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Werner syndrome as a crossroads between lipodystrophy, escleroderma-like changes and torpid ulcers in lower limbs
Síndrome de Werner como encrucijada entre lipodistrofia, cambios esclerodérmicos y úlceras tórpidas en miembros inferiores
Juan de Dios García Díaza,b,
Corresponding author
juandedios.garcia@uah.es

Corresponding author.
, Sandra Coronado Fernándezb, Sara Jiménezc, José Antonio Rubioc, Cristina Bohórquez Herasd
a Unidad de Genética Clínica y Lípidos, Hospital Universitario Príncipe de Asturias, Universidad de Alcalá, Alcalá de Henares, Madrid, Spain
b Servicio de Medicina Interna, Hospital Universitario Príncipe de Asturias, Universidad de Alcalá, Alcalá de Henares, Madrid, Spain
c Unidad de Pie Diabético, Servicio de Endocrinología y Nutrición, Hospital Universitario Príncipe de Asturias, Universidad de Alcalá, Alcalá de Henares, Madrid, Spain
d Servicio de Reumatología, Hospital Universitario Príncipe de Asturias, Universidad de Alcalá, Alcalá de Henares, Madrid, Spain
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        "titulo" => "S&#237;ndrome de Werner como encrucijada entre lipodistrofia&#44; cambios esclerod&#233;rmicos y &#250;lceras t&#243;rpidas en miembros inferiores"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Unidad de Gen&#233;tica Cl&#237;nica y L&#237;pidos&#44; Servicio de Medicina Interna&#46; Hospital Universitario Pr&#237;ncipe de Asturias&#46; Universidad de Alcal&#225;&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Campus Universitario&#46; Ctra&#46; Alcal&#225;-Meco&#44; s&#47;n&#46; 28805 Alcal&#225; de Henares&#44; Madrid&#44; Espa&#241;a&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Werner&#39;s syndrome &#40;WS&#41; or adult progeria is an autosomal recessive hereditary disorder with premature ageing beginning in the person&#39;s teens&#46; Its incidence is less than 1&#47;10<span class="elsevierStyleSup">6</span> births&#44; although it is probably underdiagnosed&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Although it was originally described in 1904&#44; its molecular basis was not established until 1996&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> It is caused by mutations in the <span class="elsevierStyleItalic">WRN</span> or <span class="elsevierStyleItalic">RECQL2</span> gene&#44; which encodes a DNA helicase&#46; This enzyme is key in DNA repair processes and in maintaining telomere integrity&#44; so a deficiency causes genomic instability&#44; risk of cancer and cellular senescence&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The main clinical manifestations are the absence of a puberty growth spurt with short stature&#44; thinning hair with early greying&#44; skin changes&#44; sarcopenia&#44; osteoporosis and glucose and lipid metabolism abnormalities with accelerated atheromatosis&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Biallelic mutations in the <span class="elsevierStyleItalic">WRN</span> gene are found in 97&#37; of patients&#46; Clinically diagnosed cases in which no <span class="elsevierStyleItalic">WRN</span> mutations are found are called atypical WS and in a significant proportion of these&#44; mutations in the <span class="elsevierStyleItalic">LMNA</span> gene are identified&#44; with earlier symptoms and more rapid progression&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">We present a case of WS diagnosed after association and exclusion of signs and symptoms and the use of next-generation genetic sequencing techniques&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">This was a 55-year-old woman who consulted with painful ulcers on both feet&#46; She had never smoked and had been diagnosed with type 2 diabetes mellitus at the age of 29 years&#44; requiring insulin and pioglitazone early&#44; which provided adequate control &#40;HbA1c around 7&#37;&#41;&#46; She had surgery for bilateral cataracts at age 50&#46; The patient&#39;s height was 147&#8239;cm&#44; weight 46&#8239;kg&#44; and she had increased abdominal adiposity &#40;circumference 94&#8239;cm&#41; with a marked decrease in the fat panniculus around the edges&#46; Her scalp hair was sparse and she had started to go grey in her 20&#8239;s&#46; The skin on her hands and feet was thick and hard&#44; with thinning of the underlying tissues&#44; leading to suspicion of scleroderma&#46; She did not have Raynaud&#39;s phenomenon and nailfold capillaroscopy showed isolated dilations and capillary ramifications&#46; She had developed the ulcers five years earlier&#44; preceded by hyperkeratosis&#44; which were now chronic&#44; with poor healing and frequent superinfection&#46; The deepest ulcers were located both in the balls and backs of the first and second toes of both feet&#44; some of them deep with bone exposure&#59; ulcers had also developed on the metatarsal heads of the first and fifth toes and on the lateral aspects of her feet&#46; She also had <span class="elsevierStyleItalic">hallux valgus</span> and claw toes&#46; Sensitivity in her lower limbs and distal peripheral pulses were normal&#44; with an indeterminate ankle-brachial index due to arterial stiffness&#46; Transcutaneous oxygen pressures &#40;TcPO2&#41; in her feet were 8 and 2&#8239;mmHg&#46; Her total cholesterol was 227&#8239;mg&#47;dl and triglycerides 289&#8239;mg&#47;dl&#46; X-rays of her hands and feet detected osteoporosis and vascular and subcutaneous calcifications&#44; and liver ultrasound revealed steatosis&#46; Further investigations ruled out involvement of the gastrointestinal tract&#44; heart&#44; lungs or kidneys&#44; and autoimmunity tests were negative&#46; There were also no signs of diabetic nephropathy or retinopathy&#46; Added to the intensive treatment of the ulcers &#40;frequent dressings&#44; discharge measures and antibiotics&#41;&#44; the patient was started on treatment with bosentan &#40;125&#8239;mg&#47;12&#8239;h&#41;&#44; but with no significant improvement&#46; The associated pain and the need for functional rest had made the use of a wheelchair necessary&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The molecular study with next-generation sequencing of 27 genes associated with hereditary lipodystrophies identified a rare homozygous variant &#40;c&#46;3711del or p&#46;K1237Nfs&#42;11&#41; in the <span class="elsevierStyleItalic">WRN</span> gene&#44; classified as pathogenic in ClinVar &#40;ID&#58; 577673&#41;&#46; None of the patient&#39;s children or siblings and neither of her parents had developed similar conditions&#46; There was no known consanguinity between the parents&#44; although their families were originally from the same town in the province of Ciudad Real&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Although Spain has had some reports of cases of patients with suspected WS&#44; most are old and prior to the discovery of the causative gene&#46; This is the first case in this country with a full clinical description and molecular confirmation&#46; The mutation found in the <span class="elsevierStyleItalic">WRN</span> gene&#44; although described as pathogenic&#44; is very uncommon worldwide&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In addition&#44; finding it as a homozygous variant has revealed the existence of some previously unknown degree of consanguinity in her parents&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Despite the patient meeting the criteria for typical WS &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#44; the delay of more than 25 years from onset of the syndrome to it being recognised is remarkable&#46; One of the aspects that most pointed to the diagnosis was her general physical appearance&#44; with regional lipodystrophy &#40;severe lipoatrophy of the extremities and truncal obesity&#41;&#46; About twenty progeroid syndromes with different molecular mechanisms are known&#59; along with premature ageing&#44; they are associated with different patterns of lipodystrophy<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> and ectopic fat deposition&#44; which can lead to the development of insulin resistance&#44; type 2 diabetes&#44; fatty liver and atherogenic dyslipidaemia&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a> Our patient had this metabolic constellation&#44; although her blood glucose control was adequate and she had no signs of diabetic microangiopathy&#46; In addition to the elevated risk of malignancy&#44; these metabolic complications contribute to the premature death of patients with WS due to accelerated atheromatosis&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">The signs of scleroderma were also striking&#46; Unlike scleroderma&#44; however&#44; she did not have Raynaud&#39;s phenomenon&#44; the capillaroscopy pattern was atypical&#44; the autoantibody screening was negative and there was no evidence of internal organ involvement&#46; The distribution of the scleroderma was also very characteristic of WS&#46; Nevertheless&#44; the differential diagnosis with systemic sclerosis can be difficult&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">However&#44; the main associated disorder is chronic ulcers&#44; severely limiting the patient&#39;s quality of life and functional autonomy&#46; The pathogenesis of these ulcers is more complex and multifactorial than that of the simple diabetic foot ulcer&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> In addition to vascular mechanisms or neuropathy&#44; which were not decisive in our case&#44; gene transcription dysfunction and cellular senescence hinder tissue repair&#46; One extensive review on ulcers in WS patients noted their frequency &#40;more than 40&#37;&#41;&#44; calluses as a prodrome&#44; their refractory nature and the frequent need for surgical procedures&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In conclusion&#44; the manifestations of WS are multisystemic and nonspecific&#44; which delays correct diagnosis and management&#46; However&#44; understanding WS alerts us to suspect the diagnosis and order the confirmatory molecular tests&#46; Despite the lack of a specific treatment&#44; identification is essential for appropriate follow-up and genetic counselling&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Ethical responsibilities</span><p id="par0060" class="elsevierStylePara elsevierViewall">The patient gave her written informed consent&#44; both for the molecular study and for taking clinical images&#46; The Independent Ethics Committee raised no objections to this publication&#46;</p></span></span>"
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        "tipo" => "MULTIMEDIATABLA"
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        "fuente" => "Source&#58; Tsuge et al&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>"
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          "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Definite diagnosis&#58; all the cardinal signs and two further signs&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Probable diagnosis&#58; the first three cardinal signs and any two further signs&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Possible diagnosis&#58; cataracts or dermatological signs and any four further signs&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Exclusion&#58; onset of signs and symptoms before adolescence &#40;except short stature&#41;&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Met by our patient<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n
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                  \t\t\t\t">I&#46; Cardinal signs and symptoms &#40;onset over 10 years old&#41;&#58;</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>1&#46; Cataracts &#40;bilateral&#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">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>2&#46; Characteristic dermatological pathology &#40;hard&#44; tight skin&#44; atrophic skin&#44; pigmentary alterations&#44; ulceration&#44; hyperkeratosis&#44; regional subcutaneous atrophy&#41; and characteristic facies &#40;&#39;bird&#39; facies&#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">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>3&#46; Short stature&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">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>4&#46; Parental consanguinity or affected sibling&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">&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>5&#46; Premature greying and&#47;or thinning of scalp hair&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">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">II&#46; Other signs and symptoms&#58;</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>1&#46; Diabetes mellitus&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">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>2&#46; Hypogonadism &#40;secondary sexual underdevelopment&#44; diminished fertility&#44; testicular or ovarian atrophy&#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">&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>3&#46; Osteoporosis&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">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>4&#46; Osteosclerosis of the distal phalanges&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">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>5&#46; Soft tissue calcifications&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">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>6&#46; Evidence of premature atherosclerosis &#40;e&#46;g&#46;&#44; myocardial infarction&#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">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>7&#46; Mesenchymal neoplasms&#44; rare neoplasms or multiple neoplasms&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">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>8&#46; Voice changes &#40;high-pitched&#44; squeaky or hoarse voice&#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">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>9&#46; Flat feet&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">&#8211;&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Diagnostic criteria of the International Registry of Werner&#39;s Syndrome&#46;</p>"
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                      "titulo" => "Recent Advances in Understanding Werner Syndrome"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "R&#46;A&#46; Shamanna"
                            1 => "D&#46;L&#46; Croteau"
                            2 => "J&#46;-H&#46; Lee"
                            3 => "V&#46;A&#46; Bohr"
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                      "doi" => "10.12688/f1000research.12110.1"
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                        "volumen" => "6"
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              "etiqueta" => "2"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Research on Werner Syndrome&#58; Trends from Past to Present and Future Prospects"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "K&#46; Tsuge"
                            1 => "A&#46; Shimamoto"
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.3390/genes13101802"
                      "Revista" => array:5 [
                        "tituloSerie" => "Genes &#40;Basel&#41;"
                        "fecha" => "2022"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/36292687"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Werner syndrome&#58; Clinical features&#44; pathogenesis and potential therapeutic interventions"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "J&#46; Oshima"
                            1 => "J&#46;M&#46; Sidorova"
                            2 => "R&#46;J&#46;J&#46; Monnat"
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                        ]
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                    ]
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                    0 => array:2 [
                      "doi" => "10.1016/j.arr.2016.03.002"
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                        "tituloSerie" => "Ageing Res Rev"
                        "fecha" => "2017"
                        "volumen" => "33"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26993153"
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                0 => array:2 [
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                      "titulo" => "WRN Mutation Update&#58; Mutation Spectrum&#44; Patient Registries&#44; and Translational Prospects"
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                          "autores" => array:6 [
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                            3 => "K&#46; Eirich"
                            4 => "M&#46; Takemoto"
                            5 => "A&#46; Watanabe"
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                      "doi" => "10.1002/humu.23128"
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                        "tituloSerie" => "Hum Mutat"
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