Interrelationships between Survival, Sex, and Blood Pressure in Patients with Multiple System Atrophy

2021 ◽  
Vol 55 (1) ◽  
pp. 56-61
Author(s):  
Tanya Gurevich ◽  
Ludmila Merkin ◽  
Alina Rozenberg ◽  
Ariel Fisher ◽  
Elly Atanasova Mishkova-Serafimova ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Multiple System Atrophy ◽  
Disease Duration ◽  
Cox Regression ◽  
Positive Association ◽  
Motor Symptom ◽  
Vertical Position ◽  
Death Risk ◽  
Tilt Testing ◽  
Survival Sex

Objective: The aim of this study is to estimate survival among patients with multiple system atrophy-parkinsonian type (MSA-P) or cerebellar type MSA (MSA-C) in relation to blood pressure (BP) measurements, by sex. Methods: A cohort of 99 MSA patients was studied retrospectively. Their BP measurements were obtained during prolonged (40 min, vertical position) drug-free tilt testing. We used K-M survival curves and Cox regression to calculate adjusted (to age of onset) hazard ratios (HRs) of BP measurements on time to death by MSA subtype and sex. Results: Fifty-two MSA patients were males and 47 were females. Sixty-three of them had MSA-P and 36 had MSA-C. The mean age at motor symptom onset was 61.1 ± 10.4 years, and mean disease duration at the time of BP assessment was 8.0 ± 4.7 years. The 2 study groups (MSA-P and MSA-C) did not differ significantly in age at MSA onset, sex ratio, or disease duration. Survival time did not differ between the groups {medians: 12 years (95% confidence interval [CI]: 8–28) and 10 years (95% CI: 8–13), respectively}. The MSA-P group showed a trend towards better survival for males (log-rank p = 0.0925). The maximal diastolic orthostatic BP decline during tilt testing had a borderline positive association with death risk among MSA-C males (adjusted HR = 1.18, p = 0.0665), and systolic BP after 10 min in a supine position had a significant positive association with death risk among MSA-P males (adjusted HR = 1.06, p = 0.0354). Conclusions: The findings of a sex-based difference in the effect of BP on death risk may be important for adjusting the therapeutic approach to MSA patients.

scholarly journals Camptocormia in patients with multiple system atrophy at different disease durations: frequency and related factors

BMC Neurology ◽  
2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Ling Yu Zhang ◽  
Bei Cao ◽  
Qian-Qian Wei ◽  
Ru Wei Ou ◽  
Bi Zhao ◽  
...  
Keyword(s):  
Multiple System Atrophy ◽  
Disease Severity ◽  
Disease Duration ◽  
Rating Scale ◽  
Cox Regression ◽  
Age Of Onset ◽  
Older Age ◽  
Related Factors ◽  
Cox Regression Analysis ◽  
The Impact

Abstract Background Camptocormia is common in patients with multiple system atrophy (MSA). The current study was aimed at assessing the frequency of camptocormia and its related factors in MSA patients with different disease durations. Also, the impact of camptocormia on disability was evaluated. Methods A total of 716 patients were enrolled in the study. They were classified into three groups based on disease duration (≤ 3, 3–5, ≥ 5 years). Specific scales were used to evaluate the motor and non-motor symptoms. Disease severity was assessed using the Unified Multiple System Atrophy Rating Scale (UMSARS). The binary logistic regression model was used to explore the factors related to camptocormia. To analyze the impact of camptocormia on disability in patients with disease duration less than 5 years, propensity score matching (PSM) and stratified Cox regression analysis were used. Results In the current study, we found that the frequency of camptocormia was 8.9, 19.7 and 19.2% when the disease duration was ≤3, 3–5, ≥ 5 years, respectively. In the disease duration ≤3 years group, we found that MSA-parkinsonian subtype (MSA-P) (OR = 2.043, P = 0.043), higher total UMSARS score (OR = 1.063, P < 0.001), older age of onset (OR = 1.047, P = 0.042), and lower score on the frontal assessment battery (FAB) (OR = 0.899, P = 0.046) were associated with camptocormia. Only greater disease severity was associated with camptocormia in the group of patients with disease duration 3–5 years (OR = 1.494, P = 0.025) and in the group of patients with disease duration ≥5 years (OR = 1.076, P = 0.005). There was no significant impact of camptocormia on disability in patients with a disease duration of < 5 years (HR = 0.687, P = 0.463). Conclusion The frequency of camptocormia increased with prolonged disease duration. Disease severity was related to camptocormia at different stages of the disease. The MSA-P subtype, older age of onset, and lower FAB score were associated with camptocormia in the early stage of the disease.

Abstract 2281: Mitral E Wave Deceleration Time to Peak E Velocity Ratio And Cardiovascular Outcome in Hypertensive Patients During Anti-Hypertensive Treatment: the LIFE Echo-Substudy.

Circulation ◽  
2007 ◽  
Vol 116 (suppl_16) ◽  
Author(s):  
Marcello Chinali ◽  
Rakesh K Mishra ◽  
Giovanni de Simone ◽  
Gerard P Aurigemma ◽  
Eva Gerdts ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Heart Rate ◽  
Cox Regression ◽  
Peak Velocity ◽  
Cox Model ◽  
Velocity Ratio ◽  
Univariate Analysis ◽  
Positive Association ◽  
Hypertensive Patients ◽  
Deceleration Time

Background: Early mitral flow deceleration time (DTE) is a prognostically validated marker of LV chamber stiffness. However, for any given LV stiffness, a higher E peak velocity (E) is associated with longer DTE, suggesting that the prognostic relevance of DTE might be influenced by variations in cardiac preload (e.g. during anti-hypertensive treatment). It is not known whether normalization of deceleration time for E-velocity (DTE/E) might be a more stable diastolic index for prediction of incident cardiovascular (CV) events in hypertensive patients during treatment, as compared to DTE. Methods: We evaluated 770 hypertensive patients (66±7 years; 42% women) with ECG-LV hypertrophy enrolled in the LIFE echo-substudy. Echocardiographic exams were performed annually for 5 years during anti-hypertensive treatment. Prognostic value of basal DTE/E was preliminary evaluated. Variation over time of both DTE/E and DTE were therefore analyzed in relation to incident combined fatal and non-fatal CV events. Results: During follow-up, 69 CV events occurred (9% of study population). Mean basal DTE/pE was 3.55±1.55 sec 2 /cm*10 −3. In univariate analysis baseline DTE/E was associated positively with age (r=0.10; p<0.01), relative wall thickness (r=0.13; p<0.01) and isovolumic relaxation time (r=0.26; p<0.001) and negatively with heart rate (r=−0.20; p<0.001); no association was found with systolic blood pressure, diastolic blood pressure, LV mass or ejection fraction. Unadjusted Cox regression showed a positive association between baseline DTE/E and CV events [(HR=1.21 (95%CI= 1.07–1.37); p=0.002]. In time-varying Cox model, independently of age, gender, type of anti-hypertensive treatment and in-treatment heart rate, higher in-treatment DTE/E was associated with higher rate of CV events [(HR=1.26 (95%CI= 1.04 –1.80); p<0.026], whereas no association was found for in-treatment DTE (p=NS). Conclusions: In a population of treated hypertensive patients with ECG-LV hypertrophy, the ratio of in-treatment DTE/E, but not DTE alone, independently predicts incident CV events. In high-risk hypertensive patients, normalization of DTE for E peak velocity might be preferred to DTE in evaluating diastolic function during anti-hypertensive treatment.

scholarly journals The Cold Hand Sign in Multiple System Atrophy: Frequency-Associated Factors and Its Impact on Survival

2021 ◽  
Vol 13 ◽  
Author(s):  
Bei Cao ◽  
Yan Liang ◽  
Ling-Yu Zhang ◽  
Yan-Bing Hou ◽  
Ru-Wei Ou ◽  
...  
Keyword(s):  
Multiple System Atrophy ◽  
Disease Duration ◽  
Rating Scale ◽  
Age At Onset ◽  
Motor Symptom ◽  
Motor Symptoms ◽  
Symptom Scale ◽  
The Impact ◽  
Early Occurrence ◽  
Non Motor Symptoms

Background: Few studies have focused on the cold hand sign (CHS), a red flag symptom, in multiple system atrophy (MSA).Objective: This study aimed to investigate the frequency and correlative factors of CHS in patients with MSA and the impact of its early occurrence on the survival of these patients.Methods: A total of 483 patients with MSA were enrolled in this study, and the motor and non-motor symptoms between patients with MSA with and without CHS were compared. Moreover, patients with disease duration ≤ 3 years at baseline were followed, and the association between CHS and survival of patients with MSA was examined.Results: The frequencies of CHS in patients with MSA were 20, 15.4, and 25.3% in MSA, MSA-parkinsonian subtype (MSA-P), and MSA-cerebellar subtype (MSA-C), respectively. Higher Unified Multiple System Atrophy Rating Scale (UMSARS) scores and higher Non-Motor Symptom Scale (NMSS) scores at baseline were associated with CHS in MSA. CHS was associated with shorter survival after adjusting for baseline diagnosis subtype, age at onset, sex, orthostatic hypotension, disease duration, autonomic onset, UMSARS total score, and NMSS score (p = 0.001; HR = 3.701; 95% CI = 1.765–7.760).Conclusion: CHS is not rare in patients with MSA. Greater disease severity and more severe non-motor symptoms were associated with CHS in patients with MSA. Patients with early occurrence of CHS had a poor prognosis.

Interrelationships between survival, sex and blood pressure in patients with multiple system atrophy

2018 ◽  
Vol 46 ◽  
pp. e31
Author(s):  
T. Gurevich ◽  
A. Fisher ◽  
L. Merkin ◽  
A. Rozenberg ◽  
E. Atanasova Mishkova-Serafinova ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Multiple System Atrophy ◽  
Survival Sex

scholarly journals Association between Blood Pressure and Serum Thyroid-Stimulating Hormone Concentration within the Reference Range: A Population-Based Study

2007 ◽  
Vol 92 (3) ◽  
pp. 841-845 ◽  
Author(s):  
Bjørn O. Åsvold ◽  
Trine Bjøro ◽  
Tom I. L. Nilsen ◽  
Lars J. Vatten
Keyword(s):  
Blood Pressure ◽  
Diastolic Blood Pressure ◽  
Outcome Measures ◽  
Odds Ratio ◽  
Reference Range ◽  
Positive Association ◽  
Population Based ◽  
Thyroid Stimulating Hormone ◽  
Cross Sectional ◽  
Population Based Study

Abstract Context: The association between thyroid function and blood pressure is insufficiently studied. Objective: The objective of the investigation was to study the association between TSH within the reference range and blood pressure. Design and Setting: This was a cross-sectional, population-based study. Subjects: A total of 30,728 individuals without previously known thyroid disease were studied. Main Outcome Measures: The main outcome measures were mean systolic and diastolic blood pressure and pulse pressure and odds ratio for hypertension (&gt;140/90 mm Hg or current or previous use of antihypertensive medication), according to categories of TSH. Results: Within the reference range of TSH (0.50–3.5 mU/liter), there was a linear increase in blood pressure with increasing TSH. The average increase in systolic blood pressure was 2.0 mm Hg [95% confidence interval (CI) 1.4–2.6 mm Hg] per milliunit per liter increase in TSH among men, and 1.8 mm Hg (95% CI 1.4–2.3 mm Hg) in women. The corresponding increase in diastolic blood pressure was 1.6 mm Hg (95% CI 1.2–2.0 mm Hg) in men and 1.1 mm Hg (95% CI 0.8–1.3 mm Hg) in women. Comparing TSH of 3.0–3.5 mU/liter (upper part of the reference) with TSH of 0.50–0.99 mU/liter (lower part of the reference), the odds ratio for hypertension was 1.98 (95% CI 1.56–2.53) in men and 1.23 (95% CI 1.04–1.46) in women. Conclusion: Within the reference range of TSH, we found a linear positive association between TSH and systolic and diastolic blood pressure that may have long-term implications for cardiovascular health.

scholarly journals POS0941 IN SPONDYLOARTHRITIS PATIENTS THE PRESENCE OF COMORBIDITIES IS AN INDEPENDENT PREDICTOR OF INSUFFICIENT RESPONSE TO THERAPY WITH BIOLOGIC AGENTS AND TREATMENT DISCONTINUATION

2021 ◽  
Vol 80 (Suppl 1) ◽  
pp. 733.2-734
Author(s):  
I. Flouri ◽  
N. Kougkas ◽  
N. Avgustidis ◽  
A. Repa ◽  
A. Eskitzis ◽  
...  
Keyword(s):  
Clinical Practice ◽  
Disease Duration ◽  
Cox Regression ◽  
Independent Predictor ◽  
Response To Therapy ◽  
Treatment Discontinuation ◽  
Randomized Controlled Studies ◽  
Insufficient Response ◽  
The Impact

Background:Long-term observational studies of patients under biologic disease-modifying anti-rheumatic drug (bDMARD) therapies in routine clinical practice can provide us with important data regarding patients with comorbidities, who are usually excluded from randomized controlled studies.Objectives:To study the impact of comorbidities in the outcome (response and persistence to therapy) of patients with spondyloarthritis (SpA) receiving bDMARDs in real-world clinical practice.Methods:Prospective study of all patients who start a bDMARD in a tertiary centre University Hospital after their consent. All patient comorbidities [among a list of approximately 100 pre-specified major comorbidities] are registered by treating physicians at baseline and during follow-up.Comorbidities were studied as total Comorbidities Count (CC) and rheumatic disease comorbidity index (RDCI). Statistical analyses were performed using logistic and Cox regression models, adjusting for the potential confounding of age, sex, disease duration, diagnosis (axial vs. peripheral SpA), number of previous conventional synthetic and biologic DMARDs, year of therapy start, and co-administered methotrexate and corticosteroids (yes/no). Analyses of response to therapy also included baseline BASDAI or ASDAS indices as confounding variables.Results:A total of 603 biologic treatments (1st: 298, 2nd: 157, ≥3rd: 148) were analyzed. Half (51%) of the patients were female, 413 patients had axial SpA (AxSpA) and 190 peripheral SpA (perSpA). At baseline, median (IQR) age: 48 (38-57) years, disease duration: 11 (4-19) years, CC: 2 (1-4) and RDCI: 1 (0-2). Both comorbidity indices were significantly higher in perSpA compared to AxSpA (p<0.001).At 6 months of therapy, 31% of patients with AxSpA achieved BASDAI50 and 39% had ASDAS-ESR < 2.1. Higher CC was an independent predictor of insufficient response according to BASDAI50 [OR (95%) = 0.70 (0.52-0.94), p=0.019] and higher RDCI was predicting failure to achieve ASDAS-ESR < 2.1 [OR (95%) = 0.59 (0.37-0.94), p=0.027]. Other independent predictors of non-response were age, longer disease duration and (for ASDAS-ESR<2.1) higher baseline disease activity.During 1405 patient-years of follow-up, 349 (58%) treatments were discontinued. The adjusted hazard ratio for bDMARD discontinuation within the first 2 years of treatment due to insufficient response was doubled in patients with CC ≥2 versus those with CC ≤1 [HR = 2.27 (1.14-4.53), p=0.020] or with RDCI ≥1 (vs. RDCI = 0) [HR = 2.23 (1.22-4.07), p=0.009]. Comorbidities’ indices were not significant predictors of treatment discontinuations due to adverse events.Conclusion:The presence of comorbidities in patients with SpA is an independent predictor for insufficient 6-month response to bDMARDs and resultant treatment discontinuation due to failure.Acknowledgements:This research is co-financed by Greece and the European Union (European Social Fund- ESF) through the Operational Programme «Human Resources Development, Education and Lifelong Learning» in the context of the project “Reinforcement of Postdoctoral Researchers - 2nd Cycle” (MIS-5033021), implemented by the State Scholarships Foundation (ΙΚΥ).Disclosure of Interests:None declared

scholarly journals Clinical Epidemiology of Systolic and Diastolic Orthostatic Hypotension in Patients on Peritoneal Dialysis

2021 ◽  
Vol 10 (14) ◽  
pp. 3075
Author(s):  
Claudia Torino ◽  
Rocco Tripepi ◽  
Maria Carmela Versace ◽  
Antonio Vilasi ◽  
Giovanni Tripepi ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Peritoneal Dialysis ◽  
Orthostatic Hypotension ◽  
Clinical Epidemiology ◽  
Hemodialysis Patients ◽  
Excess Death ◽  
Death Risk ◽  
Standardized Protocol ◽  
Pressure Changes ◽  
The Impact

Blood pressure changes upon standing reflect a hemodynamic response, which depends on the baroreflex system and euvolemia. Dysautonomia and fluctuations in blood volume are hallmarks in kidney failure requiring replacement therapy. Orthostatic hypotension has been associated with mortality in hemodialysis patients, but neither this relationship nor the impact of changes in blood pressure has been tested in patients on peritoneal dialysis. We investigated both these relationships in a cohort of 137 PD patients. The response to orthostasis was assessed according to a standardized protocol. Twenty-five patients (18%) had systolic orthostatic hypotension, and 17 patients (12%) had diastolic hypotension. The magnitude of systolic and diastolic BP changes was inversely related to the value of the corresponding supine BP component (r = −0.16, p = 0.056 (systolic) and r = −0.25, p = 0.003 (diastolic), respectively). Orthostatic changes in diastolic, but not in systolic, BP were linearly related to the death risk (HR (1 mmHg reduction): 1.04, 95% CI 1.01–1.07, p = 0.006), and this was also true for CV death (HR: 1.08, 95% CI 1.03–1.12, p = 0.001). The strength of this association was not affected by further data adjustment (p ≤ 0.05). These findings suggest that independent of the formal diagnosis of orthostatic hypotension, even minor orthostatic reductions in diastolic BP bear an excess death risk in this population.

Abstract P142: The CKD273 Urinary Peptidomic Biomarker is Associated with Mortality in People at Early Stages of Diabetic Nephropathy Independent of Traditional Risk Factors

Hypertension ◽  
2017 ◽  
Vol 70 (suppl_1) ◽  
Author(s):  
Gemma E Currie ◽  
Sheon Mary ◽  
Bernt J von Scholten ◽  
Morten Lindhardt ◽  
Harald Mischak ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Cardiovascular Disease ◽  
Diabetic Nephropathy ◽  
Cox Regression ◽  
Outcome Data ◽  
Diagnostic Purpose ◽  
Urine Albumin ◽  
Geometrical Mean ◽  
Traditional Risk Factors

Background: Mortality in type 2 diabetes (T2D) is primarily driven by cardiovascular disease. This is amplified in diabetic nephropathy (DN), even in early ‘pre-clinical’ stages. A urinary peptidomic classifier (CKD273) has been found to predict DN development in advance of detectable microalbuminuria. Whether it is also a determinant of mortality and cardiovascular disease in patients with established albuminuria is unknown. Methods: We studied 155 subjects with T2D, albuminuria (geometrical mean [IQR]: 85 [34;194] mg/24hrs), controlled blood pressure (129±16/74±11 mmHg) and preserved renal function (eGFR 88±17 ml/min/1.73m 2 ). Blood and urine samples were collected for measurement of estimated glomerular filtration rate (eGFR), urine albumin excretion (UAE), N-terminal pro-brain natriuretic peptide (NT-proBNP; ELISA) and urinary proteomics (capillary electrophoresis coupled to mass spectrometry). Computed tomography imaging was performed to assess coronary artery calcium (CAC) score. Outcome data were collected through national disease registries over a 6 year follow up period. Results: CKD273 correlated with UAE (r=0.481, p=<0.001), age (r=0.238, p=0.003), CAC score (r=0.236, p=0.003), NT-proBNP (r=0.190, p=0.018) and eGFR (r=0.265, p=0.001). On multiple regression only UAE (β=0.402, p<0.001) and eGFR (β=-0.184, p=0.039) were statistically significant determinants. Twenty participants died during follow-up. CKD273 was a determinant of mortality (log rank [Mantel-Cox] p=0.004), and retained significance (p=0.050) after adjustment for age, sex, blood pressure, NT-proBNP and CAC score in a Cox regression model. Neither eGFR nor UAE were determinants of mortality in this cohort. Conclusions: A multidimensional biomarker can provide information on outcomes associated with its primary diagnostic purpose. Here we demonstrate that the peptidomics-based classifier CKD273 is associated with mortality in albuminuric people with T2D in even when adjusted for other established cardiovascular and renal biomarkers.

Positive Association Between the Lys198 Asn Polymorphism in the Endothelin-1 and Blood Pressure in Obese Japanese Subjects: Ohasama Study

Hypertension ◽  
2000 ◽  
Vol 36 (suppl_1) ◽  
pp. 714-714
Author(s):  
Tomohiro Katsuya ◽  
Takayoshi Ohkubo ◽  
Yuxiao Fu ◽  
Ichiro Tsuji ◽  
Kenichi Nagai ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Blood Pressure Level ◽  
Positive Association ◽  
Epidemiological Studies ◽  
Buffy Coat ◽  
Baseline Characteristic ◽  
Endothelin 1 ◽  
Overweight People ◽  
Obese Subjects

P117 A recent report by Tiret et al. (Hypertension 33, 1999) revealed that a G/T polymorphism with an amino acid substitution (Lys to Asn) at codon 198 in the exon 5 of endothelin 1 gene (ET1) is associated with blood pressure in overweight people using two epidemiological studies, ECTIM and Glasgow Heart Scan Study. They suggested that G/T polymorphism strongly interacted with body mass index (BMI) in the determination of blood pressure levels. To examine the interaction among G/T polymorphism of ET1, BMI and blood pressure, we carried out an association study using a general population. Subjects (n=1,446) were recruited from Ohasama population, which is a cohort in a rural community of northern Japan. The research protocol was approved by the Institutional Review Board of the Tohoku University. DNA was extracted from the buffy coat of the participants using QIAamp DNA Blood Kit (Qiagen Inc.). G/T polymorphism of ET1 was determined by TaqMan PCR method, which is a powerful tool for semiautomatic genotype determination in a large number of samples. The frequency of T198 allele in Japanese (26%) was significantly higher than that in Caucasians (23%). The baseline characteristic (age, BMI, SBP, DBP, antihypertensive treatment) of all subjects was not significantly different according to the genotype of G/T polymorphism. In the obese subjects (≥25kg/m2), however, SBP and DBP were significantly associated with G/T polymorphism. Blood pressure level in the subjects carrying T198 allele was 2.6 mmHg in systolic (p<0.02) and 2.3 mmHg in diastolic (p<0.005) higher than that in those with GG genotype in overweight people. That the same result was obtained from different races suggested that the T198 allele of ET1 is involved in the determination of blood pressure levels in obese subjects.

scholarly journals Pulsed Wave Doppler Ultrasound Is Useful to Assess Vasomotor Response in Patients with Multiple System Atrophy and Well Correlated with Tilt Table Study

2012 ◽  
Vol 2012 ◽  
pp. 1-8 ◽  
Author(s):  
Ke-Vin Chang ◽  
Wen-Shiang Chen ◽  
Ruey-Meei Wu ◽  
Ssu-Yuan Chen ◽  
Hsiu-Yu Shen ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Heart Rate ◽  
Correlation Analysis ◽  
Multiple System Atrophy ◽  
Cardiovascular Response ◽  
Vasomotor Response ◽  
Tilt Table ◽  
Hemodynamic Variables ◽  
Pulsed Wave Doppler ◽  
Head Up Tilt

The study aim was to assess sympathetic vasomotor response (SVR) by using pulsed wave Doppler (PWD) ultrasound in patients with multiple system atrophy (MSA) and correlate with the tilt table study. We recruited 18 male patients and 10 healthy men as controls. The SVR of the radial artery was evaluated by PWD, using inspiratory cough as a provocative maneuver. The response to head-up tilt was studied by a tilt table with simultaneous heart rate and blood pressure recording. The hemodynamic variables were compared between groups, and were examined by correlation analysis. Regarding SVR, MSA patients exhibited a prolonged latency and less heart rate acceleration following inspiratory cough. Compared with the tilt table test, the elevation of heart rate upon SVR was positively correlated to the increase of heart rate after head-up tilt. The correlation analysis indicated that the magnitude of blood pressure drop from supine to upright was positively associated with the SVR latency but negatively correlated with the heart rate changes upon SVR. The present study demonstrated that blunted heart rate response might explain MSA's vulnerability to postural challenge. PWD may be used to predict cardiovascular response to orthostatic stress upon head-up tilt in MSA patients.

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