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Gravholt CH, Andersen NH, Christin-Maitre S, Davis SM, Duijnhouwer A, Gawlik A, Maciel-Guerra AT, Gutmark-Little I, Fleischer K, Hong D, Klein KO, Prakash SK, Shankar RK, Sandberg DE, Sas TCJ, Skakkebæk A, Stochholm K, van der Velden JA, Backeljauw PF. Clinical practice guidelines for the care of girls and women with Turner syndrome. Eur J Endocrinol 2024; 190:G53-G151. [PMID: 38748847 DOI: 10.1093/ejendo/lvae050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 04/19/2024] [Indexed: 06/16/2024]
Abstract
Turner syndrome (TS) affects 50 per 100 000 females. TS affects multiple organs through all stages of life, necessitating multidisciplinary care. This guideline extends previous ones and includes important new advances, within diagnostics and genetics, estrogen treatment, fertility, co-morbidities, and neurocognition and neuropsychology. Exploratory meetings were held in 2021 in Europe and United States culminating with a consensus meeting in Aarhus, Denmark in June 2023. Prior to this, eight groups addressed important areas in TS care: (1) diagnosis and genetics, (2) growth, (3) puberty and estrogen treatment, (4) cardiovascular health, (5) transition, (6) fertility assessment, monitoring, and counselling, (7) health surveillance for comorbidities throughout the lifespan, and (8) neurocognition and its implications for mental health and well-being. Each group produced proposals for the present guidelines, which were meticulously discussed by the entire group. Four pertinent questions were submitted for formal GRADE (Grading of Recommendations, Assessment, Development and Evaluation) evaluation with systematic review of the literature. The guidelines project was initiated by the European Society for Endocrinology and the Pediatric Endocrine Society, in collaboration with members from the European Society for Pediatric Endocrinology, the European Society of Human Reproduction and Embryology, the European Reference Network on Rare Endocrine Conditions, the Society for Endocrinology, and the European Society of Cardiology, Japanese Society for Pediatric Endocrinology, Australia and New Zealand Society for Pediatric Endocrinology and Diabetes, Latin American Society for Pediatric Endocrinology, Arab Society for Pediatric Endocrinology and Diabetes, and the Asia Pacific Pediatric Endocrine Society. Advocacy groups appointed representatives for pre-meeting discussions and the consensus meeting.
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Affiliation(s)
- Claus H Gravholt
- Department of Endocrinology, Aarhus University Hospital, 8200 Aarhus N, Denmark
- Department of Molecular Medicine, Aarhus University Hospital, 8200 Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus N, Denmark
| | - Niels H Andersen
- Department of Cardiology, Aalborg University Hospital, 9000 Aalborg, Denmark
| | - Sophie Christin-Maitre
- Endocrine and Reproductive Medicine Unit, Center of Rare Endocrine Diseases of Growth and Development (CMERCD), FIRENDO, Endo ERN Hôpital Saint-Antoine, Sorbonne University, Assistance Publique-Hôpitaux de Paris, 75012 Paris, France
| | - Shanlee M Davis
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO 80045, United States
- eXtraOrdinarY Kids Clinic, Children's Hospital Colorado, Aurora, CO 80045, United States
| | - Anthonie Duijnhouwer
- Department of Cardiology, Radboud University Medical Center, Nijmegen 6500 HB, The Netherlands
| | - Aneta Gawlik
- Departments of Pediatrics and Pediatric Endocrinology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland
| | - Andrea T Maciel-Guerra
- Area of Medical Genetics, Department of Translational Medicine, School of Medical Sciences, State University of Campinas, 13083-888 São Paulo, Brazil
| | - Iris Gutmark-Little
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio 45229, United States
| | - Kathrin Fleischer
- Department of Reproductive Medicine, Nij Geertgen Center for Fertility, Ripseweg 9, 5424 SM Elsendorp, The Netherlands
| | - David Hong
- Division of Interdisciplinary Brain Sciences, Stanford University School of Medicine, Stanford, CA 94304, United States
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA 94304, United States
| | - Karen O Klein
- Rady Children's Hospital, University of California, San Diego, CA 92123, United States
| | - Siddharth K Prakash
- Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, TX 77030, United States
| | - Roopa Kanakatti Shankar
- Division of Endocrinology, Children's National Hospital, The George Washington University School of Medicine, Washington, DC 20010, United States
| | - David E Sandberg
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor, MI 48109-2800, United States
- Division of Pediatric Psychology, Department of Pediatrics, University of Michigan, Ann Arbor, MI 48109-2800, United States
| | - Theo C J Sas
- Department the Pediatric Endocrinology, Sophia Children's Hospital, Rotterdam 3015 CN, The Netherlands
- Department of Pediatrics, Centre for Pediatric and Adult Diabetes Care and Research, Rotterdam 3015 CN, The Netherlands
| | - Anne Skakkebæk
- Department of Molecular Medicine, Aarhus University Hospital, 8200 Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus N, Denmark
- Department of Clinical Genetics, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Kirstine Stochholm
- Department of Endocrinology, Aarhus University Hospital, 8200 Aarhus N, Denmark
- Center for Rare Diseases, Department of Pediatrics, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Janielle A van der Velden
- Department of Pediatric Endocrinology, Radboud University Medical Center, Amalia Children's Hospital, Nijmegen 6500 HB, The Netherlands
| | - Philippe F Backeljauw
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio 45229, United States
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Mondal S, Gargari P, Nagendra L, Mandal S, Kumar RC, Shah P, Haldar M, Chowdhury S, Mukhopadhyay S. Growth hormone therapy is associated with improved uterine dimensions in girls with Turner syndrome prior to oestrogen replacement. Clin Endocrinol (Oxf) 2024; 100:66-75. [PMID: 37555570 DOI: 10.1111/cen.14957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 07/21/2023] [Accepted: 07/24/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND Adult women with Turner syndrome (TS) have high rates of miscarriage, presumably due to the abnormal size and shape of the uterus. There is a paucity of data regarding the determinants of uterine volume (UtVol) in young girls with TS before the initiation of oestrogen replacement therapy (ERT). METHODS We performed a cross-sectional study on premenarchal girls with TS, aged 5-15 years, pubertal stage B1-B3, not having received ERT (n = 73) and 50 age-matched healthy controls. Anthropometric parameters and a history of growth hormone (GH) therapy (≥1 year) were noted. Uterine length (UtL), UtVol, and mean-ovarian-volume (MOV) standard-deviation scores (SDS) were determined from transabdominal ultrasonography data. RESULTS Girls with TS had lower median UtVol-SDS (-1.07 vs. 0.86; p < .001), UtL-SDS (-3.72 vs. -0.41; p < .001) and MOV-SDS (-5.53 vs. 1.96; p < .001) compared to age-matched controls. Among TS girls, recipients of GH (n = 38) had higher UtVol-SDS (-0.63 vs. -1.39; p = .0001), UtL-SDS (-1.73 vs. -6.49; p < .0001) but similar MOV-SDS compared to nonrecipients (n = 35). Those with normal uterine volume for age (NUVA, n = 29) had earlier initiation (7.8 vs. 9.3 years; p = .03) and a longer duration of GH (3.71 vs. 2.14 years; p = .002) than those with low UtVol for age (n = 44). UtVol-SDS correlated with duration of GH (ρ = 0.411, p = .01) and negatively with age at GH initiation (ρ = -0.479, p = .003). In a model adjusted for pubertal status, karyotype and height-SDS, GH use could independently predict having NUVA (odds ratio: 5.09, confidence interval: 1.63-15.94, p = .005). CONCLUSION GH therapy has a stimulatory effect on uterine dimensions in pre-and peripubertal girls with TS. Earlier initiation and longer duration of GH is important in TS girls before ERT.
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Affiliation(s)
- Sunetra Mondal
- Department of Endocrinology, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
| | - Piyas Gargari
- Department of Endocrinology, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
| | - Lakshmi Nagendra
- Department of Endocrinology, JSS Medical College and Hospital, JSS Academy of Higher Education and Research, Mysore, Karnataka, India
| | - Santanu Mandal
- Department of Radiology, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
| | - Rathin C Kumar
- Department of Radiology, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
| | - Pooja Shah
- Department of Radiology, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
| | | | - Subhankar Chowdhury
- Department of Endocrinology, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
| | - Satinath Mukhopadhyay
- Department of Endocrinology, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
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Khadilkar V, Mondkar S, Oza C, Gondhalekar K, Khadilkar A. Adult Height in Indian Girls with Turner Syndrome Treated with Long-Term Growth Hormone Therapy - A Western India Tertiary Centre Experience. Indian J Endocrinol Metab 2023; 27:249-254. [PMID: 37583400 PMCID: PMC10424106 DOI: 10.4103/ijem.ijem_255_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 01/23/2023] [Accepted: 02/25/2023] [Indexed: 08/17/2023] Open
Abstract
Background and Objectives Owing to paucity of data on adult height in Indian girls with Turner syndrome treated with growth hormone (GH), this study was conducted to assess improvement in height following GH therapy and adult height achieved with long-term GH therapy in Indian girls with Turner syndrome and to assess relationship between achieved and predicted height. Methodology Retrospective analysis was performed on 12 girls with karyotype-proven Turner syndrome, who had attained adult height following mean duration of GH therapy of 4.8 years (range: 2.7-7.6). Adult height predictions were performed using index of responsiveness (IOR) and Ranke's prediction model. Results Mean age at starting GH was 10.2 ± 1.9 years; Pubertal induction was between 11 and 15 years. Mean height gain was 29.3 ± 9.8 cm (range: 14-39.5) from onset of treatment to adult height. Significant improvement in height Z scores (IAP 2015 and Indian Turner reference data) following GH therapy (p = 0.002 and 0.012, respectively) was noted. Using Indian Turner reference data, the height Z score improved from pre-treatment 0.8 ± 0.8 to 2.0 ± 0.9 on stopping GH and adult height Z score of 1.3 ± 0.7. Using Ranke's equation for prediction of near adult height, predicted and achieved adult height showed a strong positive correlation (Spearman correlation coefficient = 0.827, significant at 0.01 level). Conclusion At a dose in the lower range (40-50 mcg/kg/day) of recommendation and duration of 5 years, Indian girls with Turner syndrome can achieve adult height within the healthy Indian reference range. Dose individualization based on IOR would help in optimizing GH dosage and would turn out to be economically sustainable without compromising on height outcomes.
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Affiliation(s)
- Vaman Khadilkar
- Department of Growth and Paediatric Endocrinology, Hirabai Cowasji Jehangir Medical Research Institute, Pune, Maharashtra, India
- Department of Health Sciences, Savitribai Phule Pune University, Pune, Maharashtra, India
| | - Shruti Mondkar
- Department of Growth and Paediatric Endocrinology, Hirabai Cowasji Jehangir Medical Research Institute, Pune, Maharashtra, India
| | - Chirantap Oza
- Department of Growth and Paediatric Endocrinology, Hirabai Cowasji Jehangir Medical Research Institute, Pune, Maharashtra, India
| | - Ketan Gondhalekar
- Department of Growth and Paediatric Endocrinology, Hirabai Cowasji Jehangir Medical Research Institute, Pune, Maharashtra, India
| | - Anuradha Khadilkar
- Department of Growth and Paediatric Endocrinology, Hirabai Cowasji Jehangir Medical Research Institute, Pune, Maharashtra, India
- Department of Health Sciences, Savitribai Phule Pune University, Pune, Maharashtra, India
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Essaddam L, Zitouni O, Kraoua L, Trabelsi M, Sassi H, Kmiha S, Charfi F, El Guiche D, Kebaïli R, Jaballah N, Rjeb M, Zouari N, El Aribi Y, Hizem S, Wannes S, Fkih Romdhane I, Sfar MT, Ben Hamouda H, Hadj Salem R, Khlayfia Z, Khmiss T, Monastiri K, Siala N, Chouchane S, Souaa H, Khochtali I, Mahjoub B, Sfar H, Ben Jemâa L, Abroug S, Boughamoura L, Kamoun I, Kamoun T, Mrad R, Ben Becher S. Turner Syndrome: results of the first Tunisian study group on Turner Syndrome (TuSGOT). J Pediatr Endocrinol Metab 2023:jpem-2022-0360. [PMID: 37084413 DOI: 10.1515/jpem-2022-0360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 04/04/2023] [Indexed: 04/23/2023]
Abstract
OBJECTIVES Early diagnosis in Turner syndrome is desirable to optimize growth and puberty and yet, it is often made late. Here, we aim to identify age at diagnosis, clinical features at presentation and potential strategies to improve the care of TS girls. METHODS Retrospective study, including patients from 14 care centers across Tunisia including neonatal and pediatric care units, adult endocrinology and genetics departments. RESULTS We identified 175 patients with TS, karyotype showing 45, xmonosomy in 83(47.4 %) with mosaicism in 37(20 %). Mean ± SD, median (range) age at diagnosis available in 173 patients was 13 ± 9.2,12 (birth-48) years. The diagnosis was antenatal in 4(2.3 %), from birth-2 years in 14 (8 %)with lymphoedema (8)and dysmorphic features (9),2-12 years in 53 (35.5 %) including 35 with short stature, 13-18 years in 43(28.8 %) with short stature(28) and delayed puberty(14) and 35(23.5 %) after 18 years, related to ovarian insufficiency (20) and short stature (11). The associated malformations were cardiac in 14 (12.8 %), renal in 22 (19.6 %). A total of 56 girls (32 %) had proven gonadal dysgenesis and 13 (7 %) had otological problems. Parental height was available in 71 girls (40 %) of whom 59 were below the lower end of parental target range (LTR) (83 %). CONCLUSIONS This first Tunisian multicenter study, the first African of its kind, reveals that more than half of Turner syndrome cases are diagnosed after the age of 12 years. Subsequently, national strategies for an earlier TS diagnosis are needed such as measuring and plotting parental heights as well as introducing a systematic height screening at 5 years in Tunisia with a view to carrying out a re-audit in five years' time.
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Affiliation(s)
- Leila Essaddam
- Department of Pediatrics-PUC, BéchirHamza Children's Hospital, Faculty of Medicine of Tunis and University of Tunis El Manar, Tunis, Tunisia
| | - Ons Zitouni
- Department of Pediatrics-PUC, BéchirHamza Children's Hospital, Faculty of Medicine of Tunis and University of Tunis El Manar, Tunis, Tunisia
| | - Lilia Kraoua
- Department of genetics, H.Charles Nicolle, Tunis, Tunisia
| | | | - Hella Sassi
- Department of genetics, H.Charles Nicolle, Tunis, Tunisia
| | - Sana Kmiha
- Department of Pediatrics, H.Hédi Chaker, Sfax, Tunisia
| | - Fatma Charfi
- Department of Pediatrics, H.Hédi Chaker, Sfax, Tunisia
| | - Dorra El Guiche
- Department of Endocrinology, B. Institut de nutrition, Tunis, Tunisia
| | | | | | - Maroua Rjeb
- Department of Pediatrics, H.Sahloul, Sousse, Tunisia
| | - Noura Zouari
- Department of Pediatrics, H.Sahloul, Sousse, Tunisia
| | | | - Syrine Hizem
- Department of genetics, H.M.Slim, La Marsa, Tunisia
| | | | | | | | | | | | - Zied Khlayfia
- Department of Pediatrics, H.M.Slim, La Marsa, Tunisia
| | | | | | - Nadia Siala
- Department of Pediatrics, H.M.Slim, La Marsa, Tunisia
| | | | | | | | | | - Habib Sfar
- Department of endocrinology, Mahdia, Tunisia
| | | | | | | | - Inès Kamoun
- Department of Endocrinology, B. Institut de nutrition, Tunis, Tunisia
| | | | - Ridha Mrad
- Department of genetics, H.Charles Nicolle, Tunis, Tunisia
| | - Saayda Ben Becher
- Department of Pediatrics-PUC, BéchirHamza Children's Hospital, Faculty of Medicine of Tunis and University of Tunis El Manar, Tunis, Tunisia
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Qi X, Wang Q, Yu M, Kong Y, Shi F, Wang S. Bioinformatic analysis identifies the immunological profile of turner syndrome with different X chromosome origins. Front Endocrinol (Lausanne) 2023; 14:1024244. [PMID: 36733527 PMCID: PMC9887020 DOI: 10.3389/fendo.2023.1024244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 01/03/2023] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION Turner syndrome (TS) is a chromosomal disorder that affects phenotypic females who have one intact X chromosome and complete or partial absence of the second sex chromosome in association with one or more clinical manifestations. However, the immunological profile of TS with different X chromosome origins is incompletely understood. METHODS In this study, transcriptomic expression profiles of 26 TS (45,X) samples and 10 normal karyotype (46,XX) samples derived from GSE46687 cohort were employed. Differentially expressed immune-related genes (DEIRGs) between monosomy X TS patients with different X chromosome origins and normal females were investigated respectively. Subsequently, functional annotation, protein-protein interaction (PPI) network analysis, immunocyte infiltration evaluation, tissue-specific gene expression and Weighted gene co expression network analysis (WGCNA) were performed to explore the immunological characteristic in TS with different X chromosome origins. RESULTS 34 and 52 DEIRGs were respectively identified in 45,Xm and 45,Xp patients compared with normal individuals. The identified DEIRGs in Xm group were significantly enriched in pathways associated with cancer. In Xp TS patients, the most enriched signals were immune response-related. A majority of genes involved in the above pathways were downregulated. PPI analysis identified 4 (FLT3, IL3RA, CSF2RA, PIK3R3) and 6 (PDGFRB, CSF2, IL5, PRL, CCL17 and IL2)hub genes for Xm and Xp groups, respectively. CIBERSORT results showed that the proportion of Tregs in the Xm group and the naive B cells and resting NK cells in the Xp group significantly increased, respectively. Tissue-specific expression results indicated that BDCA4+_dentritic cells and CD19+ B cells were the prominent specific expressed tissues in Xp patients. Results of WGCNA support the above analysis. CONCLUSIONS This study aims at studying the immunological characteristics of TS with different X chromosome origins. Pathways in cancer in Xm group and immune response in Xp group were suppressed. 4 and 6 hub IRGs were identified as biomarkers for Xm and Xp patients, respectively. B cells played important roles in Xp patients. Further studies are needed to draw more attention to the functional validation of these hub genes and the roles of B cells.
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Affiliation(s)
- Xiao Qi
- Department of Health Statistics, Key Laboratory of Medicine and Health of Shandong Province, School of Public Health, Weifang Medical University, Weifang, Shandong, China
| | - Qinghua Wang
- Department of Health Statistics, Key Laboratory of Medicine and Health of Shandong Province, School of Public Health, Weifang Medical University, Weifang, Shandong, China
| | - Mingdong Yu
- Department of Spine Surgery, Weifang People’s Hospital, Weifang, Shandong, China
| | - Yujia Kong
- Department of Health Statistics, Key Laboratory of Medicine and Health of Shandong Province, School of Public Health, Weifang Medical University, Weifang, Shandong, China
| | - Fuyan Shi
- Department of Health Statistics, Key Laboratory of Medicine and Health of Shandong Province, School of Public Health, Weifang Medical University, Weifang, Shandong, China
- *Correspondence: Fuyan Shi, ; Suzhen Wang,
| | - Suzhen Wang
- Department of Health Statistics, Key Laboratory of Medicine and Health of Shandong Province, School of Public Health, Weifang Medical University, Weifang, Shandong, China
- *Correspondence: Fuyan Shi, ; Suzhen Wang,
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McGlacken-Byrne SM, Achermann JC, Conway GS. Management of a Girl With Delayed Puberty and Elevated Gonadotropins. J Endocr Soc 2022; 6:bvac108. [PMID: 35935072 PMCID: PMC9351373 DOI: 10.1210/jendso/bvac108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Indexed: 11/19/2022] Open
Abstract
A girl presenting with delayed puberty and elevated gonadotropins may have a range of conditions such as Turner syndrome (TS), primary ovarian insufficiency (POI), and 46,XY disorders of sexual development (DSD). An organized and measured approach to investigation can help reach a timely diagnosis. Management of young people often requires specialist multidisciplinary input to address the endocrine and nonendocrine features of these complex conditions, as well as the psychological challenges posed by their diagnosis. Next-generation sequencing within the research setting has revealed several genetic causes of POI and 46,XY DSD, which may further facilitate an individualized approach to care of these young people in the future. Pubertal induction is required in many and the timing of this may need to be balanced with other issues specific to the condition (eg, allowing time for information-sharing in 46,XY DSD, optimizing growth in TS). Shared decision-making and sign-posting to relevant support groups from the outset can help empower young people and their families to manage these conditions. We describe 3 clinical vignettes of girls presenting with delayed puberty and hypergonadotropic amenorrhea and discuss their clinical management in the context of current literature and guidelines.
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Affiliation(s)
- Sinéad M McGlacken-Byrne
- Institute for Women’s Health, University College London, London WC1E 6AU, UK
- Genetics and Genomic Medicine, UCL Great Ormond Street Institute of Child Health, University College London, London WC1N 1EH, UK
- Department of Paediatric Endocrinology, Great Ormond Street Hospital, London WC1N 3JH, UK
| | - John C Achermann
- Genetics and Genomic Medicine, UCL Great Ormond Street Institute of Child Health, University College London, London WC1N 1EH, UK
| | - Gerard S Conway
- Institute for Women’s Health, University College London, London WC1E 6AU, UK
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Burt E, Yasmin E, Davies MC, Creighton S, Brain C, Ruff C, Learner HI, Williams L, Cameron-Pimblett A, Talaulikar V, Conway G. Variability of response to early puberty induction demonstrated by transverse uterine diameter measurement and a novel method of 3D breast imaging. Clin Endocrinol (Oxf) 2022; 97:91-99. [PMID: 35436365 DOI: 10.1111/cen.14740] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 03/08/2022] [Accepted: 03/20/2022] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Induction of puberty with exogenous oestrogen results in considerable variability in final uterine and breast volumes. We set out to quantify the variability of these two outcome measures with a view to establishing monitoring methods that could be used to individualise treatment protocols. DESIGN A prospective observational study. PARTICIPANTS Sixteen participants with pubertal delay and primary amenorrhoea, due to hypogonadism were recruited from paediatric gynaecology and endocrinology clinics at University College London Hospital. A standardised protocol of transdermal 17β oestradiol (17βE) was used (Evorel™), with a starting dose of 12.5 mcg increasing to 25 mcg (patch changed twice weekly) after 4 months. Follow up was every 2 months for a total of 8 months. MEASUREMENTS Uterine dimensions using ultrasound, oestradiol concentrations and breast development assessed by both Tanner staging and 3D photographic imaging. RESULTS After 8 months of treatment, the changes in oestradiol concentrations (0-174 pmol), uterine volume growth (4.4-16.4 ml) and breast volume (1.76-140.1 ml) varied greatly between individuals. Of uterine parameters, transverse uterine diameter was most closely associated with serum oestradiol levels at 8 months (beta standardised coefficient = 0.80, p = .001). Change in breast volume was associated with age of treatment initiation (beta standardised coefficient 0.55 p = .04). CONCLUSIONS We demonstrate variation in response to exogenous oestrogen, emphasising the necessity for individualised dose titration. In the absence of sensitive oestradiol assays, uterine transverse measurements may be used as a surrogate marker of oestrogen sensitivity to guide early dose adjustment. 3D breast imaging may provide a quantitative assessment of breast development to complement Tanner breast staging.
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Affiliation(s)
- Elizabeth Burt
- Reproductive Medicine Unit, Institute for Women's Health, University College London Hospitals, London, UK
| | - Ephia Yasmin
- Reproductive Medicine Unit, Institute for Women's Health, University College London Hospitals, London, UK
| | - Melanie C Davies
- Reproductive Medicine Unit, Institute for Women's Health, University College London Hospitals, London, UK
| | - Sarah Creighton
- Department of Paediatric and Adolescent Gynaecology, University College London Hospitals, London, UK
| | - Caroline Brain
- Department of Paediatric Endocrinology, University College London Hospitals, London, UK
| | - Clifford Ruff
- Department of Medical Physics and Biomedical Engineering, University College London Hospitals, London, UK
| | - Hazel Isabella Learner
- Department of Paediatric and Adolescent Gynaecology, University College London Hospitals, London, UK
| | - Louise Williams
- Department of Paediatric and Adolescent Gynaecology, University College London Hospitals, London, UK
| | | | - Vikram Talaulikar
- Reproductive Medicine Unit, Institute for Women's Health, University College London Hospitals, London, UK
| | - Gerard Conway
- Reproductive Medicine Unit, Institute for Women's Health, University College London Hospitals, London, UK
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Xue R, Tang Q, Zhang Y, Xie M, Li C, Wang S, Yang H. Integrative Analyses of Genes Associated With Otologic Disorders in Turner Syndrome. Front Genet 2022; 13:799783. [PMID: 35273637 PMCID: PMC8902304 DOI: 10.3389/fgene.2022.799783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 02/08/2022] [Indexed: 12/02/2022] Open
Abstract
Background: Loss or partial loss of one X chromosome induces Turner syndrome (TS) in females, causing major medical concerns, including otologic disorders. However, the underlying genetic pathophysiology of otologic disorders in TS is mostly unclear. Methods: Ear-related genes of TS (TSEs) were identified by analyzing differentially expressed genes (DEGs) in two Gene Expression Omnibus (GEO)-derived expression profiles and ear-genes in the Comparative Toxicogenomic Database (CTD). Subsequently, Gene Ontology (GO), Kyoto Encyclopedia of Genes and Genomes (KEGG), and Disease Ontology (DO) analyses; Gene Set Enrichment Analysis (GSEA); and Gene Set Variation Analysis (GSVA) were adopted to study biological functions. Moreover, hub genes within the TSEs were identified by assessing protein-protein interaction (PPI), gene-microRNA, and gene-transcription factor (TF) networks. Drug-Gene Interaction Database (DGIdb) analysis was performed to predict molecular drugs for TS. Furthermore, three machine-learning analysis outcomes were comprehensively compared to explore optimal biomarkers of otologic disorders in TS. Finally, immune cell infiltration was analyzed. Results: The TSEs included 30 significantly upregulated genes and 14 significantly downregulated genes. Enrichment analyses suggested that TSEs play crucial roles in inflammatory responses, phospholipid and glycerolipid metabolism, transcriptional processes, and epigenetic processes, such as histone acetylation, and their importance for inner ear development. Subsequently, we described three hub genes in the PPI network and confirmed their involvement in Wnt/β-catenin signaling pathway and immune cell regulation and roles in maintaining normal auditory function. We also constructed gene-microRNA and gene-TF networks. A novel biomarker (SLC25A6) of the pathogenesis of otologic disorders in TS was identified by comprehensive comparisons of three machine-learning analyses with the best predictive performance. Potential therapeutic agents in TS were predicted using the DGIdb. Immune cell infiltration analysis showed that TSEs are related to immune-infiltrating cells. Conclusion: Overall, our findings have deepened the understanding of the pathophysiology of otologic disorders in TS and made contributions to present a promising biomarker and treatment targets for in-depth research.
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Affiliation(s)
- Ruoyan Xue
- Department of Otolaryngology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qi Tang
- Department of Otolaryngology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yongli Zhang
- Department of Otolaryngology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Mengyao Xie
- Department of Otolaryngology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chen Li
- Department of Otolaryngology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shu Wang
- Department of Otolaryngology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hua Yang
- Department of Otolaryngology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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9
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Ibarra-Ramírez M, Lugo-Trampe JDJ, Campos-Acevedo LD, Zamudio-Osuna M, Torres-Muñoz I, Gómez-Puente V, García-Castañeda G, Arredondo-Vázquez P, Rodríguez-Sánchez IP, Schaeffer SE, Velasco-Sepúlveda BH, Villarreal-Pérez JZ, Martínez-de-Villarreal LE. Gene Copy Number Quantification of SHOX, VAMP7, and SRY for the Detection of Sex Chromosome Aneuploidies in Neonates. Genet Test Mol Biomarkers 2020; 24:352-358. [PMID: 32423256 DOI: 10.1089/gtmb.2019.0226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Aims: To explore the feasibility of detecting sex chromosome aneuploidies (SCAs) by means of gene copy number quantification of short stature homeobox (SHOX), vesicle-associated membrane protein 7 (VAMP7), and SRY in newborns. Materials and Methods: Gene doses of SHOX, VAMP7, and SRY were determined by quantitative polymerase chain reaction (qPCR) using DNA obtained from dried blood samples from newborns. Relative quantification values were obtained. An aneuploidy profile was established according to cutoff values. Samples with ≥2 gene doses (out of range) were reanalyzed, and those with aneuploidy profiles were confirmed by karyotyping. Sensitivity, specificity, and positive and negative predictive values were obtained. Results: A total of 10,033 samples were collected (4945 females and 5088 males). Of 244 (2.43%) samples with ≥2 gene doses that were retested, 20 cases were confirmed. The overall incidence of SCAs was 1 in 500 live newborns. There were six cases of Turner syndrome (1/824), 3 cases of XXX (1/1648), 7 cases of Klinefelter syndrome (1/726), and 4 cases of of XYY (1/1272). The sensitivity was 0.952 (95.42%); the specificity was 0.975 (97.56%); the positive predictive value was 0.909 (90.91%) and the negative predictive value was 0.987 (98.77%). Conclusions: Gene copy number analyses of the VAMP7, SHOX, and SRY genes by qPCR from blood samples spotted onto filter paper is a highly reliable method for the early detection of male and female SCAs.
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Affiliation(s)
- Marisol Ibarra-Ramírez
- Departamento de Genética and Facultad de Medicina y Hospital Universitario José E. González, Universidad Autónoma de Nuevo León (UANL), Monterrey, Nuevo León, México
| | - José de Jesús Lugo-Trampe
- Departamento de Genética and Facultad de Medicina y Hospital Universitario José E. González, Universidad Autónoma de Nuevo León (UANL), Monterrey, Nuevo León, México
| | - Luis Daniel Campos-Acevedo
- Departamento de Genética and Facultad de Medicina y Hospital Universitario José E. González, Universidad Autónoma de Nuevo León (UANL), Monterrey, Nuevo León, México
| | - Michelle Zamudio-Osuna
- Departamento de Genética and Facultad de Medicina y Hospital Universitario José E. González, Universidad Autónoma de Nuevo León (UANL), Monterrey, Nuevo León, México
| | - Iris Torres-Muñoz
- Departamento de Genética and Facultad de Medicina y Hospital Universitario José E. González, Universidad Autónoma de Nuevo León (UANL), Monterrey, Nuevo León, México
| | - Viviana Gómez-Puente
- Departamento de Genética and Facultad de Medicina y Hospital Universitario José E. González, Universidad Autónoma de Nuevo León (UANL), Monterrey, Nuevo León, México
| | - Gloria García-Castañeda
- Departamento de Genética and Facultad de Medicina y Hospital Universitario José E. González, Universidad Autónoma de Nuevo León (UANL), Monterrey, Nuevo León, México
| | | | - Irám Pablo Rodríguez-Sánchez
- Departamento de Genética and Facultad de Medicina y Hospital Universitario José E. González, Universidad Autónoma de Nuevo León (UANL), Monterrey, Nuevo León, México
| | - S Elisa Schaeffer
- Departamento de Posgrado en Ingeniería de Sistemas (PISIS), FIME, Universidad Autónoma de Nuevo León (UANL), San Nicolas de los Garza, Nuevo León, México
| | - Braulio Hernán Velasco-Sepúlveda
- Departamento de Genética and Facultad de Medicina y Hospital Universitario José E. González, Universidad Autónoma de Nuevo León (UANL), Monterrey, Nuevo León, México
| | - Jesús Zacarías Villarreal-Pérez
- Departamento de Endocrinología, Facultad de Medicina y Hospital Universitario José E. González, Universidad Autónoma de Nuevo León (UANL), Monterrey, Nuevo León, México
| | - Laura Elia Martínez-de-Villarreal
- Departamento de Genética and Facultad de Medicina y Hospital Universitario José E. González, Universidad Autónoma de Nuevo León (UANL), Monterrey, Nuevo León, México
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10
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Eroğlu Filibeli B, Havare N, Erbak Yılmaz H, Yıldırım JG, Çatlı G, Dündar BN. Evaluation of Turner Syndrome Knowledge among Physicians and Parents. J Clin Res Pediatr Endocrinol 2020; 12:95-103. [PMID: 31486330 PMCID: PMC7127883 DOI: 10.4274/jcrpe.galenos.2019.2019.0041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVE Turner syndrome (TS) is one of the most common chromosomal abnormalities and an important cause of short stature and infertility due to ovarian failure in females. The aim was to evaluate the knowledge of TS among physicians and parents of children with TS and to enhance awareness about this subject. METHODS One hundred and forty physicians were included in the study. The study population comprised 37 pediatricians (26.4%), 15 gynecologists (10.7%), 88 family physicians (62.9%) and 30 parents who had daughters with a diagnosis of TS. Two separate questionnaires were administered to evaluate TS knowledge of physicians and parents. RESULTS According to the self-reports of physicians, 49% had insufficient knowledge of TS, while 15.7% indicated that they had no knowledge of TS. The mean percentage of correct answers was 50.71±16.17% for all physicians. When the entire group of physicians was considered, 67.1% of them did not know the approximate incidence of TS, while 14.3% of them incorrectly indicated that TS was a condition that was seen in boys. The mean percentage of correct answers among parents was 68±15%, and there was no difference between the mothers’ and fathers’ correct answer rates (p=0.063). The majority of parents was not aware of TS-associated diseases and increased malignancy risk in TS. CONCLUSION Physician knowledge of TS was poor and that there is a need for continued education about TS at the medical faculty and post-graduate levels.
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Affiliation(s)
- Berna Eroğlu Filibeli
- University of Health Sciences Turkey, Tepecik Training and Research Hospital, Clinic of Pediatric Endocrinology, İzmir, Turkey,* Address for Correspondence: University of Health Sciences Turkey, Tepecik Training and Research Hospital, Clinic of Pediatric Endocrinology, İzmir, Turkey Phone: +90 232 469 69 69 E-mail:
| | - Nesrin Havare
- University of Health Sciences Turkey, Tepecik Training and Research Hospital, Clinic of Pediatrics, İzmir, Turkey
| | - Huriye Erbak Yılmaz
- Katip Çelebi University, Atatürk Traning and Research Hospital, Clinic of Biochemistry, İzmir, Turkey
| | - Jülide Gülizar Yıldırım
- Katip Çelebi University Faculty of Health Sciences, Department of Public Health Nursing, İzmir, Turkey
| | - Gönül Çatlı
- Katip Çelebi University Faculty of Medicine, Department of Pediatric Endocrinology, İzmir, Turkey
| | - Bumin N. Dündar
- Katip Çelebi University Faculty of Medicine, Department of Pediatric Endocrinology, İzmir, Turkey
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11
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Lin AE, Prakash SK, Andersen NH, Viuff MH, Levitsky LL, Rivera-Davila M, Crenshaw ML, Hansen L, Colvin MK, Hayes FJ, Lilly E, Snyder EA, Nader-Eftekhari S, Aldrich MB, Bhatt AB, Prager LM, Arenivas A, Skakkebaek A, Steeves MA, Kreher JB, Gravholt CH. Recognition and management of adults with Turner syndrome: From the transition of adolescence through the senior years. Am J Med Genet A 2019; 179:1987-2033. [PMID: 31418527 DOI: 10.1002/ajmg.a.61310] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 06/11/2019] [Accepted: 07/18/2019] [Indexed: 12/16/2022]
Abstract
Turner syndrome is recognized now as a syndrome familiar not only to pediatricians and pediatric specialists, medical geneticists, adult endocrinologists, and cardiologists, but also increasingly to primary care providers, internal medicine specialists, obstetricians, and reproductive medicine specialists. In addition, the care of women with Turner syndrome may involve social services, and various educational and neuropsychologic therapies. This article focuses on the recognition and management of Turner syndrome from adolescents in transition, through adulthood, and into another transition as older women. It can be viewed as an interpretation of recent international guidelines, complementary to those recommendations, and in some instances, an update. An attempt was made to provide an international perspective. Finally, the women and families who live with Turner syndrome and who inspired several sections, are themselves part of the broad readership that may benefit from this review.
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Affiliation(s)
- Angela E Lin
- Medical Genetics Unit, Mass General Hospital for Children, Boston, Massachusetts
| | - Siddharth K Prakash
- Division of Cardiology, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Niels H Andersen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Mette H Viuff
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Lynne L Levitsky
- Division of Pediatric Endocrinology, Department of Pediatrics, Mass General Hospital for Children, Boston, Massachusetts
| | - Michelle Rivera-Davila
- Division of Pediatric Endocrinology, Department of Pediatrics, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Melissa L Crenshaw
- Medical Genetics Services, Division of Genetics, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Lars Hansen
- Department of Otorhinolaryngology, Aarhus University Hospital, Aarhus, Denmark
| | - Mary K Colvin
- Psychology Assessment Center, Massachusetts General Hospital, Boston, Massachusetts.,Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Frances J Hayes
- Reproductive Endocrine Unit of the Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Evelyn Lilly
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
| | - Emma A Snyder
- Medical Genetics Unit, Mass General Hospital for Children, Boston, Massachusetts
| | - Shahla Nader-Eftekhari
- Division of Endocrinology, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Melissa B Aldrich
- Center for Molecular Imaging, The Brown Institute for Molecular Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Ami B Bhatt
- Corrigan Minehan Heart Center, Adult Congenital Heart Disease Program, Massachusetts General Hospital, Boston, Massachusetts.,Yawkey Center for Outpatient Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Laura M Prager
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Ana Arenivas
- Department of Rehabilitation Psychology/Neuropsychology, TIRR Memorial Hermann Rehabilitation Network, Houston, Texas.,Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas
| | - Anne Skakkebaek
- Department of Internal Medicine and Endocrinology, Aarhus University Hospital, Aarhus, Denmark
| | - Marcie A Steeves
- Medical Genetics Unit, Mass General Hospital for Children, Boston, Massachusetts
| | - Jeffrey B Kreher
- Department of Pediatrics and Orthopaedics, Massachusetts General Hospital, Boston, Massachusetts
| | - Claus H Gravholt
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark
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12
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Cameron-Pimblett A, Davies MC, Burt E, Talaulikar VS, La Rosa C, King TFJ, Conway GS. Effects of Estrogen Therapies on Outcomes in Turner Syndrome: Assessment of Induction of Puberty and Adult Estrogen Use. J Clin Endocrinol Metab 2019; 104:2820-2826. [PMID: 30726925 DOI: 10.1210/jc.2018-02137] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 02/01/2019] [Indexed: 12/27/2022]
Abstract
CONTEXT Turner syndrome (TS) is often associated with delayed puberty. To induce puberty, estrogen is administered in incremental doses at an age determined by age of presentation. After puberty, various types of maintenance estrogen replacement therapy (ERT) are used. OBJECTIVE We sought associations between age of induction of puberty and type of ERT on adult health outcomes. DESIGN Health surveillance data included blood profiles, bone density, and blood pressure. We assessed interactions between these data and age at first estrogen exposure in women with primary amenorrhea. We also assessed these data according to ERT subgroups [combined oral contraceptive pill (OCP), oral estrogen (OE), and transdermal estradiol (TE)] using data from each of 6679 clinic visits, controlling for age, body mass index, and height. SETTING Adult TS clinic at University College London Hospital. PATIENTS Of 799 women with TS, 624 had primary amenorrhea and 599 had accurate maintenance ERT data. MAIN OUTCOME MEASURES Parameters of health surveillance derived from clinical guidelines. RESULTS Estrogen start age was negatively correlated with adult bone density (spine: r = -0.20 and hip: r = -0.022; P ≤ 0.001). OCP users had higher blood pressure and an adverse lipid profile compared with other ERT subgroups. TE was associated with elevated liver enzymes and hemoglobin A1c compared with OE (P ≤ 0.01). CONCLUSIONS An earlier age of induction of puberty may be beneficial for adult bone density. Given the high prevalence of hypertension in TS, the use of OCP for ERT should be limited. OE may be a benefit for steatohepatitis.
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Affiliation(s)
| | - Melanie C Davies
- Reproductive Medicine Unit, University College London Hospital, London, United Kingdom
| | - Elizabeth Burt
- Reproductive Medicine Unit, University College London Hospital, London, United Kingdom
| | | | - Clementina La Rosa
- Reproductive Medicine Unit, University College London Hospital, London, United Kingdom
| | - Thomas F J King
- Reproductive Medicine Unit, University College London Hospital, London, United Kingdom
| | - Gerard S Conway
- Reproductive Medicine Unit, University College London Hospital, London, United Kingdom
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13
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Berglund A, Viuff MH, Skakkebæk A, Chang S, Stochholm K, Gravholt CH. Changes in the cohort composition of turner syndrome and severe non-diagnosis of Klinefelter, 47,XXX and 47,XYY syndrome: a nationwide cohort study. Orphanet J Rare Dis 2019; 14:16. [PMID: 30642344 PMCID: PMC6332849 DOI: 10.1186/s13023-018-0976-2] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 12/11/2018] [Indexed: 01/15/2023] Open
Abstract
Background Knowledge on the prevalence of sex chromosome abnormalities (SCAs) is limited, and delayed diagnosis or non-diagnosis of SCAs are a continuous concern. We aimed to investigate change over time in incidence, prevalence and age at diagnosis among Turner syndrome (TS), Klinefelter syndrome (KS), Triple X syndrome (Triple X) and Double Y syndrome (Double Y). Methods This study is a nationwide cohort study in a public health care system. The Danish Cytogenetic Central Registry (DCCR) holds information on all karyotypes performed in Denmark since 1961. We identified all individuals in the DCCR with a relevant SCA during 1961–2014; TS: n = 1156; KS: n = 1235; Triple X: n = 197; and Double Y: n = 287. From Statistics Denmark, which holds an extensive collection of data on the Danish population, complete data concerning dates of death and migrations in and out of Denmark were retrieved for all individuals. Results The prevalence among newborns was as follows: TS: 59 per 100,000 females; KS: 57 per 100,000 males; Triple X: 11 per 100,000 females; and Double Y: 18 per 100,000 males. Compared with the expected number among newborns, all TS, 38% of KS, 13% of Triple X, and 18% of Double Y did eventually receive a diagnosis. The incidence of TS with other karyotypes than 45,X (P < 0.0001), KS (P = 0.02), and Double Y (P = 0.03) increased during the study period whereas the incidence of 45,X TS decreased (P = 0.0006). The incidence of Triple X was stable (P = 0.22). Conclusions The prevalence of TS is higher than previously identified, and the karyotypic composition of the TS population is changing. Non-diagnosis is extensive among KS, Triple X and Double Y, whereas all TS seem to become diagnosed. The diagnostic activity has increased among TS with other karyotypes than 45,X as well as among KS and Double Y.
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Affiliation(s)
- Agnethe Berglund
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark. .,Department of Molecular Medicine, Aarhus University Hospital, Brendstrupgaardsvej 21A, 8200, Aarhus N, Denmark.
| | - Mette Hansen Viuff
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark.,Department of Molecular Medicine, Aarhus University Hospital, Brendstrupgaardsvej 21A, 8200, Aarhus N, Denmark
| | - Anne Skakkebæk
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark.,Department of Clinical Genetics, Odense University Hospital, J.B. Winsløws Vej 4, 5000, Odense C, Denmark
| | - Simon Chang
- Unit for Thrombosis Research, Department of Regional Health Research, University of Southern Denmark, Odense, Denmark.,Department of Clinical Biochemistry, Hospital of South West Jutland, Finsensgade 35, 6700, Esbjerg, Denmark
| | - Kirstine Stochholm
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark.,Department of Pediatrics, Center of Rare Diseases, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Claus Højbjerg Gravholt
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark.,Department of Molecular Medicine, Aarhus University Hospital, Brendstrupgaardsvej 21A, 8200, Aarhus N, Denmark
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14
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Affiliation(s)
- S. Shah
- Department of Endocrinology, Monash Health, Clayton, Victoria, Australia
| | - H. H. Nguyen
- Department of Endocrinology, Monash Health, Clayton, Victoria, Australia
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
| | - A. J. Vincent
- Department of Endocrinology, Monash Health, Clayton, Victoria, Australia
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia
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15
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Apperley L, Das U, Ramakrishnan R, Dharmaraj P, Blair J, Didi M, Senniappan S. Mode of clinical presentation and delayed diagnosis of Turner syndrome: a single Centre UK study. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2018; 2018:4. [PMID: 29983717 PMCID: PMC6019720 DOI: 10.1186/s13633-018-0058-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 06/15/2018] [Indexed: 11/16/2022]
Abstract
Background Early diagnosis of girls with Turner syndrome (TS) is essential to provide timely intervention and support. The screening guidelines for TS suggest karyotype evaluation in patients presenting with short stature, webbed neck, lymphoedema, coarctation of aorta or ≥ two dysmorphic features. The aim of the study was to determine the age and clinical features at the time of presentation and to identify potential delays in diagnosis of TS. Methods Retrospective data on age at diagnosis, reason for karyotype analysis and presenting clinical features was collected from the medical records of 67 girls with TS. Results The mean age of diagnosis was 5.89 (±5.3) years ranging from pre-natal to 17.9 years (median 4.6 years). 10% were diagnosed antenatally, 16% in infancy, 54% in childhood (1–12 years) and 20% in adolescence (12–18 years). Lymphoedema (27.3%) and dysmorphic features (27.3%) were the main signs that triggered screening in infancy. Short stature was the commonest presenting feature in both childhood (52.8%) and adolescent (38.5%) years. At least 12% of girls fulfilled the criteria for earlier screening but were diagnosed only at a later age (mean age = 8.78 years). 13.4% of patients had classical 45XO karyotype and 52.3% of girls had a variant karyotype. Conclusion Majority of girls with TS were diagnosed only after the age of 5 years. Short stature triggered evaluation for most patients diagnosed in childhood and adolescence. Lack of dedicated community height-screening programme to identify children with short stature and lack of awareness could have led to potential delays in diagnosing TS. New strategies for earlier detection of TS are needed.
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Affiliation(s)
- Louise Apperley
- Department of Paediatric Endocrinology, Alder Hey Children's Hospital NHS Trust, Liverpool, UK
| | - Urmi Das
- Department of Paediatric Endocrinology, Alder Hey Children's Hospital NHS Trust, Liverpool, UK
| | - Renuka Ramakrishnan
- Department of Paediatric Endocrinology, Alder Hey Children's Hospital NHS Trust, Liverpool, UK
| | - Poonam Dharmaraj
- Department of Paediatric Endocrinology, Alder Hey Children's Hospital NHS Trust, Liverpool, UK
| | - Jo Blair
- Department of Paediatric Endocrinology, Alder Hey Children's Hospital NHS Trust, Liverpool, UK
| | - Mohammed Didi
- Department of Paediatric Endocrinology, Alder Hey Children's Hospital NHS Trust, Liverpool, UK
| | - Senthil Senniappan
- Department of Paediatric Endocrinology, Alder Hey Children's Hospital NHS Trust, Liverpool, UK
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16
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Horita S, Simsek E, Simsek T, Yildirim N, Ishiura H, Nakamura M, Satoh N, Suzuki A, Tsukada H, Mizuno T, Seki G, Tsuji S, Nangaku M. SLC4A4 compound heterozygous mutations in exon-intron boundary regions presenting with severe proximal renal tubular acidosis and extrarenal symptoms coexisting with Turner's syndrome: a case report. BMC MEDICAL GENETICS 2018; 19:103. [PMID: 29914390 PMCID: PMC6006740 DOI: 10.1186/s12881-018-0612-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 05/21/2018] [Indexed: 12/14/2022]
Abstract
Background Congenital NBCe1A deficiency with the SLC4A4 mutation causes severe proximal renal tubular acidosis, which often comprises extrarenal symptoms, such as intellectual disability and developmental delay, glaucoma, cataract and band keratopathy. To date, almost all mutations have been found to be homozygous mutations located in exons. Case presentation We performed direct nucleotide sequencing analysis of exons and exon–intron boundary regions of the SLC4A4 in a patient presenting with severe renal proximal tubule acidosis, glaucoma and intellectual disability and her parents without these signs. The examination revealed compound heterozygous mutations in exon–intron boundary regions, c.1076 + 3A > C and c.1772 − 2A > T, neither of which have been reported previously. While the former mutation was found in the mother, the latter was found in the father. The transcript of the SLC4A4 gene was almost undetectable, and the patient was also diagnosed with Turner’s syndrome. Conclusions We identified two novel SLC4A4 mutations, c.1076 + 3A > C and c.1772 − 2A > T. When presented in a compound heterozygous state, these mutations caused a phenotype of severe renal proximal tubular acidosis along with glaucoma and mental retardation. This is the first report of congenital proximal renal tubular acidosis carrying compound heterozygous SLC4A4 mutations in exon–intron boundary regions. We suggest that an mRNA surveillance mechanism, nonsense-mediated RNA decay, following aberrant splicing was the reason that the SLC4A4 transcript was almost undetectable in the proband.
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Affiliation(s)
- Shoko Horita
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo, Tokyo, 113 0033, Japan.
| | - Enver Simsek
- Department of Paediatric Endocrinology, Eskisehir Osmangazi University School of Medicine, Esogu Meşelik Yerleşkesi, 26480, Eskisehir, Turkey
| | - Tulay Simsek
- Department of Ophthalmology, Eskisehir Osmangazi University School of Medicine, Esogu Meşelik Yerleşkesi, 26480, Eskisehir, Turkey
| | - Nilgun Yildirim
- Department of Ophthalmology, Eskisehir Osmangazi University School of Medicine, Esogu Meşelik Yerleşkesi, 26480, Eskisehir, Turkey
| | - Hiroyuki Ishiura
- Department of Neurology, The University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo, Tokyo, 113 0033, Japan
| | - Motonobu Nakamura
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo, Tokyo, 113 0033, Japan
| | - Nobuhiko Satoh
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo, Tokyo, 113 0033, Japan
| | - Atsushi Suzuki
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo, Tokyo, 113 0033, Japan
| | - Hiroyuki Tsukada
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo, Tokyo, 113 0033, Japan
| | - Tomohito Mizuno
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo, Tokyo, 113 0033, Japan
| | - George Seki
- Yaizu City Hospital, 1000, Dobara, Yaizu, 425 0055, Japan
| | - Shoji Tsuji
- Department of Molecular Neurology, The University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo, Tokyo, 113 0033, Japan.,Institute of Medical Genomics, International University of Health and Welfare, 4-3, Kozunomori, Narita-shi, Chiba-ken, 286 8686, Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo, Tokyo, 113 0033, Japan
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17
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Zhang H, Yang X, Feng X, Xu H, Yang Q, Zou L, Yan M, Liu D, Su X, Jiao B. Chromosome-wide gene dosage rebalance may benefit tumor progression. Mol Genet Genomics 2018; 293:895-906. [DOI: 10.1007/s00438-018-1429-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 03/09/2018] [Indexed: 01/22/2023]
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18
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Gravholt CH, Andersen NH, Conway GS, Dekkers OM, Geffner ME, Klein KO, Lin AE, Mauras N, Quigley CA, Rubin K, Sandberg DE, Sas TCJ, Silberbach M, Söderström-Anttila V, Stochholm K, van Alfen-van derVelden JA, Woelfle J, Backeljauw PF. Clinical practice guidelines for the care of girls and women with Turner syndrome: proceedings from the 2016 Cincinnati International Turner Syndrome Meeting. Eur J Endocrinol 2017; 177:G1-G70. [PMID: 28705803 DOI: 10.1530/eje-17-0430] [Citation(s) in RCA: 603] [Impact Index Per Article: 86.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 06/07/2017] [Indexed: 12/14/2022]
Abstract
Turner syndrome affects 25-50 per 100,000 females and can involve multiple organs through all stages of life, necessitating multidisciplinary approach to care. Previous guidelines have highlighted this, but numerous important advances have been noted recently. These advances cover all specialty fields involved in the care of girls and women with TS. This paper is based on an international effort that started with exploratory meetings in 2014 in both Europe and the USA, and culminated with a Consensus Meeting held in Cincinnati, Ohio, USA in July 2016. Prior to this meeting, five groups each addressed important areas in TS care: 1) diagnostic and genetic issues, 2) growth and development during childhood and adolescence, 3) congenital and acquired cardiovascular disease, 4) transition and adult care, and 5) other comorbidities and neurocognitive issues. These groups produced proposals for the present guidelines. Additionally, four pertinent questions were submitted for formal GRADE (Grading of Recommendations, Assessment, Development and Evaluation) evaluation with a separate systematic review of the literature. These four questions related to the efficacy and most optimal treatment of short stature, infertility, hypertension, and hormonal replacement therapy. The guidelines project was initiated by the European Society for Endocrinology and the Pediatric Endocrine Society, in collaboration with The European Society for Pediatric Endocrinology, The Endocrine Society, European Society of Human Reproduction and Embryology, The American Heart Association, The Society for Endocrinology, and the European Society of Cardiology. The guideline has been formally endorsed by the European Society for Endocrinology, the Pediatric Endocrine Society, the European Society for Pediatric Endocrinology, the European Society of Human Reproduction and Embryology and the Endocrine Society. Advocacy groups appointed representatives who participated in pre-meeting discussions and in the consensus meeting.
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Affiliation(s)
- Claus H Gravholt
- Departments of Endocrinology and Internal Medicine
- Departments of Molecular Medicine
| | - Niels H Andersen
- Departments of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Gerard S Conway
- Department of Women's Health, University College London, London, UK
| | - Olaf M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Mitchell E Geffner
- The Saban Research Institute, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Karen O Klein
- Rady Children's Hospital, University of California, San Diego, California, USA
| | - Angela E Lin
- Department of Pediatrics, Medical Genetics Unit, Mass General Hospital for Children, Boston, Massachusetts, USA
| | - Nelly Mauras
- Division of Endocrinology, Nemours Children's Health System, Jacksonville, Florida, USA
| | | | - Karen Rubin
- Connecticut Children's Medical Center, Hartford, Connecticut, USA
| | - David E Sandberg
- Division of Psychology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Theo C J Sas
- Department of Pediatric Endocrinology, Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of Pediatrics, Dordrecht, The Netherlands
| | - Michael Silberbach
- Department of Pediatrics, Doernbecher Children's Hospital, Portland, Oregon, USA
| | | | - Kirstine Stochholm
- Departments of Endocrinology and Internal Medicine
- Center for Rare Diseases, Department of Pediatrics, Aarhus University Hospital, Aarhus, Denmark
| | | | - Joachim Woelfle
- Department of Pediatric Endocrinology, Children's Hospital, University of Bonn, Bonn, Germany
| | - Philippe F Backeljauw
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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19
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Vincent AJ, Nguyen HH, Ranasinha S, Vollenhoven B. Increased detection of co-morbidities with evaluation at a dedicated adult Turner syndrome clinic. Climacteric 2017; 20:442-447. [DOI: 10.1080/13697137.2017.1350841] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- A. J. Vincent
- Menopause Unit, Monash Medical Centre, Monash Health, Clayton, VIC, Australia
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Clayton, VIC, Australia
- Department of Endocrinology, Monash Health, Clayton, VIC, Australia
| | - H. H. Nguyen
- Department of Endocrinology, Monash Health, Clayton, VIC, Australia
- Department of Medicine, Monash University, Clayton, VIC, Australia
| | - S. Ranasinha
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Clayton, VIC, Australia
| | - B. Vollenhoven
- Menopause Unit, Monash Medical Centre, Monash Health, Clayton, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
- Monash IVF, Clayton, VIC, Australia
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20
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Detection of Turner syndrome using X-chromosome inactivation specific differentially methylated CpG sites: A pilot study. Clin Chim Acta 2017; 468:174-179. [DOI: 10.1016/j.cca.2017.03.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 03/02/2017] [Accepted: 03/07/2017] [Indexed: 11/17/2022]
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21
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Saikia UK, Sarma D, Yadav Y. Delayed Presentation of Turner Syndrome: Challenge to Optimal Management. J Hum Reprod Sci 2017; 10:297-301. [PMID: 29430158 PMCID: PMC5799935 DOI: 10.4103/jhrs.jhrs_114_17] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background Turner syndrome (TS) is a chromosomal disorder associated with dysmorphic features and comorbidities, with recent trends focusing on early diagnosis for adequate management. Aim The aim is to study the age and mode of presentation of TS, associated comorbidities and look for any correlation with the genotype. Material and Methods This was a retrospective analysis of girls with TS attending the endocrinology clinic of a tertiary care center. Their age, mode of presentation, and clinical features were noted. All participants underwent ear examination, echocardiography, and ultrasonography of the abdomen. Laboratory investigations included serum T4, thyroid-stimulating hormone, thyroid peroxidase antibodies, follicle-stimulating hormone, fasting, and 2-h plasma glucose after 75 g glucose load and a karyotype. Simple descriptive statistical methods were used. Results Seventeen cases of TS were seen with a median age of presentation of 18 years (range 14-42 years). Primary amenorrhea was the most common reason for seeking medical attention (76.4%) followed by short stature and diabetes mellitus (11.8% each). The mean height at presentation was 137.5 ± 5.4 cm. Monosomy of X chromosome (45,X) was the most common karyotype obtained in 58.8% of the patients, followed by 45,X/46, XX in 17.6%, 45,X/46X,i(X)(q10) in 11.8%, and 45,X/47,XXX and 46X,delXp11.2 in 5.9% patients each. Bicuspid aortic valve was seen in two patients having a 45,X/46,XX karyotype. Conclusion Primary amenorrhea is the most common presenting feature in girls with TS leading to a delayed age of presentation. Short stature and dysmorphic features are often overlooked in infancy and childhood due to socioeconomic factors. This late age of presentation is a cause of concern as early detection and management is important for height outcomes, bone health, and psychosocial support. Assessment of comorbidities becomes important in this setting.
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Affiliation(s)
- Uma Kaimal Saikia
- Department of Endocrinology, Gauhati Medical College, Guwahati, Assam, India
| | - Dipti Sarma
- Department of Endocrinology, Gauhati Medical College, Guwahati, Assam, India
| | - Yogesh Yadav
- Department of Endocrinology, Gauhati Medical College, Guwahati, Assam, India
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22
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Campos-Acevedo LD, Ibarra-Ramirez M, de Jesús Lugo-Trampe J, de Jesús Zamudio-Osuna M, Torres-Muñoz I, Del Roble Velasco-Campos M, Rojas-Patlan L, Rodríguez-Sánchez IP, Martínez-de-Villarreal LE. Dosage of Sex Chromosomal Genes in Blood Deposited on Filter Paper for Neonatal Screening of Sex Chromosome Aneuploidy. Genet Test Mol Biomarkers 2016; 20:786-790. [PMID: 27997249 DOI: 10.1089/gtmb.2016.0101] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS In this study, we examined the doses of the stature homeobox (SHOX), vesicle-associated membrane protein 7 (VAMP7), and SRY genes to establish a protocol for using peripheral blood samples deposited on filter paper for the screening of sex chromosome aneuploidy in neonates. We also measured correlations with karyotypes to assess this method as a neonatal screening strategy. MATERIALS AND METHODS This was an observational, descriptive, comparative blind study. Thirty-two healthy young adults (17 women, 15 men; age, ≥18 years), four patients with known sex chromosome aneuploidy (positive control group), and 1000 healthy newborns were included. Gene dosages were determined using quantitative real-time polymerase chain reaction (RT-PCR). Values with standard deviations (SDs) of three or more were considered abnormal. RESULTS Men and women differed in the gene dosage of the SRY gene. Cases with Turner syndrome showed values below 3 SDs for SHOX and VAMP7 genes, and cases with Klinefelter syndrome showed values above 3 SDs for SHOX and VAMP7 genes. Two suspected cases of sex chromosome aneuploidy were diagnosed using our neonatal screening strategy; these cases were confirmed as Turner syndrome and 47,XYY syndrome by karyotyping. CONCLUSIONS Our data establish a basis for the determination of chromosomal sex and neonatal screening of sex chromosome aneuploidy using RT-PCR.
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Affiliation(s)
- Luis Daniel Campos-Acevedo
- Departamento de Genética, Facultad de Medicina y Hospital Universitario José E. González, Universidad Autónoma de Nuevo León (UANL) , Monterrey, México
| | - Marisol Ibarra-Ramirez
- Departamento de Genética, Facultad de Medicina y Hospital Universitario José E. González, Universidad Autónoma de Nuevo León (UANL) , Monterrey, México
| | - José de Jesús Lugo-Trampe
- Departamento de Genética, Facultad de Medicina y Hospital Universitario José E. González, Universidad Autónoma de Nuevo León (UANL) , Monterrey, México
| | - Michelle de Jesús Zamudio-Osuna
- Departamento de Genética, Facultad de Medicina y Hospital Universitario José E. González, Universidad Autónoma de Nuevo León (UANL) , Monterrey, México
| | - Iris Torres-Muñoz
- Departamento de Genética, Facultad de Medicina y Hospital Universitario José E. González, Universidad Autónoma de Nuevo León (UANL) , Monterrey, México
| | - Ma Del Roble Velasco-Campos
- Departamento de Genética, Facultad de Medicina y Hospital Universitario José E. González, Universidad Autónoma de Nuevo León (UANL) , Monterrey, México
| | - Luz Rojas-Patlan
- Departamento de Genética, Facultad de Medicina y Hospital Universitario José E. González, Universidad Autónoma de Nuevo León (UANL) , Monterrey, México
| | - Irám Pablo Rodríguez-Sánchez
- Departamento de Genética, Facultad de Medicina y Hospital Universitario José E. González, Universidad Autónoma de Nuevo León (UANL) , Monterrey, México
| | - Laura Elia Martínez-de-Villarreal
- Departamento de Genética, Facultad de Medicina y Hospital Universitario José E. González, Universidad Autónoma de Nuevo León (UANL) , Monterrey, México
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Ji J, Zöller B, Sundquist J, Sundquist K. Risk of solid tumors and hematological malignancy in persons with Turner and Klinefelter syndromes: A national cohort study. Int J Cancer 2016; 139:754-8. [DOI: 10.1002/ijc.30126] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 03/08/2016] [Accepted: 03/31/2016] [Indexed: 11/09/2022]
Affiliation(s)
- Jianguang Ji
- Center for Primary Health Care Research, Lund University; Lund Sweden
| | - Bengt Zöller
- Center for Primary Health Care Research, Lund University; Lund Sweden
| | - Jan Sundquist
- Center for Primary Health Care Research, Lund University; Lund Sweden
- Stanford Prevention Research Center, Stanford University School of Medicine; Stanford CA
| | - Kristina Sundquist
- Center for Primary Health Care Research, Lund University; Lund Sweden
- Stanford Prevention Research Center, Stanford University School of Medicine; Stanford CA
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