; it was only possible to relate cholestanol levels to the presence of polyneuropathy&#46; Among the 3 patients without neuropathy&#44; the levels found were 66<span class="elsevierStyleHsp" style=""></span>&#956;mol&#47;L &#40;SD 16&#41;&#44; whereas the 9 with neuropathy had levels of 118<span class="elsevierStyleHsp" style=""></span>&#956;mol&#47;L &#40;SD 58&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;052&#41;&#46; In two cases&#44; the review of the case history was not sufficient to confirm or rule out the presence of polyneuropathy&#46; Although this difference did not achieve statistical significance&#44; the presence of polyneuropathy can be seen as a trend in cases with higher serum levels of cholestanol&#46; No differences were found in the levels on the basis of the types of neuropathy found in the electroneurogram&#46; No statistically significant relationship was found between cholestanol levels and the degree of disability as measured through the EDSS at the moment of the diagnosis &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;3&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Nor was any statistically significant relationship found between cholestanol levels and the radiological findings &#40;in both the cranial CT scan and in the cranial MRI&#44; as well as in the spinal MRI&#41;&#44; using evoked potentials and the electroencephalogram&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">With respect to the lipid profile&#44; this was normal in most cases&#46; In only one patient&#44; the triglyceride levels were a little high &#40;175<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#59; No&#46;&#58; 40&#8211;160<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41;&#44; with the mean triglyceride levels being 92<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#46; Total cholesterol and LDL cholesterol were found to be normal in all cases&#44; with means of 174<span class="elsevierStyleHsp" style=""></span>mg&#47;dL &#40;No&#46;&#58; 120&#8211;220<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41; and 92&#46;6<span class="elsevierStyleHsp" style=""></span>mg&#47;dL &#40;No&#46;&#58; 60&#8211;190<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41;&#44; respectively&#46; One patient presented low levels of HDL cholesterol &#40;24<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#59; No&#46;&#58; 30&#8211;100<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41;&#44; with mean HDL cholesterol levels of 59<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#46; No correlation was found between the levels of cholestanol and levels of cholesterol&#44; its fractions and triglycerides&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Of these 14 patients&#44; one &#40;7&#46;1&#37;&#41; received only vitamin E &#40;very late diagnosis&#59; he died shortly after being diagnosed&#41;&#44; two &#40;14&#46;3&#37;&#41; received only CDCA&#44; 8 &#40;57&#46;17&#37;&#41; the association of CDCA and a statin&#44; while three &#40;21&#46;4&#37;&#41; received the association of CDCA&#44; a statin and vitamin E&#46; All patients under treatment with CDCA received the standard dose &#40;750<span class="elsevierStyleHsp" style=""></span>mg&#41;&#44; except for one patient who received 500<span class="elsevierStyleHsp" style=""></span>mg &#40;patient 11&#8211;1&#41; and another who received 1000<span class="elsevierStyleHsp" style=""></span>mg &#40;patient 9&#8211;1&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">In 8 of the patients &#40;57&#37;&#41;&#44; at least one further determination of cholestanol levels was made after the beginning of treatment in order to monitor their progression&#44; with a significant reduction being observed in all cases and even a return to normal levels in three of them &#40;37&#46;5&#37;&#41;&#46; The mean reduction observed was 91<span class="elsevierStyleHsp" style=""></span>&#956;mol&#47;L &#40;range&#58; 29&#8211;193&#41; over a mean time of 34 months &#40;range&#58; 7&#8211;94&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; Despite the significant reduction in the cholestanol levels in the 8 patients monitored&#44; only one of them &#40;12&#46;5&#37;&#41; became stabilized from a clinical standpoint&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">Globally&#44; despite treatment&#44; only 4 of the 14 patients in the series &#40;28&#46;6&#37;&#41; became stabilized&#46; In addition&#44; 4 patients &#40;28&#46;6&#37;&#41; had died in the period between being diagnosed and the start of the present retrospective study&#44; with a mean age at decease of 51 years &#40;range&#58; 47&#8211;56&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0125" class="elsevierStylePara elsevierViewall">The goal of the present study was to analyze the possible relationship between the plasma levels of cholestanol and a range of clinical parameters and prognoses in CTX&#46; For this purpose&#44; we carried out a retrospective investigation through the review of the case histories of 14 Spanish patients with a genetic and biochemistry diagnosis of the disease&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Lipid profiles were normal in most patients&#46; This coincides with what has been published previously in the medical literature&#44; suggesting that the levels of cholesterol and its fractions are usually normal or a little low in patients with CTX&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;16</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">The mean cholestanol level found was 106<span class="elsevierStyleHsp" style=""></span>&#956;mol&#47;L&#44; so the levels in all patients with CTX studied were elevated &#40;between 5 and 20 times the upper value of normality&#41;&#46; Elevated cholestanol levels are not exclusive to CTX and can be observed&#44; for example&#44; in hepatic illnesses&#44; phytosterolaemia&#44; hypothyroidism and type II familial hyperlipoproteinaemia&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;17</span></a> Moderate elevations were also found in asymptomatic heterozygotic carriers&#44; although never as low as the minimum levels detected in the patients with CTX&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Higher levels of cholestanol were found among those patients with xanthomas&#44; cataracts and polyneuropathy&#46; These findings suggest the accumulation of cholestanol at the level of the tendons&#44; crystalline lenses and the peripheral nervous system related to higher levels of cholestanol in circulation&#59; that is to say&#44; the accumulation of cholestanol in tissues would be favoured in patients with very elevated levels&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">It is striking that no significant relationship was seen between cholestanol levels and the degree of disability as measured on the EDSS scale at the time of diagnosis&#46; Although it is frequently taken for granted that higher levels of cholestanol are related to a worse functional prognosis&#44; the results in our series do not support this interpretation&#46; Nonetheless&#44; the scale used present major limitations as it places excessive emphasis on motor symptoms versus the rest of the non-motor symptoms and&#44; therefore&#44; underestimates the complexity of the disease&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Some authors have used the monitoring of cholestanol levels for the therapeutic follow-up of patients&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> In the 8 patients in our series in whom at least one additional determination was effected after the start of therapy&#44; the reduction was significant&#44; with the levels even returning to normal in three of them&#46; It is&#44; therefore&#44; striking that&#44; despite presenting very elevated levels&#44; it is possible to achieve a significant reduction with the same dose of CDCA &#40;the standard dose was 750<span class="elsevierStyleHsp" style=""></span>mg&#41;&#46; Increasing CDCA doses in cases where levels do not return to normal is a moot point&#58; the biochemical improvement did not correlate with a symptomatic improvement&#44; as only one patient managed to stabilize from a clinical standpoint&#46; This patient had been diagnosed at 14 years of age and is currently 22&#44; so the main factor determining stabilization might have been the early institution of treatment&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Significantly lower levels of cholestanol were found in the group of patients who died in comparison with those still alive&#46; Bearing in mind that the patients who died are those who were diagnosed with the greatest delay&#59; this might indicate that&#44; in the advanced stages of the illness&#44; there is perhaps a fall in cholestanol levels&#46; This agrees with the negative correlation found between the time since onset of the illness and plasma levels&#58; patients with a longer history of illness presented lower levels of cholestanol&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Another possible explanation might be that the most severely affected patients are those with larger amounts of cholestanol deposited in the various tissues &#40;crystalline lens&#44; tendons&#44; brain&#41; and that is why they have lower levels of cholestanol circulating in their blood&#46; Our data also show a poor correlation between plasma levels of cholestanol and functional prognosis&#46; The reason why cholestanol is deposited selectively in certain tissues &#40;in nerve tissue&#44; for example&#44; and more specifically in the dentate nuclei&#41; and why some patients are more susceptible to this tissue accumulation&#44; the cause of irreversible cerebral lesions &#40;neuronal loss&#44; accumulation of lipidic crystals&#41; described in several autopsy-based studies<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;21&#44;22</span></a> is still unknown&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">As a result&#44; it is necessary to apply caution when interpreting the significance of plasma levels of cholestanol in patients with CTX&#46; Elevated levels are very useful for establishing the diagnosis&#44; but they have no prognostic value &#40;i&#46;e&#46; higher levels are not necessarily related to a worse functional situation&#41; and do not allow monitoring of the clinical effectiveness of treatment &#40;normalization of levels is not always accompanied by clinical stabilization&#41;&#46; On the other hand&#44; they may be useful for adjusting CDCA dosage&#44; as well as in the verification of therapeutic compliance&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">The evaluation of our results presents several limitations&#46; First&#44; there is considerable data dispersion as each patient&#39;s cholestanol levels were determined at the moment of the diagnosis&#44; corresponding in each case to a different moment in the natural course of the illness and at different ages&#46; Second&#44; we do not know the curve of the natural course of these levels throughout the course of the illness&#46; Although our findings suggest an initial increase in terms of the start of symptoms&#44; and subsequently a gradual decline as the disease develops&#44; the transversal design of the study does not allow this hypothesis to be confirmed&#46; Finally&#44; the small sample size &#40;due to the low prevalence of the disease&#41; constrains the statistical analysis of the data&#46; Thus&#44; additional prospective studies&#44; with more extensive series and detailed follow-up&#44; are necessary to document more precisely the clinical value of cholestanol levels for the prognosis and monitoring of patients with CTX&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of interest</span><p id="par0175" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
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          "titulo" => array:5 [
            0 => "Resumen"
            1 => "Introducci&#243;n"
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            3 => "Resultados"
            4 => "Conclusiones"
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          "titulo" => "Palabras clave"
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        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Patients and methods"
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        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Results"
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        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Discussion"
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        8 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Conflict of interest"
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        9 => array:2 [
          "identificador" => "xack44738"
          "titulo" => "Acknowledgements"
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        10 => array:1 [
          "titulo" => "References"
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    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2010-06-04"
    "fechaAceptado" => "2010-12-01"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec157584"
          "palabras" => array:3 [
            0 => "Cerebrotendinous xanthomatosis"
            1 => "Cholestanol"
            2 => "Chenodeoxycholic acid"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec157585"
          "palabras" => array:3 [
            0 => "Xantomatosis cerebro-tendinosa"
            1 => "Colestanol"
            2 => "&#193;cido quenodeoxic&#243;lico"
          ]
        ]
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      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cerebrotendinous xanthomatosis &#40;CTX&#41; is an autosomal recessive disease caused by a deficiency of mitochondrial enzyme sterol 27-hydrolylase&#46; Such a deficiency results in a reduced production of chenodeoxycholic acid and in an increased formation of cholestanol&#46; It is clinically characterized by cataracts&#44; diarrhoea&#44; xanthomas&#44; premature arteriosclerosis and a number of progressive neurological symptoms&#46; Although cholestanol levels are used for the diagnosis of CTX&#44; their correlation with the clinical symptoms and their prognostic usefulness have not been assessed so far&#46;</p> <span class="elsevierStyleSectionTitle">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We reviewed 14 CTX patients diagnosed between 1995 and 2008 in two reference centres for the genetic diagnosis of this disorder&#44; whose cholestanol levels had been recorded&#46; We studied the main demographic&#44; clinical and therapeutical data and their correlation with plasma cholestanol levels&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The average cholestanol level at diagnosis was 105&#46;8<span class="elsevierStyleHsp" style=""></span>&#956;mol&#47;l&#46; These levels did not correlate with any neurological symptoms or with disability at diagnosis scored by the EDSS&#46; After treatment&#44; all patients achieved a significant reduction in plasma cholestanol levels &#40;average reduction of 91<span class="elsevierStyleHsp" style=""></span>&#956;mol&#47;l in an average follow-up of 34 months&#41;&#44; although only one patient remained clinically stable&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">High cholestanol levels are very useful for diagnosis of CTX but they do not have a prognostic value &#40;they do not correlate with severity&#41;&#46; Normalization of cholestanol levels is not always associated with clinical stabilization&#46; However&#44; follow-up of cholestanol levels can be useful for the dose adjustment&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La xantomatosis cerebro-tendinosa &#40;XCT&#41; es una enfermedad autos&#243;mica recesiva producida por un d&#233;ficit del enzima 27-hidroxilasa&#46; Como consecuencia&#44; existe una deficiencia de &#225;cido quenodeoxic&#243;lico y una sobreproducci&#243;n de colestanol que se deposita en los tejidos&#46; Cl&#237;nicamente cursa con cataratas&#44; diarrea&#44; xantomas y diferentes s&#237;ntomas neurol&#243;gicos&#46; A pesar de que los niveles de colestanol se emplean en el diagn&#243;stico de la XCT&#44; se desconoce su correlaci&#243;n con la cl&#237;nica y el pron&#243;stico&#46;</p> <span class="elsevierStyleSectionTitle">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se han revisado 14 pacientes de XCT&#44; diagnosticados entre 1995 y 2008 en dos centros de referencia para el diagn&#243;stico gen&#233;tico&#44; en los que se hab&#237;a determinado el colestanol&#46; Se han estudiado los principales datos demogr&#225;ficos&#44; cl&#237;nicos y terap&#233;uticos y su posible relaci&#243;n con los niveles de colestanol&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La media de los niveles de colestanol al diagn&#243;stico fue de 106<span class="elsevierStyleHsp" style=""></span>&#956;mol&#47;l&#46; No se encontr&#243; ninguna relaci&#243;n entre el colestanol plasm&#225;tico y los diferentes s&#237;ntomas neurol&#243;gicos&#44; ni con el grado de discapacidad al diagn&#243;stico medido mediante la EDSS&#46; Tras la instauraci&#243;n del tratamiento se obtuvo una reducci&#243;n significativa del colestanol plasm&#225;tico en todos los casos &#40;reducci&#243;n media de 91<span class="elsevierStyleHsp" style=""></span>&#956;mol&#47;l en una media de 34 meses&#41;&#44; a pesar de lo cual s&#243;lo un paciente se estabiliz&#243; cl&#237;nicamente&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La presencia de niveles elevados de colestanol es muy &#250;til para el diagn&#243;stico de la XCT&#44; pero no tiene valor pron&#243;stico &#40;no se correlaciona con la situaci&#243;n funcional&#41;&#46; Su normalizaci&#243;n no siempre se acompa&#241;a de una estabilizaci&#243;n cl&#237;nica&#44; pero su monitorizaci&#243;n puede ser &#250;til para el ajuste del tratamiento&#46;</p>"
      ]
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Pilo de la Fuente B&#44; et al&#46; Utilidad de los niveles de colestanol en el diagn&#243;stico y seguimiento de los pacientes con xantomatosis cerebrotendinosa&#46; Neurolog&#237;a&#46; 2011 26&#58;397-404&#46;</p>"
      ]
      1 => array:2 [
        "etiqueta" => "&#9734;&#9734;"
        "nota" => "<p class="elsevierStyleNotepara">This paper was presented in part at the 13th Meeting of the European Federation of the Neurological Societies &#40;Florence&#44; September 12th-15th&#44; 2009&#41; as a poster entitled &#8220;Cerebrotendinous Xanthomatosis in Spain&#8221;&#46; This work did not receive any funding&#46;</p>"
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Family no&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Patient no&#46; and Gender&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Mutation 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Mutation 2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Age at onset&nbsp;\t\t\t\t\t\t\n
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                  \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" style="border-bottom: 2px solid black">Age at diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Index symptom&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">EDSS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Baseline cholestanol &#40;&#956;mol&#47;L&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Post-treatment cholestanol &#40;&#956;mol&#47;L&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#8211;1 &#9792;&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">c&#46;399G<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>A &#40;p&#46;W133X&#41;&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
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                  \t\t\t\t">c&#46;399G<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>A &#40;p&#46;W133X&#41;&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="char" valign="\n
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                  \t\t\t\t">12&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="char" valign="\n
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                  \t\t\t\t">38&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">Backwardness at school&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="char" valign="\n
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                  \t\t\t\t">3&#46;5&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">189&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">12 &#40;40 months&#41;&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">CDCA&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Impairment&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">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">2&#8211;1 &#9792;&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">c&#46;688C<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>T &#40;p&#46;Q230X&#41;&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">c&#46;1183C<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>T &#40;p&#46;R395C&#41;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&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">Epilepsy&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;5&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">66&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">32 &#40;10 months&#41;&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">CDCA&#44; vitamin E&#44; pravastatin&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">Impairment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">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">2&#8211;2 &#9792;&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">c&#46;688C<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>T &#40;p&#46;Q230X&#41;&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">c&#46;1183C<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>T &#40;p&#46;R395C&#41;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23&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">Backwardness at school&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;5&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">63&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">21 &#40;10 months&#41;&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">CDCA&#44; vitamin E&#44; pravastatin&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">Impairment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">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">3&#8211;1 &#9792;&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">c&#46;804G<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>T &#40;p&#46;W268C&#41;&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">c&#46;804G<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>T &#40;p&#46;W268C&#41;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">46&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">Backwardness at school&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">82&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">CDCA&#44; pravastatin&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">Exitus &#40;47 years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&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">4&#8211;1 &#9794;&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">c&#46;844<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>1G<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>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">c&#46;1183C<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>T &#40;p&#46;R395C&#41;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32&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">Epilepsy&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;5&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">120&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">CDCA&#44; vitamin E&#44; atorvastatin&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">Stable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&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">5&#8211;1 &#9794;&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">c&#46;845-1G<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>A&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">c&#46;845-1G<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>A&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">54&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">Psychiatric alterations&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">57&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">CDCA&#44; atorvastatin&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">Exitus &#40;56 years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&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">6&#8211;1 &#9792;&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">c&#46;1016C<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>T &#40;p&#46;T339M&#41;&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">c&#46;1209C<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>G &#40;p&#46;N403K&#41;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">46&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">Epilepsy&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;5&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">56&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">28 &#40;7 months&#41;&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">CDCA&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">Exitus &#40;47 years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&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">7&#8211;1 &#9794;&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">c&#46;1043-1054 delTGTACCACCTCT&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">c&#46;1043-1054 delTGTACCACCTCT&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">51&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">Alteration in gait&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">57&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">Vitamin E&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">Exitus &#40;52 years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&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">8&#8211;1 &#9792;&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">c&#46;1043-1054 delTGTACCACCTCT&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">c&#46;1183C<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>T &#40;p&#46;R395C&#41;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">42&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">46&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">Alteration in gait&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;5&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">86&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">17 &#40;16 months&#41;&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">CDCA&#44; pravastatin&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">Impairment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&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">8&#8211;2 &#9792;&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">c&#46;1043-1054 delTGTACCACCTCT&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">c&#46;1183C<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>T &#40;p&#46;R395C&#41;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">50&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">52&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">Alteration in gait&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;5&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">167&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">CDCA&#44; pravastatin&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">Stable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&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">9&#8211;1 &#9792;&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">c&#46;1183C<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>T &#40;p&#46;R395C&#41;&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">c&#46;1183C<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>T &#40;p&#46;R395C&#41;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&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">Backwardness at school&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">102&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">CDCA &#40;1000<span class="elsevierStyleHsp" style=""></span>mg&#41; pravastatin&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">Impairment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&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">10&#8211;1 &#9794;&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">c&#46;1183C<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>T &#40;p&#46;R395C&#41;&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">c&#46;1213C<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>G &#40;p&#46;R405W&#41;&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&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">Backwardness at school&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;5&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">98&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">9 &#40;94 months&#41;&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">CDCA&#44; simvastatin&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">Stable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&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">11&#8211;1 &#9794;&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">c&#46;1184<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>1G<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>A&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">c&#46;1184<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>1G<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>A&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&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">Backwardness at school&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;5&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">105&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">12 &#40;84 months&#41;&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">CDCA &#40;500<span class="elsevierStyleHsp" style=""></span>mg&#41;&#44; atorvastatin&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">Stable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&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">12&#8211;1 &#9792;&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">c&#46;1213C<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>G &#40;p&#46;R405W&#41;&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">c&#46;1213C<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>G &#40;p&#46;R405W&#41;&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="char" valign="\n
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                  \t\t\t\t">37&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="char" valign="\n
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                  \t\t\t\t">44&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">Alteration in gait&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="char" valign="\n
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                  \t\t\t\t">6&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">239&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">46 &#40;9 months&#41;&nbsp;\t\t\t\t\t\t\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">CDCA&#44; simvastatin&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">Impairment&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Main clinical&#44; genetic and biochemical data for the 14 patients with CTX&#46;</p>"
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                  \t\t\t\t" style="border-bottom: 2px solid black">Symptom&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Frequency&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Ataxia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">14&#47;14 &#40;100&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">13&#47;14 &#40;93&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">13&#47;14 &#40;93&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Polyneuropathy&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9&#47;12 &#40;75&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">9&#47;14 &#40;64&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Cognitive impairment&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">9&#47;14 &#40;64&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Psychomotor delay&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
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                  \t\t\t\t">7&#47;14 &#40;50&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Epilepsy&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Parkinson&#39;s disease&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3&#47;14 &#40;21&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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    ]
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      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:22 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46; Verrips"
                            1 => "L&#46;H&#46; Hoefsloot"
                            2 => "G&#46;C&#46; Steenbergen"
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                            4 => "R&#46;A&#46; Wevers"
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                      ]
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                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
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                            "web" => "Medline"
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                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "L&#46; Van Bogaert"
                            1 => "H&#46;J&#46; Scherer"
                            2 => "E&#46; Epstein"
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                  "host" => array:1 [
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cerebrotendinous xanthomatosis&#58; clinical course&#44; genotypes and metabolic backgrounds"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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                            0 => "M&#46;H&#46; Moghadasian"
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                  "host" => array:1 [
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            ]
            3 => array:3 [
              "identificador" => "bib0020"
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              "referencia" => array:1 [
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                  "contribucion" => array:1 [
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                            0 => "F&#46; Grandas"
                            1 => "M&#46; Martin-Moro"
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                  "host" => array:1 [
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                      "doi" => "10.1002/mds.10287"
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            4 => array:3 [
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                  "contribucion" => array:1 [
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                        0 => array:2 [
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                            0 => "J&#46; Arpa"
                            1 => "C&#46; Sanchez"
                            2 => "A&#46; Vega"
                            3 => "A&#46; Cruz-Martinez"
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                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8597991"
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              "identificador" => "bib0030"
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                0 => array:1 [
                  "referenciaCompleta" => "Pilo B&#44; de Blas G&#44; Sobrido MJ&#44; Navarro C&#44; Grandas F&#44; Barrero FJ&#44; et al&#46; Neurophysiological study in cerebrotendinous xanthomatosis&#46; 2011&#44; In press&#46;"
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            ]
            6 => array:3 [
              "identificador" => "bib0035"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cerebrotendinous xanthomatosis without tendinous xanthomas&#58; presentation of two cases"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "J&#46; Campdelacreu"
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                            2 => "A&#46; Cervera"
                            3 => "S&#46; Jauma"
                            4 => "M&#46; Giros"
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                        "tituloSerie" => "Neurologia"
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Biologic role&#40;s&#41; of the 25&#40;R&#41;&#44;26-hydroxycholesterol metabolic pathway"
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                        0 => array:2 [
                          "etal" => false
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                            0 => "N&#46;B&#46; Javitt"
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                    0 => array:1 [
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                        "tituloSerie" => "Biochim Biophys Acta"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11111083"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "On the substrate specificity of human CYP27A1&#58; implications for bile acid and cholestanol formation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "M&#46; Norlin"
                            1 => "S&#46; von Bahr"
                            2 => "I&#46; Bjorkhem"
                            3 => "K&#46; Wikvall"
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                        "tituloSerie" => "J Lipid Res"
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                    0 => array:2 [
                      "titulo" => "Hypercholestanolemia in diagnosing cerebrotendinous xanthomatosis vs&#46; familial hypercholesterolemia&#44; primary biliary cirrhosis&#44; and hypothyroidism"
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                        0 => array:2 [
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        "texto" => "<p id="par0180" class="elsevierStylePara elsevierViewall">Our thanks to the neurologists who collaborated in the performance of this study&#58; Dr&#46; M&#46; Arias &#40;CHUS&#41;&#44; Dr&#46; A&#46; Ares &#40;Hospital de Le&#243;n&#41;&#44; Dr&#46; J&#46; Duarte &#40;Hospital General de Segovia&#41;&#44; Dr&#46; I&#46; Garc&#237;a Casta&#241;&#243;n &#40;Hospital San Pedro Alc&#225;ntara&#41;&#44; Dr&#46; A&#46; L&#243;pez de Munain &#40;Hospital de San Sebasti&#225;n&#41;&#44; Dr&#46; A&#46; Molina &#40;Hospital 12 de Octubre&#41;&#44; Dr&#46; M&#46; Moya &#40;Hospital L&#237;nea de la Concepci&#243;n&#41;&#44; Dr&#46; D&#46; Ezpeleta &#40;Hospital Gregorio Mara&#241;&#243;n&#41; and Dr&#46; F&#46;J&#46; Jim&#233;nez Jim&#233;nez &#40;Hospital del Sureste&#41;&#46;</p>"
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